Category Archives: OPM Book

Publication details & Table of Contents

First published in 1997 by Occupational Performance Network
Copyright 1997 Christine Chapparo and Judy Ranka
All rights reserved. This monograph is protected by copyright. No partof this book may be utilised by any information storage and retrievalsystem or transmitted in any form or by any means, including photocopying, recording or otherwise without prior written permissionfrom the copyright owner.

Produced by:
Occupational Performance Network
Available from:
Authors
Schoolof Occupational Therapy
The University of Sydney, Building C42
East St.
Lidcombe,New South Wales, 2141
Australia

Printed by:
Total Print Control
10/6 Anella Ave.
Castle Hill, NSW 2154
Australia

National Library of Australia
Occupational performance model (Australia) monograph 1
Authors:Christine Chapparo, Judy Ranka
ISBNNumber: 0909353 95 6

Occupational Performance Model (Australia)
Monograph 1 April, 1997

Edited by
ChristineChapparo, MAMacq., DipOTNSW,OTR, FAOTA
Senior Lecturer
Schoolof Occupational Therapy
Faculty of Health Sciences (C42)
The University of Sydney
Sydney,New South Wales, 2141, AUSTRALIA

JudyRanka, BScWMU, MAMacq.,OTR
Lecturer
Schoolof Occupational Therapy
Faculty of Health Sciences (C42)
The University of Sydney
Sydney,New South Wales, 2141, AUSTRALIA

Dedication:
to thememory of John Balla, PhD
who firstrealised and encouraged the idea of this monograph.

Acknowledgments:
We acknowledge the individual and collective contribution of : the contributors for giving us insight into the ways theory can be applied to practice, Associate Professor Colleen Mullavey-O’Byrne, Head of School and members of staff of the School of Occupational Therapy, The University of Sydney for their encouragement, Ev Innes for assistance with generating selected graphics, clients who allowed us to interpret their stories throughout the monograph, and our families.

Preface:

The purpose of this monograph is to introduce the Occupational Performance Model (OPM) (Australia) in its current stage of development. The structure of the model, as it is presented in this monograph, is not viewed as a new paradigmatic development but as an alternate representation of contemporary ideas about occupational performance. The inclusion of (Australia) in the title simply indicates the Model’s sociocultural derivation. It is not presented as a national model as, for example, is found in Canada. The development of this model has occurred over the last decade and isoutlined in Part 1 of this Monograph. The development of the model has been a circular theory-practice-theory process. Clinicians and clinical research have played a major part in how constructs in the model have been conceptualised. Therefore,Part 2 of this monograph contains examples of how the constructshave been applied. These examples are from a range of practiceenvironments. Occupational Performance has been applied todeveloping perspectives about the needs of various client populations, administration and education. The range of examples illustrate how occupational therapists apply theory to practice at varying levels of sophistication and complexity. Future OPM (Australia) monographs will contain more detail about each of the constructs as well as reflecting the on going work into the nature of processes within and between constructs.

Occupational Performance Model (Australia) Monograph1, April, 1997

CONTENTS

PART 1:

The Occupational Performance Model (Australia): A description of constructs and structure 1
Christine Chapparo and Judy Ranka

Towards a model of occupational performance: Model development 24
Christine Chapparo and Judy Ranka

Occupational Performance: A practice model for occupational therapy 45
Judy Ranka and Christine Chapparo

OccupationalPerformance Model (Australia): Definition of terms 58

OccupationalPerformance Model (Australia): Formal dissemination 61

PART 2:

Occupationalperformance: A guide for upper limb orthotic prescription inspinal cord injury 66
Judy Ranka

Effect of wrist immobilisation on upper limb occupational performance of elderly males 83
Winnie Yuen Yee Chan and Christine Chapparo

Wristcasting to improve control of the wrist and hand during theperformance of occupational tasks 95
Kirsty Stewart and Christine Chapparo

The Occupational Performance Model (Australia): Application to group intervention for children with handwriting problems 105
Traci-Anne Goyen, Sharon Doyle and Christine Chapparo

Occupational performance and sensory integration therapy: Preliminary findingsof a rating scale 116
Veronica Steer

The immediate effects of three occupational therapy interventions on specific play behaviours of three children with developmental disability 125
Kylie Wilkinson and Christine Chapparo

Usingthe Occupational Performance Model in practice: Developing intervention aims for a child with acute burns, and her mother 149
Roman Weigl

Socialexperiences of children with fragile X syndrome: An occupational performance perspective 155
Kristan Baker

An investigation of occupational role performance in men over sixty years of age following a stroke 164
Anne Hillman and Christine Chapparo

Time: Management of distortions of the perception of time in clients after traumatic brain impairment 175
Sharon Reynolds and Christine Chapparo

Improving performance of occupational tasks and routines in clients with extreme agitation after traumatic brain impairment 182
Jodie Nicholls and Christine Chapparo

The Perceive, Recall, Plan, Perform (PRPP) System of task analysis 189
Christine Chapparo and Judy Ranka

Usingthe Perceive, Recall, Plan and Perform System to assess cognitive deficits intraumatic brain impairment: A case study 199
Kerrie Fry and Leanne O’Brien

Usingthe Occupational Performance model to unite occupational therapy servicesin a rehabilitation setting 205
Sandra Colyer

Using the Occupational Performance Model (Australia) to structure process and outcome measures for occupational therapists working with children 209
Jill Hummell, Diana Barnett and Sharon Doyle

Occupationalperformance in productivity and prevention 223
Ev Innes

Developinga ‘postmodern’ occupational therapy curriculum model using the structure and operations of Occupational Performance 231
Judy Ranka

Occupational Performance: Curriculum theorising in occupational therapy 245
Judy Ranka and Christine Chapparo

A guide for upper limb orthotic prescription in spinal cord injury

Judy Ranka is a Lecturer in the School of Occupational Therapy, The University of Sydney

PURPOSE

This aim of this paper is to present an example of how the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) can be used to guide occupational therapists in their prescription of upper limb orthotics with clients whose hand function has been compromised by spinal cord injury. The example presented is an extension of an action research project originally completed by Ranka, Colyer, Dickson and Chow (1994) in which an earlier version of Occupational Performance (Chapparo & Ranka, 1992) was used as the foundation for an upper limb orthotic program.

BACKGROUND:

Occupational therapists and orthotists have long used upper limb orthotic systems with clients who have wrist and hand weakness or paralysis resulting from spinal cord injury (Anderson, 1965; Lohman, 1982; Mallick, 1965; Cuilford & Perry, 1975; Wilson, McKenzie & Barber, 1974). Reasons include:

1 to prevent deformity through ‘static’ positioning (Chapparo, 1980; Guilford & Perry, 1975; Mallick, & Meyer, 1978).
2 to promote functional use of the hand through ‘dynamic’ orthoses such as Ranch los Amigos wrist-driven flexor hinge orthoses, the RIC tenodesis splint or various shoulder-driven and myoelectric devices (Chapparo, 1980; Hill & Presperin, 1986; Guilford & Perry, 1975; Nichols, Peach, Haworth & Ennis (1978).

Orthotics fabricated by occupational therapists are usually viewed as temporary devices (Hill & Presperin, 1986) and constructed of low temperature thermoplastics. Those fabricated by orthotists tend to be constructed of more rigid products such as polypropylene, laminated plastic or metal. Plaster of paris bandage may also be used in situations where resources are limited (Ranka & Zhuo, 1987). Although orthotists specialise in the design and fabrication of orthotics, occupational therapists are often solely responsible for the prescription and fabrication of ‘hand splints’. Even when an orthotist is available, occupational therapists may still identify the need for intervention and provide follow-up orthotic use training.

Considerable evidence exists which supports the need for early and long-term orthotic intervention in clients with upper limb problems resulting from spinal cord injury. For example, Yarkony, Bass, Keenan and Meyer (1985) and others describe biochemical and pathological factors associated with contracture formation and note the speed with which deformity develops (Akeson, Amiel, Abel, Garfin & Woo, 1987; Booth, 1987 Botte, Nickel & Akeson, 1988; Enneking & Horowitz, 1972). Others such as, Brand (1985), Wynn Parry and Berkely (1975) and Guilford and Perry (1975) report the effects of an unsupported joint on secondary deformity elsewhere, for example, when an unsupported wrist rests in flexion and results in secondary extension contractures at the metacarpal-phalangeal joints. Deforming forces created by muscle imbalance have also been described (Perry, 1975); for example, when denervation to the triceps results in a lack of an opposing force to elbow flexion/supination and a wrist extension contracture ensues.

Literature which specifically addresses the use of upper limb orthotics as a method of intervention in this area of practice consists of:

1 descriptions of new orthotic designs and clinical observations of their effect (see for example, Lightbody, 1994; Sutton, 1993, Yarkony, 1990)
2 guidelines, protocols and instructions for fabrication of orthoses (see for example: Chapparo, 1980; Hill & Presperin, 1986; Mallick & Meyer, 1978; Newsom, Keenan, Maytree & Aguilar, 1969; Wilson, McKenzie, Barber & Watson, 1984; Sargent & Braun, 1986).
3 surveys of client groups about long-term orthotic use (see for example, Lee, 1988; Martin, 1987; Shepherd & Ruzicka, 1991; Wise, Wharton & Robinson, 1986)
4 empirical studies of orthotic effect (DiPasquale-Lehnerz, 1994).

Objective findings reported in the literature indicate that many clients discontinue upper limb orthotic use after they return home (Lee, 1988; Martin, 1987; Shepherd & Ruzicka, 1991), and that factors associated with continued use following return home include, 1) early prescription and use of the orthosis, and 2) client recognition of a functional need for an orthosis. These findings are not surprising when one considers literature associated with the impact of spinal cord injury on psychological functioning and comprehension of information (Partridge, 1994; Patterson, 1993). Others also note the importance of effective teaching and learning strategies on clients abilities to understand information about proposed interventions (Boss, 1994).

Results from empirical studies are limited. DiPasquale-Lehnerz (1994) used an experimental design to investigate the effect of night wear of wrist-hand or hand orthoses of the opponens design on improvements in hand function, range of motion and tenodesis prehension in persons with C6 spinal cord injury. She found no significant differences in this study but acknowledges that client engagement in wheelchair propulsion tasks during the day may have compromised any orthotic effect produced during night wear (DiPasquale-Lehnertz, 1994, p.141). No other empirical studies of orthotic effect have been located in the literature.

Also lacking in the literature are discussions of occupational therapy theoretical bases for the prescription of upper limb orthoses with this population, or studies which go beyond the broad aims of deformity management and improving hand function. Consequently, occupational therapists have little guidance in developing rationales for clinical decisions in this area of practice and controversy remains evident (DiPasquale-Lehnertz, 1994; Spinal Practitioners Group – Sydney, personal communication, October, 1994).

Questions asked include:

Is orthotic intervention implicated for specific clients or not? Why?
How should an orthosis position the wrist and/or hand?
What wearing schedule should be adhered to?
Over what duration is orthotic intervention required?

DEVELOPING A GUIDE FOR SERVICE DELIVERY

The Occupational Performance Model (Chapparo & Ranka, 1992, 1996) has been used by occupational therapists as a guide for practice in this area (Ranka, Colyer, Dickson & Chow, 1994). This occurred through action research (Kemmis & McTaggart, 1988) involving the author and occupational therapists working at the Royal Rehabilitation Centre Sydney. Ranka, Colyer, Dickson and Chow (1994) identified that one thematic concern of occupational therapists working in the Moorong Spinal Unit of the Centre revolved around,

Developing a cohesive approach to orthotic intervention which is theoretically sound, reflects occupational therapy practice and the philosophy of the Occupational Therapy Service in the Centre and gives guidance to current and newly employed therapists.

Kemmis and McTaggart (1988, p. 12) note that in action research any action taken is deliberate, controlled and critically informed. Action is a careful and thoughtful variation of practice (Kemmis & McTaggart, 1988, p.11). In this project this involved extensive and ongoing values clarification about orthotic intervention, the impact of spinal cord injury on clients lives and occupational therapy practice in this area as reported in the literature. Philosophical discussions about approaches to intervention and specific case management also occurred throughout the process.

As the project progressed a decision was made to develop a program rationale and prescription manual for orthotic intervention which was congruent with the model of Occupational Performance (Chapparo & Ranka, 1992). It was decided that this would address the thematic concern identified and was consistent with developments taking place in the Occupational Therapy Service of the Centre (Colyer, 1994). Continual reflection on the process and outcomes occurred throughout the project to ensure that decisions made were congruent with the views of the occupational therapists, the philosophy of the spinal unit and the larger Occupational Therapy Service of the Centre.

The outcome was a Policy and Procedure Manual for Upper Limb Orthotic Intervention in Occupational Therapy (Ranka, Colyer, Dickson & Chow, 1994) which contains:

  • statement of beliefs and values
  • theoretical framework
  • program aims
  • specific aims of orthotic intervention for each level of spinal injury
  • assessment strategies
  • orthotic patterns and fabrication guidelines
  • program protocol
  • methods to evaluate program effectiveness.

Readers interested in finding out more about the content of this manual are encouraged to contact the Service or the author directly. The remainder of this paper contains an extension and reconfiguration of aspects of this original work. It includes an example of a ‘beliefs and values’ statement, a theoretical rationale, program aims and an example of how they have been used to guide specific upper limb orthotic prescription in occupational therapy for clients whose hand function has been compromised by spinal cord injury.

OCCUPATIONAL PERFORMANCE: A PROGRAM GUIDE FOR THE PRESCRIPTION OF UPPER LIMB ORTHOTICS.

A statement of beliefs, values and assumptions.

The underlying beliefs, values and assumptions of the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) provide a vehicle for discussing these issues as they relate to the provision of orthotic systems in occupational therapy. The following is an example of a ‘Beliefs, Values and Assumptions’ statement related to clients with spinal cord injury and orthotic intervention in occupational therapy. It is an extension of the original work of Ranka, Colyer, Dickson & Chow (1994).

Occupational therapists believe that clients with a spinal cord injury have a right to equal opportunity in returning to their needed or desired occupational roles within the constraints of their disability and environments. We recognise that paralysis, muscle imbalance, and sensory loss which directly result from spinal cord injury will interfere with a clients ability to perform the activities and tasks required by these roles. Upper limb orthotic intervention is a primary method of intervention used by occupational therapists to prevent problems associated with loss of sensory and motor innervation to the upper limb and to enhance occupational role, routine and task performance.

Occupational therapists view clients as the directors of their care who are capable of making informed choices, and strive to involve them in all aspects of their occupational therapy program. We recognise that spinal cord injury is often accompanied by prolonged periods of emotional distress which can affect both the client and their family’s ability to process and act on information provided. As a result, we understand that neither the client nor their family may be able to make informed choices about suggested interventions until later in the adjustment process. For this reason, we believe it is imperative that orthoses are provided as soon as possible after injury to ensure optimum wrist and hand position for performance of occupational tasks involving gestural communication, manipulating tools, transporting objects and operating environmental and transportation controls until the client and/or their family choose to continue or discontinue their use.

Occupational therapists believe in a minimalist approach to orthotic prescription for the wrist and hand. This involves prescribing an orthosis which accomplishes its aims but is as unobtrusive as possible. We view any equipment provided as an integral part of the client’s personal belongings and will exercise care during fabrication to make all orthoses asaesthetically appealing as possible. We will treat both the client and their equipment with respect.

THEORETICAL FRAMEWORK:

The theoretical foundation supporting upper limb orthotic prescription in occupational therapy is based on the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) (Fig. 1). Occupational performance is the ability to perceive, desire, recall, plan and perform roles, routines, tasks and subtasks for the purposes of self-maintenance, productivity/school, play/leisure and/or rest (Chapparo & Ranka, 1996) (Fig. 1).

appendix_large_large

Figure 1: Occupational Performance Model

Occupational performance results from the interactions occurring within and between the remaining seven constructs of the model, Occupational Performance Roles, Occupational Areas, Components of Occupational Performance, Core Elements, External Environment, Space and Time.

The use of this theoretical framework for upper limb orthotic prescription in occupational therapy ensures that occupational therapists consider more than deformity management and the enhancement of hand function in clients when making a clinical decision to prescribe an orthosis or not. Consideration of each construct in the model contributes to this decision.

Occupational Performance Roles

This interaction of constructs in this Model signify that the domain of concern of occupational therapy is the enhancement of occupational role performance. Occupational Performance Roles involve ‘doing’ the routines, tasks and sub-tasks required by a role, ‘knowing’ how these routines, tasks and sub-tasks are performed, and ‘being’ the type of performer one desires or is capable of. Upper limb orthotics are one technique used to enable people to ‘do’ what they choose to, ‘know’ how they can still perform in a role and ‘be’ in the roles they need or desire. For example, orthotic systems may be used to enable someone with a spinal cord injury to bring a fork to his mouth to eat (‘doing’) or members of a spinal cord injury cooking group may use their orthosis to prepare a meal (‘doing’). Another person with a spinal cord injury may use a tenodesis splint to learn how to transfer wrist extension muscle power into the prehension force required for transporting objects of various sizes and weights (‘knowing’). Alternatively, another person may not use her tenodesis orthosis but knows she can use it for specific tasks if she wants to (‘knowing’). Yet another person who is unable to move his upper limb may benefit from a positional orthosis which prevents deformity thereby allowing him to be a ‘son’ or ‘worker’ whose hand has a desired aesthetic appearance (‘being’).

Occupational Areas: Routines, Tasks & Subtasks:

Using the Occupational Performance Model (Australia), occupational therapists identify the roles a person wishes to return to or will be required to assume, and, then, identify with the client the tasks and routines required by these roles which are posing difficulty. These tasks and routines may include: self-maintenance tasks, productivity or school tasks, leisure or play tasks and rest tasks. Upper limb orthotics are prescribed specifically with these sub-tasks, tasks and routines in mind and orthotic-use training involves using the orthosis to practice methods of performing these tasks.

Components of Occupational Performance:

The routines, tasks and sub-tasks from these occupational areas require various human operations which, in this Model, are classified as biomechanical, sensory-motor, cognitive, intrapersonal and interpersonal. These component operations are a part of every sub-task, task, routine and occupational role. Some of the consequences of a spinal cord injury are reduced strength (biomechanical) and impaired differentiation between painful and non-painful stimuli (sensory-motor) which interfere with use of the limb. This, in turn, may also produce dysfunction in cognitive, intrapersonal and interpersonal operations. Upper limb orthotic systems are usually prescribed to maintain passive range of motion in the wrist and hand (biomechanical component), however, operations in the other component areas (cognitive component, intrapersonal component, interpersonal components) are also considered in order to optimise subtask, task, routine and occupational role performance.

Core Elements:

Underlying all of these Components of Occupational Performance is the body-mind-spirit unit. These ‘Core Elements’ are the human body, the human nervous system, the human mind, the human consciousness of self and the human awareness of the universe (Popper, 1981). They represent the fundamental uniqueness of each individual and experience the direct effects of a spinal cord injury. Upper limb orthotics may be prescribed to address the affect of disease processes, disorders and/or injuries to a client on these core elements as they influence that client’s total occupational performance. For example, a wrist-hand orthosis may be prescribed to promote soft tissue shortening at the metacarpal phalangeal joint into flexion (body). Another orthosis may be prescribed to demonstrate to a client that he is still worthy of care in spite of profound disability (mind, spirit).

External Environment:

As portrayed in the diagram of the Occupational Performance Model (Australia), the external environment has physical, sensory, social and cultural dimensions. The interaction of these aspects create political and economic subdivisions of the environment (Chapparo & Ranka, 1996). The environment constrains performance, can be modified by performance and may be an asset which supports performance. Upper limb orthotics are prescribed with consideration of all aspects of the environment. For example, a hot sensory environment may influence the choice of materials used in fabrication and client acceptance of the orthosis, or an orthosis may enable a client to control the environment more effectively as in managing electric wheelchair controls or operating a computer to access the internet. Political and economic factors may affect the options available.

Time and Space:

The presence of these two constructs in the Model signify that all transactions occurring between the constructs during occupational performance take place in both objective dimensions and personal interpretations of space and time. Occupational therapists consider the timing and duration of upper limb orthotic intervention and the ultimate form a client’s hand will take.

Summary of Implications for Practice:

Principles underlying the Occupational Performance Model (Australia) emphasise that the primary goal of occupational therapy is to enable persons or groups to identify, choose and perform needed or desired occupational roles including routines, activities, tasks and sub-tasks to the satisfaction of one’s self or significant others. Methods employed focus on this primary goal and consist of strategies to modify or compensate for dysfunctional aspects of the internal or external environment. The prescription, fabrication and provision of upper limb orthotic systems is one skill an occupational therapist may use to accomplish this broad aim.

POPULATION:

Ranka & Chapparo (1993) have stated that occupational therapists who use the Occupational Performance Model (Chapparo & Ranka, 1992, 1996) to guide practice address the occupational needs of their clients and that therapy provided which does not address this need, is not occupational therapy. Therefore, the prescription of upper limb orthotic systems will be considered for any client whose hand function has been compromised by spinal cord injury. A decision to prescribe an orthosis will be based on whether or not a client ‘occupational need’ is identified.

PROGRAM AIMS:

The aims of a program provide an indication of the focus of the program and the expected changes in client performance as a result of participation in the program. Consistent with the view described in the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996), the broad aims of upper limb orthotic intervention include:

Occupational Performance Roles:
1. To provide clients with opportunities to achieve optimum occupational role performance; including ‘doing’, ‘knowing’ and ‘being’ dimensions.
Occupational Performance Areas:
2. To enhance a client’s performance of routines, tasks and sub-tasks required by their roles in the areas of self-maintenance, leisure/play, productivity/ school and rest.
Other Dimensions of Occupational Performance:
3. To address obstacles to role, routine, task or sub-task performance which arise from other areas identified in the Model. Aims which address these obstacles include:
Biomechanical Component Aims:
  • Prevent, control or correct deformities of the upper limb
  • Increase controlled reach
  • Improve tenodesis action
  • Increase upper limb strength and endurance
  • Assist postural stability
Sensorymotor Aims:
  • Provide optimum sensory contact between sensate areas of the hand and the environment
  • Protect insensitive areas from injury
  • Increase stability in the wrist & hand
Cognitive Aims:
  • Improve planning and coordinated use of existing musculature
Intrapersonal Aims:
  • Create a hand position which supports a positive self-image
  • Increase confidence in task performance
  • Increase desire to interact with others
Interpersonal Aims:
  • Improve the ability to engage in gestural communication
  • Maintain an appearance which supports interpersonal interaction
Core elements of Body-Mind-Spirit:
  • Support functional tissue changes
  • Protect weakened body structures
  • Prevent, reduce or eliminate oedema in the hand
  • Control spasm
  • Support client beliefs in his/her own self-worth
  • Support client beliefs in being viewed as a valued member of society
Environment:
  • Enhance ability to overcome environmental obstacles
  • Enhance ability to change the environment.
  • Optimise use of environmental assets
Time & Space:
  • Control positional changes over time.

PRESCRIPTION GUIDELINES FOR LEVELS OF SPINAL CORD INJURY:

Guidelines for orthotic prescription which are consistent with the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) were developed by Ranka, Colyer, Dickson and Chow (1994) using orthotic protocols described by Chapparo (1980), Hill and Presperin (1986), Mallick and Meyer (1978) and personal experience. These have been developed further in this paper and are presented to illustrate how the constructs and principles of the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) can be used to develop a specific rationale for orthotic prescription.

At this time, these guidelines are limited to wrist-hand orthoses (WHO), hand orthoses (HO) and thumb orthoses (TO). An expanded version of this paper will include prescription principles for balanced forearm orthoses (BFO’s).

Procedures for client assessment, therapy regimes which incorporate the use of upper limb orthotics into a clients occupational performance and methods to evaluate the effectiveness of the program are also beyond the scope of this paper.

OCCUPATIONAL THERAPY PRESCRIPTION GUIDELINES FOR WRIST-HAND AND HAND ORTHOSES IN CLIENTS WITH SPINAL CORD INJURY

C1-3 Absent arm placement
0 Wrist Musculature
0 Finger or Finger Musculature

OCCUPATIONAL PERFORMANCE RATIONALE:

1. To maintain a hand position which supports ‘knowing’ & ‘being’ aspects of occupational role performance.
2. To enhance participation in routines, tasks and sub-tasks required by client occupational roles.
3. To address other obstacles to occupational performance, including:
Biomechanical
To prevent, control or correct deformities of the upper limb
To assist postural stability
Sensorymotor
To protect insensitive areas of the hand from injury
Intrapersonal
To create a hand position which supports a positive self-image
To increase the desire to interact with others
Interpersonal
To maintain an appearance which supports interpersonal interaction
Core Element
To support functional tissue changes
To control spasm
To prevent, reduce or eliminate oedema in the hand
To support client beliefs in his/her own self-worth
To support client beliefs in being viewed as a valued member of society
Time & Space
To control positional changes over time
DAY POSITIONING:
WHO- Long Opponens Type
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
30� wrist extension
Full thumb CMC abduction
Full thumb MP extension
MP extension stop, if required
NIGHT POSITIONING:
WHO – Resting type
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
30� wrist extension
Full thumb CMC abduction
Full thumb MP extension
Relaxed IP flexion
C4-5 Limited arm placement
0 Wrist Musculature
0 Finger or Thumb Musculature

OCCUPATIONAL PERFORMANCE RATIONALE:

1. To maintain a hand position which supports ‘doing’, ‘knowing’ & ‘being’ aspects of occupational role performance.
2. To enhance performance of routines, tasks and sub-tasks required by client occupational roles.
3. To address other obstacles to occupational performance, including:
Biomechanical
To prevent, control or correct deformities of the upper limb
To assist postural stability
To increase controlled reach
To increase upper limb strength and endurance
To increase stability in the wrist
Sensorymotor
To protect insensitive areas of the hand from injury
Cognitive
To improve planning and coordinated use of existing musculature
Intrapersonal
To create a hand position which supports a positive self-image
To increase confidence in task performance
To increase the desire to interact with others
Interpersonal
To improve the ability to engage in gestural communication
To maintain an appearance which supports interpersonal interaction
Core Element
To support functional tissue changes
To protect weakened body structures
To prevent, reduce or eliminate oedema in the hand
To control spasm
To support client beliefs in his/her own self-worth
To support client beliefs in being viewed as a valued member of society
Environment
To enhance ability to overcome environmental obstacles
To enhance ability to change the environment
Optimise use of environmental assets
Space & Time
To control positional changes over time
DAY POSITIONING:
WHO- Long Opponens Type
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
30� wrist extension
Full thumb CMC abduction
Full thumb MP extension
MP extension stop, if required
NIGHT POSITIONING:
WHO – Resting type
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
30� wrist extension
Full thumb CMC abduction
Full thumb MP extension
Relaxed IP flexion
FUNCTIONAL ORTHOSES:
Consider:
Shoulder-driven, myoelectric or Ratchet styles of orthoses depending on arm placement abilities and occupational need.
C5-6 Limited but functional arm placement
0-3 Wrist Musculature
0 Finger or Thumb Musculature

OCCUPATIONAL PERFORMANCE RATIONALE:

1. To maintain a hand position which supports ‘doing’, ‘knowing’ & ‘being’ aspects of occupational role performance.
2. To enhance performance of routines, tasks and sub-tasks required by client occupational roles.
3. To address other obstacles to occupational performance, including:
Biomechanical
To prevent, control or correct deformities of the upper limb
To assist postural stability
To increase controlled reach
To increase upper limb strength and endurance
To increase stability in the wrist
To improve tenodesis action
Sensorymotor
To protect insensitive areas of the hand from injury
To increase wrist and hand stability
To provide optimum sensory contact between sensate areas of the thumb and the environment
Cognitive
To improve planning and coordinated use of existing musculature
Intrapersonal
To create a hand position which supports a positive self-image
To increase confidence in task performance
To increase the desire to interact with others
Interpersonal
To improve the ability to engage in gestural communication
To maintain an appearance which supports interpersonal interaction
Core Element
To support functional tissue changes
To protect weakened body structures
To prevent, reduce or eliminate oedema in the hand
To control spasm
To support client beliefs in his/her own self-worth
To support client beliefs in being viewed as a valued member of society
Environment
To enhance ability to overcome environmental obstacles
To enhance ability to change the environment
Optimise use of environmental assets
Space & Time
To control positional changes over time
DAY POSITIONING:
WHO- Long Opponens Type
WHO- Long Opponens Type with Wrist Extension Assist
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
30� wrist extension
35� thumb CMC abduction
Full thumb MP extension
MP extension stop, if required
NIGHT POSITIONING:
WHO – Resting type
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
30� wrist extension
Full thumb CMC abduction
Full thumb MP extension
Relaxed IP flexion
FUNCTIONAL ORTHOSES:
Consider:
Tenodesis orthosis with wrist extension assist depending on wrist strength and occupational need
C6 Functional arm placement to face, side and back of neck and partially across midline
3+ to 5 Wrist Extension
0 Wrist Flexion
0 Finger or Thumb Musculature

OCCUPATIONAL PERFORMANCE RATIONALE:

1. To maintain a hand position which supports ‘doing’, ‘knowing’ & ‘being’ aspects of occupational role performance.
2. To enhance performance of routines, tasks and sub-tasks required by client occupational roles.
3. To address other obstacles to occupational performance, including:
Biomechanical
To prevent, control or correct deformities of the upper limb
To increase controlled reach
To increase upper limb strength and endurance
To improve tenodesis action
Sensorymotor
To protect insensitive areas of the hand from injury
Cognitive
To improve planning and coordinated use of existing musculature
Intrapersonal
To create a hand position which supports a positive self-image
To increase confidence in task performance
To increase the desire to interact with others
Interpersonal
To maintain an appearance which supports interpersonal interaction
Core Element
To support functional tissue changes
To control spasm
To support client beliefs in his/her own self-worth
To support client beliefs in being viewed as a valued member of society
Environment
To enhance ability to overcome environmental obstacles
To enhance ability to change the environment
Optimise use of environmental assets
Space & Time
To control positional changes over time
DAY POSITIONING:
HO- Short Opponens Type
Adapted Equipment
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
Full thumb CMC abduction
Full thumb MP extension
MP extension stop, if required
NIGHT POSITIONING:
HO – Short Opponens Type
HO – Resting type
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
Full thumb CMC abduction
Full thumb MP extension
MP extension stop, if required
For Resting Type include:
15� PIP and IP flexion
FUNCTIONAL ORTHOSES:
Consider:
Tenodesis Orthosis, tenodesis orthosis with variable wrist position depending on occupational need
C7 Full arm placement
3+ to 5 Wrist Extension and Flexion
0-3 Extrinsic finger and thumb musculature
0 intrinsic finger thumb musculature

OCCUPATIONAL PERFORMANCE RATIONALE:

1. To maintain a hand position which supports ‘doing’, ‘knowing’ & ‘being’ aspects of occupational role performance.
2. To enhance performance of routines, tasks and sub-tasks required by client occupational roles.
3. To address other obstacles to occupational performance, including:
Biomechanical
To prevent, control or correct deformities of the upper limb
To increase upper limb strength and endurance
Cognitive
To improve planning and coordinated use of existing musculature
Intrapersonal
To create a hand position which supports a positive self-image
To increase confidence in task performance
Interpersonal
To maintain an appearance which supports interpersonal interaction
Core Element
To support functional tissue changes
To control spasm
To support client beliefs in his/her own self-worth
To support client beliefs in being viewed as a valued member of society
Environment
To enhance ability to overcome environmental obstacles
To enhance ability to change the environment
Optimise use of environmental assets
Space & Time
To control positional changes over time
DAY POSITIONING:
HO- Short Opponens Type
Adapted Equipment
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
Full thumb CMC abduction
Full thumb MP extension
MP extension stop, if required
NIGHT POSITIONING:
HO – Short Opponens Type
HO – Resting type
Support proximal & distal transverse arch
Support longitudinal arch
Position in:
Full thumb CMC abduction
Full thumb MP extension
MP extension stop, if required
For Resting Type include:
15� PIP and IP flexion
FUNCTIONAL ORTHOSES:
Consider:
HO – Short Opponens Type
TO – Thumb orthosis
C8-T1 Full arm placement and wrist function isolated finger and thumb weakness

OCCUPATIONAL PERFORMANCE RATIONALE:

1. To maintain a hand position which supports ‘doing’, ‘knowing’ & ‘being’ aspects of occupational role performance.
2. To enhance performance of routines, tasks and sub-tasks required by client occupational roles.
3. To address other obstacles to occupational performance, including:
Biomechanical
To prevent, control or correct deformities of the upper limb
To increase upper limb strength and endurance
Cognitive
To improve planning and coordinated use of existing musculature
Intrapersonal
To create a hand position which supports a positive self-image
To increase confidence in task performance
Interpersonal
To maintain an appearance which supports interpersonal interaction
Core Element
To support functional tissue changes
To control spasm
To support client beliefs in his/her own self-worth
To support client beliefs in being viewed as a valued member of society
Environment
To enhance ability to overcome environmental obstacles
To enhance ability to change the environment
Optimise use of environmental assets
Space & Time
To control positional changes over time
DAY POSITIONING: None except to manage specific problems resulting from weakness, muscle imbalance, spasm, etc.
NIGHT POSITIONING: None, except to manage specific problems resulting from weakness, muscle imbalance, spasm, etc.

SUMMARY:

The Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) has been applied to the development of upper limb orthotic prescription guidelines for occupational therapists working in the area of spinal cord injuries. Using this Model, occupational therapists are directed to consider aspects of human function which go beyond deformity control and hand function when making clinical decisions in this area. Intervention focuses on using upper limb orthotics to address the occupational needs of clients by enhancing their occupational role performance.

Occupational therapists can use the prescription guideline presented here to construct their own program or to design occupation-centred research in this area of practice. For example, Ranka and Chapparo (1993) and Chapparo and Ranka (1996) suggest that the relationship between each construct in the model can be a question for research. The aims of intervention described in this paper reflect a relationships between constructs in the model. When these are posed as research questions, occupational therapists may investigate, for example:

Does specific orthotic intervention have an effect on gestural communication?

Does specific orthotic intervention have an effect on reach patterns required for specific occupational tasks?

Does specific orthotic intervention have an effect on speed and control of prehension patterns during performance of specific occupational tasks?

Does specific orthotic intervention have an effect on client perceptions of self-worth?

Does specific orthotic intervention have an effect on speed and accuracy of handwriting?

Answers to questions such as these will build a body of knowledge on which occupational therapists can make sound clinical decisions in this area of practice.

ACKNOWLEDGMENT:

The Occupational Therapy Service of the Royal Rehabilitation Centre Sydney and Moorong Spinal Unit.

REFERENCES:

Akeson, W.H. Amiel, D., Abel, M.R., Garfin, S.R., & Woo, S. L-Y. (1987). Effects of immobilisation on joints. Clinical Orthopedics and Related Research, 219, 28-37.

Anderson, M. (1965). Functional bracing of the upper extremities. Springfield, IL: Charles C. Thomas

Booth, F.W. (1987). Physiologic and biochemical effects of immobilisation on muscle. Clinical Orthopedics and Related Research, 219, 15-20

Boss, B.J. (1994). The neurophysiological basis of learning: concept formation/abstraction, reasoning and executinve functions — implications for SCI nurses (Part 2). SCI Nursing, 11(Mar), 3-6.

Botte, M.J., Nickel, V.L., & Akeson, W.H. (1988). Spasticity and contracture: Physiologic aspects of formation. Clinical Orthopedics, 8, 7-18.

Brand, P. (1985). Clinical mechanics of the hand. St. Louis: CV Mosby

Chapparo, C. (1980). Upper extremity orthotic systems for patients with quadriplegia. (Slide/sound training package). Chicago: RIC Education and Training Centre.

Chapparo, C., & Ranka, J. (1992). Occupational Performance, Draft Manuscript. (Available from authors, School of Occupational Therapy, The University of Sydney, PO Box 170, Lidcombe, NSW, Australia 2141)

Chapparo, C., & Ranka, J. (1996). Occupational Performance Model (Australia) Draft Manuscript. (Available from authors, School of Occupational Therapy, The University of Sydney, PO Box 170, Lidcombe, NSW, Australia 2141)

DiPasquale-Lehnertz, P. (1994). Orthotic intervention for development of hand function with C-6 quadriplegia. Amercian Journal of Occupational Therapy, 48(2), 138-144.

Guilford, A., & Perry, J. (1975). Orthotic components. In American Academy of Orthopedic Surgeons, Atlas of Orthotics: Biomechanical principles and application (pp. 81-104). St. Louis: CV Mosby

Hill, J. , & Presperin, J. (1986). Deformity control. In J. Hill (Ed.), Spinal cord injury: a guide to functional outcomes in occupational therapy (pp. 49-86). Rockville, MD: Aspen

Knox, C.C., Engel, W.H., & Siebens, A.A. (1971). Results of a survey on the use of a wrist-driven splint for prehension. American Journal of Occupational Therapy, 25, 109-111.

Lee, A.C. (1988). Survey of Rancho flexor hinge splint users. British Journal of Occupational Therapy, 51(6), 197-198.

Lightbody, S. (1994). Dynamic pronation splint in high level spinal cord injury: a case study. Australian Occupational Therapy Journal, 41(2), 83-85.

Lohman, M. (1982). Survey: current orthotic practices in occupational therapy. Orthotics and Prosthetics, 36(2), 42-48.

Mallick, M. (1965). Manual on static hand splinting: new materials and techniques. Pittsburgh, PA: Harmarville Rehabilitation Centre

Mallick, M., & Meyer, C. (1978). Manual on managementof the quadriplegic upper extremity. Pittsburg: Harmarville, Rehabilitation Centre.

Martin, C. (1987). Functional hand orthoses for quadriplegics: Long term use: 1987 American Spinal Injury Association Abstracts Digest, 372.

Newsom, M.J., Keenan, G., Maddry, J., & Aguilar, S. (1969). An occupational therapy training program for the C5-6 quadriplegic. American Journal of Occupational Therapy, 22, 126-129.

Nichols, P.J.R., Peach, S.L, Haworth, R.J., & Ennis, J. (1978). The value of hand splints. Prosthetic Orthotics, 2, 86-94.

Partridge, C. (1994). Spinal cord injuries: aspects of psychological care. British Journal of Nursing, 3(1), 12-15.

Patterson, D.R. (1993). Psychological intervention with spinal cord injured patients: promoting control out of dependence. SCI Psychosocial Process, 6(2), 2-8.

Perry, J. (1975b). Pathomechanics. In American Academy of Orthopedic Surgeons, Atlas of Orthotics: Biomechanical principles and application (pp. 57-64). St. Louis: CV Mosby

Popper, C. (1981). Part 1, In K. Popper, & J. Eccles, The self and its brain: an argument for interactionism (pp. 3-211). Berlin: Springer International

Ranka, J., & Chapparo, C. (1993, September). Occupational performance: A practice model for occupational therapy. Paper presented at the 6th State conference of OT Australia AAOT-NSW, Mudgee, NSW.

Ranka, J., Colyer, S., Dickson, K., & Chow, M. (1994). Orthotic prescription in occupational therapy at Moorong Spinal Unit. (Available from Occupational Therapy Department, Moorong Spinal Unit, Royal Rehabilitation Centre Sydney, Morrison Rd., Ryde, NSW)

Ranka, J., & Zhuo Dahong. (1987). Occupational therapy: a ten-day course for doctors. Course presented at Sun Yat-Sen University of Medical Sciences, Guangzhou, PRC

Sargant, C., & Braun, M.A. (1986). Occupational therapy management of the acute spinal cord-injured patient. American Journal of Occupatiional Therapy, 40, 333-337

Shepherd, C., & Ruzicka, S.H. (1991). Tenodesis brace use by persons with spinal cord injuries. American Journal of Occupational Therapy, 45(1), 81-83.

Sutton, S. (1993). An overview of the management of the C6 quadriplegic patient’s hand: an occupational therapist’s perspective. British Journal of Occupational Therapy, 56(10), 376-380..

Trombley, C. (1989). Orthoses: purposes and types. In C.A. Trombley (Ed.) Occupational therapy for physical dysfunction (pp. 329-355). Baltimore: Williams & Wilkins

Wilson, McKenzie, Barber, & Watson (1974). Spinal cord injury: A treatment guide for occupational therapists (2nd ed.). Thorofare, NJ: Slack, Inc.

Wilson, McKenzie, Barber, & Watson (1984). Spinal cord injury: A treatment guide for occupational therapists (2nd ed.). Thorofare, NJ: Slack, Inc.

Wise, M., Wharton, g., & Robinson, T. (1980). Long term use of functional hand orthoses by quadriplegics. 1980 American Spinal Injury Association Abstracts Digest, 45.

Wynn Parry, C.B., Berkeley, C. (1981). Rehabilitation of the hand (4th ed.). London: Butterworth

Yarkony, G. (1990). A new orthosis for central cord syndrome and brachial plexus injuries. Archives of Physical Medicine & Rehabilitation, 71(12), 1006-1009.

Yarkony, G., Bass, M., Keenan, B., & Meyer, P. (1985). Contractures complicating spinal cord injury: Incidence and comparison between spinal cord centre and general hospital acute care. Paraplegia 23, 265-271.

 

Effect of wrist immobilisation on upper limb occupational performance of elderly males

Winnie Yuen Yee Chan,

Christine Chapparo

WinnieYuen Yee Chan, BAppSc(OT)(Hons) is an occupational therapist workingat the Singapore General Hospital. This paper reports on part of herHonour’s Thesis ‘The effects of wrist immobilisation on upper limbfunction in elderly males’, submitted through the School ofOccupational Therapy, The University of Sydney.

ChristineChapparo,MA,DipOT,OTR,FAOTA, is a senior lecturer in the School ofOccupational Therapy, Faculty of Health Sciences, The University ofSydney.

ABSTRACT

Nine normal male subjects, between 60-79 years old participated in a study designed to determine the effect of wrist immobilisation on upper limb occupational performance. An upper limb measurement system using the Motion Analysis System, ExpertvisionTM was developed and this was used to quantify and describe the three dimensional movement of the subjects during performance on the Jebsen Hand Function test. Comparisons of the time, and range of the upper limb movement between the free and immobilised wrist condition were made. Results revealed statistically significant increases in the time taken and the total degree of shoulder motion used, as well as significant decreases in the total elbow motion during the immobilised condition. Results also showed great variation in the effect of wrist immobilisation on upper limb joints. These reinforce the need for occupational therapists to evaluate the upper limb as an entity and to evaluate each client on an individual basis when immobilising the wrist. The upper limb measurement system in this study provides future direction for research methodology that can analyze the effects of orthotic intervention on everyday occupational performance.

INTRODUCTION

Hand splinting plays an important role in the physical rehabilitation of clients with neurological and orthopaedic disorders. One common splint used by occupational therapists to improve hand function is the static wrist hand orthosis. Research evidence supports the use of static wrist hand orthoses to increase wrist stability and diminish pain (Carlson & Trombly, 1983; Kraft & Detels, l972; Linscheid & Beckenbaugh, l976; Malick, 1988; Millender & Nalebuff, 1973; Stern, 1991). When the wrist is stabilised through application of a wrist hand orthosis and pain is reduced, then the function of the hand is assumed to be improved. However, reservations in using splints are also expressed by some authors, on the basis that external mechanical devices, such as the wrist hand orthosis, may interfere with normal hand and upper limb function (Barr & Swan, 1988; Brand, 1985; Carr & Shepherd, 1987; Charness, 1988; Perry, 1975).

Although physiological responses to joint immobilisation are well documented, adequate information concerning the biomechanical effects of wrist immobilisation on the hand is not available. Little has been done to investigate the effect of wrist immobilisation on hand function and compensatory upper limb movement. If these effects can be better defined and identified, occupational therapists may be in a better position to weight the gain and loss of splinting relative to occupational performance and determine if use is justified on a case to case basis. This will enhance the clinical reasoning process of determining the most appropriate candidates for orthotic application.

It is well recognised that the upper limb works as a mechanical linkage unit and that immobilisation of one part has a potential impact on movement patterns of the entire upper limb. Previous research studying the biomechanical effects of wrist immobilisation has been limited to evaluating the effect on function solely on the basis of time (Carlson and Trombly, 1983; Stern 1991). This research offers little information about the altered prehension patterns caused by orthotic application during occupational performance. In an attempt to demonstrate the link between speed and quality of hand function, an upper extremity measurement system was developed in this study using a motion analysis system (ExpertvisionTM). With this system, the three-dimensional movement of the upper extremity during common daily activities was quantified. This provided more information on the impact of wrist immobilisation on upper limb movement, and gave useful information about the normal variability in the upper limb movement during activities of daily living.

REVIEWOF THE LITERATURE

The upper extremity is divided into five functional units: 1) Shoulder girdle 2) Shoulder joint 3) Elbow 4) Radioulnar joint 5) Wrist and hand (Kreighbaum & Barthels, 1985). These functional units work together to promote efficient upper limb function (Barr & Swan, 1988; Lehmkuhl & Smith, 1983). The wrist, being the most distal joint of the upper limb before the hand, is the final determinant of hand location and gives precision to hand placement. It also allows the hand to assume the optimal position for prehension (Perry, 1978).

Although the wrist joint is an important functional unit of the upper extremity, it is also vulnerable to a wide assortment of injuries and diseases. Static wrist hand orthoses are frequently prescribed to rest and to protect structures of the hand, to prevent deformity or to support a painful joint (Barr & Swan, 1988; Malick, 1976; Rossi, 1988). When the wrist is immobilised, its three major functions are compromised. They include providing stability for hand function, augmenting grip strength, and positioning the fingers (Carlson & Trombly, 1983; Millender, & Nalebuff, 1973; Sarrafian, 1975). Not only is hand function potentially affected, but changed motion above or below the wrist may result.

Two studies compared the time taken to complete the Jebsen hand function test (JHFT) in a free and immobilised hand position (Carlson & Trombly, 1983; Stern, 1991). Both studies revealed that a significantly longer time was required for all the subtests in the immobilised condition than in the free hand condition. Quality and change in upper limb movement, however, was not studied.

Although compensatory upper limb movements during wrist immobilisation have not been specifically measured in reported research studies, they have been described. Millender et al. (1973) evaluated the effect of wrist fusion on hand function in sixty clients. Follow up of the clients described uniform patterns of substitution, which involved the elbow and shoulder.

In Carlson et al.’s (1983) study, subjects reported feeling mild fatigue in their shoulder and upper trunk after upper limb performance in the immobilised wrist condition. This indicated an accommodation of these joints to wrist immobilisation. Stern (1991) noted differences in patterns that were used for grasping a spoon during eating when performance of the free and immobilised state of the wrist was compared. The pattern employed by subjects when the wrists were immobilised emphasised movement of the elbow and shoulder rather than wrist and finger.

The concept of the upper limb functioning as an entity, with each segment interdependent on the another found early support by Linscheid and Beckenbaugh (1976) and later Feldon (1988). Linscheid et al proposed that arthrodesis of the wrist places a greater demand on the other parts of the upper limb for positioning the hand. Similarly, Feldon suggested that upper extremity function is not greatly undermined by wrist immobilisation as long as the rest of the upper limb joints have relatively well preserved function and are able to position the hand in space.

Despite the wide range of literature suggesting the presence of compensatory movement on wrist immobilisation, experimental evidence demonstrating the relationship between wrist immobilisation and compensatory movement has not yet been established. There is support, therefore, for investigation of the changes in active range of motion of upper limb joints during occupational performance while in both free and immobilised conditions.

Recent advances in motion analysis techniques have made possible the measurement of body movement in three dimensions using multiple videography. In 1989, The Motion Analysis Corporation designed the Motion Analysis System, ExpertvisionTM to provide clinicians and researchers with a method to determine quantitative measurements of joint movements in place of subjective estimates. To date, this measurement system has been mostly limited to gait analysis of the lower limb in rehabilitation biomechanics (DeLozier, Alexander, & Narayanaswamy, 1991; Moseley, 1992). This may be due to the fact that analysis of the upper limb involves multiple joints and is considered more complicated and time-consuming than lower limb analysis.

This study was conducted on nine elderly male subjects. In elderly people, there are age related changes in joints, bones and muscles which may have additional implications for the effect of joint immobilisation (Linscheid and Beckenbaugh, 1976). Previous studies conducted by Carlson et al. (1983) and Stern (1991) to investigate the effect of wrist immobilisation on hand function employed a younger population. The results provided little insight as to how 60-79 year-old individuals might react to wrist immobilisation. Given that elderly people make up a large percentage of occupational therapy clients that receive orthotic intervention, it was considered important to study the effects of immobilisation on individuals in this age range.

The purpose of this study was therefore, to:

1.develop an upper limb measurement system to quantify the upper limb movement of elderly males during occupational performance,.

2. to determine the effect of wrist immobilisation on upper limb occupational performance in elderly males.

METHODS

Subjects

9 elderly males, ranging in age from 60-78 years, volunteered for and completed the study. They had no known orthopaedic and neurological problems and were right-hand dominant. All participants were retired.

Instrumentation

a. Jebsen hand function test (JHFT) evaluates unilateral hand function which includes a series of seven subtests representing a wide range of occupational performance tasks involving the upper extremity. They are: 1) copying a 24 letter sentence, 2) turning over cards 3) picking up small common objects 4) simulated eating 5) stacking checkers 6) moving large empty cans;

7) moving weighted cans.

The JHFT was chosen because it was reviewed in the literature as being able to fulfil the validity and reliability requirements of a standardised test (Backman, Mackie & Harris, 1971; Fess, 1986). It also emphasised functional task performance, which supports the occupational performance frame of reference underlying this study.

b. The Motion Analysis ExpertisionTM system is a video and computer based motion tracking and analysis system for examining three dimensional (3-D) motion. There are four principal components in this system (Figure 1):

*a video monitor for checking of camera views

*video cameras to detect position of markers and send video signals to video processor

*a Motion Analysis video processor which automatically converts video images into 2-D marker outline positions

*a host computer with ExpertvisionTM 3-D software to generate kinematic and statistical data describing the behaviour of the markers.

Figure1: Four Components of the Motion Analysis System

For this study, 14 reflective markers were attached to the subject and six video cameras were used to record the images from the markers at 60 frames per second.

The ExpertvisionTM was chosen because it was able to transmit video images directly thereby eliminating multiple human operations that are required in photographic analysis. The use of light weight reflective markers in multiple joint evaluation of the upper limb were chosen because they cause minimal encumbrance to movement. In addition, it was also reported by the manufacturer and VanderLinden, Carlson and Hubbard (1992) that the system used is a reliable and accurate system in providing angle measurements when using the reflective markers.

Procedures

1. Set up of the data collection area

To accurately and reliably measure the 3-D upper limb movement during the JHFT, numerous pilot trials were conducted to finalise the protocol of setting up the data collection area so that optimal marker images were obtained. These involved careful investigation of the effects of varying the (1) camera placement (2) marker positions and (3) marker sizes on the marker images obtained. Six final camera positions were chosen. Five cameras were placed from right to left of the subject’s working space. One camera was mounted overhead. Six cameras were used to ensure that every marker remained in view of at least two cameras at any one instant.

The data collection area was calibrated prior to each subject̓s testing by a 3-D calibration structure with known locations. The relationship between 2-D camera image co-ordinates and the known 3-D object space co-ordinates was determined. The calibration structure was then removed and the subject was videotaped in the same object space without altering the camera configuration.

2. Test administration

Each subject completed the JHFT according to the published protocol as described by Jebsen et al (1969). The following exceptions were adopted: 1) Only the right dominant hand was tested. 2) In Test 2 the subjects were requested to turn the cards in a standardised way suit the purpose of motion analysis in this study. 3. Additional criteria for placement of test items were also included to allow valid comparison of movement between and within subjects

Subjects were asked to perform the test twice, once in the free wrist condition and another in the immobilised condition. To control for the effect of practice, 4 subjects started with the free condition while 5 started with the immobilised condition. Before data collection commenced, subjects were given time to practice each test item in the free wrist condition until the performance time levelled off. No practice trials were done in the immobilised condition.

3. Orthotic application

In the immobilised condition, a wrist hand orthosis that holds the wrist at 20° wrist extension was applied to the subjectÌ“s right wrist.Three sizes: small, medium and large sizes were available and the orthosis of best fit was applied.

4. Timing of performance

A light synchroniser was set up so that a light beam was targeted at one of the cameras (camera two). At the command “go!”, the researcher manually activated the light synchroniser and again at the completion of the tests. The ExpertvisionTM was then used as a timing device by determining the number of frames between the appearance of the two light beams on camera two. The value was divided by 60 to obtain the number of seconds in two decimal places.

5. Motion Analysis: movement pattern

14 markers were placed on the subject̓s right anterior thorax and upper limb. Markers sites were carefully chosen during the pilot phase to minimise errors as a result of skin or soft tissue movement. Sites that resulted in coalescing of markers during test performance were also avoided. The finalised marker sites is shown in Table 1.

During the performance of the JHFT, images of the retroreflective markers were recorded by the Motion analysis system at 60 frames per second. Up to 25 seconds of each subtest were videotaped and video signals were fed directly to the video processor for digitising. At the same time, recordings were also made to provide a means of archiving the data as standard video images.

Digitisation of the image of movement during test performance from each camera was performed on line by the Video Processor (VP320) and stored in memory as pixel positions corresponding to the edge of each marker. The digitised data were then transferred to the SUN/sparc 4-110 Colour Graphics Work station Table1: Marker Sites and stored in files on hard disc.

6. Reliability of Test Administration

Consistency of test administration was achieved by involving the same two testers for all subjects. Testers were trained prior to the data collection to reach 100% agreement on both administration and measurement of performance on the JHFT. Intratester agreement of 98.9% was established prior to the beginning of the study by test-retesting of the videotaped performance of five subjects in the pilot trials.

7. Data reduction

To obtain the movement path of each marker, tracking was performed by the computer and was monitored closely by the researchers to minimise digitisation errors. On completion, marker paths were visually inspected and manually edited to free data from contamination by undetected digitisation errors. Problems such as gaps in marker paths were resolved by extrapolation between known locations preceding and following the gap. Data were then smoothed using the two-pass fourth-order Butterworth filter at the frequency of 10 hertz.

Two sets of data were developed from the total data pool.
1) time taken to perform the subtests and
2) proximal joint motion used to complete the subtests.

The motion data was in turn divided into five subsets:
a. trunk rotation, b. trunk side flexion, c. shoulder, d. elbow and e. wrist.

In this study, one data record was equated with the pair of scores (free and immobilised) of one subject for each data set and each subtest. Thus, one subject generated 42 records (6 data set x 7 subtest), yielding a total of 378 records for 9 subjects. Each record was examined for unacceptable quality.

DATAANALYSIS

Means and standard deviations were calculated for all data sets using the SPSS-x packages (SPSSxTM, 1986). One tailed t-test for paired samples was used to determine if there were statistically significant differences in the means of time in the free and immobilised condition. Directional, one tailed t-test was used as prior research studies indicated that the immobilised wrist would take a longer time to complete the tests than that of the free condition (Stern, 1991; Carlson, et al., 1983).

Two analyses were perform using the motion data sets: first, the total degrees of motion for the trunk were computed for each subtest and then comparisons were made between the two conditions. Similar analysis was completed for the shoulder and elbow. The purpose of this analysis was to determine the general trend of the compensatory pattern of the trunk, shoulder and elbow when the wrist was immobilised. Second, the degrees of motion in the proximal parts of the upper limb was also examined individually across each subtest. The purpose of this analysis was to determine whether upper limb performance was more affected by wrist immobilisation in some tasks than others.

Non-parametric Wilcoxon test for related means was used for the motion scores. The non-parametric test was chosen over two-tailed t-test because it does not assume normality of data and is applicable to the small sample size in this study.

RESULTS

Time

Means and standard deviation scores for time of performance in each subtest are included in Table 2. Subjects took a longer time to complete all the subtests in the immobilised condition than in the free condition Setting the significance level at 0.05, a significant increase in time was found for all subtests except test six (Table 2).

Mean time taken to complete the subtests in the free condition appeared to be slower than the normative value for males in similar age groups of past studies (Hackel, et al., 1992; Jebsen, et al., 1969). Criteria of performance in this study was slightly modified to suit the motion analysis purpose. For instance, instead of holding on to the pen in test one before timing begins, as stated in the original Jebsen protocol, subjects were asked to pick up the pen themselves. Likewise, the subjects were asked to pick up the spoon in test four. In test two, subjects were also requested to turn the index card in a standardised way. These modifications could have contributed to the differences in the results between this study and others reported in the literature.

Movementpattern: Total degrees of motion (All tests)

Means and standard deviations of the total degrees of motion of the upper limb joints in the entire JHFT were computed and included in Table 3. Both rotation and side flexion of the trunk, as well as the shoulder showed an increase in the mean degrees of motion in the immobilised condition. The elbow was the only joint that had a reduction in mean score when the wrist was immobilised. Non-parametric Wilcoxon test revealed that only the shoulder and elbow showed significant differences in the overall degree of motion (p<0.05, df=8). The shoulder showed a significant increase and the elbow a significant reduction in motion. This indicates that the shoulder moved significantly more and the elbow significantly less when the wrist was immobilised.

Movementpattern: Degrees of motion (Across each test)

When the two conditions were compared across each subtest performance, it is seen that all tests except Test 1.(writing) and Test 3. (picking up small objects) followed the general trend of the previous analysis: ie increased motion at the trunk and shoulder, with restriction in the elbow (Table 4).

Writing was the only test that showed a reverse pattern where rotation of the trunk and shoulder movement was reduced and elbow motion increased. Test three: picking up small objects, on the other hand, showed an increase in motion for all joints including that of the elbow. In spite of the significant differences of the total degrees of motion in the shoulder and elbow found in the previous analysis, only four out of twenty eight subtests revealed significant differences at the 0.05 level when analysed statistically across each subtest. (Table 5)

Wilcoxon paired tests revealed that side flexion of trunk in placing light cans, shoulder in stacking checkers, elbow in turning over cards and simulated eating showed significant differences in the degree of motion when compared between the two conditions. Of these, the trunk and shoulder showed significant increases in movement while elbow showed significant reduction of motion.

DISCUSSION

Time

When the wrist was immobilised, there were significant increases in performance time for all subtests except test 6: placing light cans. Since the Jebsen hand function test is a simulation of common occupational performance tasks, it may be inferred that when the wrist is immobilised, an elderly person is likely to take a significantly longer time to perform everyday tasks.

When the time scores in this present investigation were compared with past studies, both similar and distinct findings were noted. The overall significant increase in time in the immobilised condition agreed with the findings of past investigations by Carlson et al. (1983) and Stern (1991). Both studies had been conducted on a younger population. It therefore appears that wrist immobilisation significantly increases the time taken for performance, regardless of one’s age group. Nevertheless, though the immobilised condition resulted in statistically significant increases in time, the difference amounted to less than two seconds for any activity for both Carlson et al. (1983) and Stern (1991) (mean differences were 0.85 and 0.45 seconds respectively). The differences in time for the elderly males in this study are comparatively higher, with the highest difference to be 3.39 seconds (mean difference was 1.60 seconds). This higher mean difference could imply that wrist immobilisation may have a greater impact on the elderly population, especially if they are also limited by other conditions such as poor endurance or general weakness in the body. When therapists apply splints to elderly clients, they perhaps should allow for a longer time for performance of occupational tasks.

Although most activities appear to require a significantly longer time to complete in the immobilised condition, Stern (1991) noted no significant increase in the time for tests that only required gross grasp and release (test six and seven). In this study, only test six: picking up light cans showed no significant increase. In the light of the results in this study, it may be proposed that in the elderly, the time to perform light-weighted activity involving gross grasp and release is not significantly increased by wrist immobilisation but resistive activity of the same nature does.

Compensatorymovement

While both past studies by Carlson (1983) and Stern (1991) and this study revealed significant differences in performance time on the JHFT between the two conditions, this study went beyond looking at the speed and investigated the altered upper limb movement patterns using the 3D upper limb measurement system. Visual inspection of the mean motion scores in the various parts of the upper limb indicated that subjects tend to increase trunk and shoulder motion when the wrist was immobilised. Elbow movement, on the other hand appeared to decrease during wrist immobilisation.

The increases in trunk and shoulder motion supported the proposition of past studies that wrist immobilisation results in accommodation of the above joints (Barr & Swan, 1988; Carlson, et al., 1983; Linscheid, et al., 1976; Perry, 1978). Specifically, it was found from this study that compensatory movement in the trunk was made predominately in the form of increased trunk rotation rather than side flexion (mean increase of 3.07 vs 0.92 in trunk flexion). This may be due to the fact that the average range of motion in the thoracic spine of an individual is greater for rotation than side flexion (Magee, 1987). Those tasks that required the subjects to cross the midline showed the greatest difference in trunk rotation when the wrist was immobilised (eg. Test 2: turning over cards and test 6 and 7: lifting light and heavy cans)

While trunk rotation and shoulder movement increased for most subtests in the immobilised condition, the elbow showed a distinct pattern of compensation: reduction of motion in most of the subtests. Stern (1991) suggested that movement of the elbow and shoulder becomes more important when the wrist is immobilised. Millender et al. (1973) and Linscheid et al. (1976) also proposed that immobilisation of the wrist places greater demands on other parts of the upper limb, especially the shoulder and the elbow, in positioning the hand. Although most authors have cited the elbow as one of the sources of compensatory joint motion during wrist immobilisation, the general assumption was that joint movement increases rather than decreases. The reduction of elbow motion as a compensation, which was found in this study is unexpected. It appears that immobilisation of the wrist somehow also restricted the elbow, possibly due to their proximity. It is possible that when the wrist is immobilised, the elbow and wrist move as a functional unit, resulting in a reduction of elbow motion. Further research is required to investigate this proposition.

It is interesting to note that while the differences in the total amount of motion in the shoulder and elbow were statistically significant when compared collectively for all the tests, analysis across each subtest showed that the majority of them do not differ significantly. With the significant level set at 0.05, only one out of seven tests (test five: stacking checkers) showed a significant increase in shoulder movement. In the elbow, two out of seven tests showed significant reduction in motion when the wrist was immobilised. It is possible that the significance in the first analysis was solely due to the few tests that were found to be statistically significant in the second analysis. However, it was the researchers’ opinion that the statistical analysis alone does not give the full picture of the effect of wrist immobilisation on the proximal joints of the upper limb. Some trends that appear to exist among the subjects are either not revealed at all by the statistical analysis or found to be statistically insignificant.

The lack of significance in the results may be attributed to various factors. First, great variability appears to exist among the subjects, both in the joint, the range and the mechanisms of compensation. Some subjects may compensate predominantly in a single joint while others may adapt in a global way. Not only do the site and mechanism of compensation vary between subjects, they also appear to vary according to the nature of the tasks attempted. Polgar and Thomas (1991) listed high variability of data as one of the reasons why researchers may obtain a null result. Trends that are subtle may be another reason. In such cases, a larger sample than that used in this study may be necessary to detect these subtle trends.

One of the most striking results of the study was the great variation in the effect of wrist immobilisation on the compensatory patterns of the upper limb joints. To further explore the variability of the upper limb movement patterns, a qualitative research method was used in addition to those described above because a) there is little information on the nature of movement pattern in the upper limb during activities of daily living and during wrist immobilisation; b) it would allow the generation of hypotheses so that future studies may be conducted. Specifically, content analysis in the form of visual inspection of the data for common themes and characteristics were performed. From there, three main patterns were noted and a further exploratory investigation was done in the form of a case study from each of the three pattern groups. These findings are reported elswhere (Chan & Chapparo, 1997).

Clinicalimplication

The results of this study remind therapists to be aware of the increased time factor when working with clients experiencing acute loss of wrist motion. It is important that not only the therapists but also the clients, are aware of this time increase. In this way, clients will not have unrealistic expectations of orthotic intervention that immobilises the wrist, which may reduce their acceptance of the orthosis and thus compliance to treatment.

The link between three constructs studied in this research: time, biomechanical component ability and occupational task performance is congruent with the same hypothetical relationships outlined in the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996). One assertion in the model is that occupational tasks are to a certain extent dependent on efficient biomechanical function. Where biomechanical function is compromised, it is possible that performance of occupational tasks, also will be compromised. In this study, that relationship is demonstrated. Where biomechanical efficiency of the wrist is compromised by immobilisation, so too, is efficient performance of some occupational tasks. Similarly, time is viewed as an important construct in occupational performance. The relationship between timing of movement and timing of occupational tasks has also been illustrated in the results of this study.

It can be suggested from this study that the shoulder appears to be the major compensatory joint during wrist immobilisation by increasing motion for most activities. By increasing the strength or range of motion at the shoulder, it may potentially contribute to the adaptations of loss of wrist motion. However, further research needs to be carried out to investigate whether this trend is consistent over time and if it is beneficial to the outcome of splinting and wrist fusion. Similar suggestions may be made for the trunk as it also showed relatively consistent increases in motion in the immobilised condition.

The results of this study illustrate the interdependence of upper limb joints. When the wrist is immobilised, the rest of the upper limb also appeared to be affected. When therapists immobilise a client’s wrist, attention must be paid to the other upper limb joints too.

The upper limb measurement system developed from this study could be used for a wide range of purposes and may have broader applications for studying other aspects of occupational performance. First, basic kinematic studies on the movement of the upper limb during a wider range of occupations will increase the knowledge and understanding of normal upper limb movement. This may include resistive activities and activities not limited to the tabletop. Developmental research may also be conducted to investigate how hand and upper limb function change over time.

Second, the system may be used in clinical research to investigate the differences between normal and “abnormal” upper limb movement. For instance, cerebral vascular accident is one of the most prevalent diseases that strikes the adult population in the present society. Many clients do not fully recover upper limb and hand function (Pedretti, 1990). Research is needed to compare the three-dimensional kinematics of the upper limb in these client groups with normal subjects to identify those dysfunctional components. Similarly, this system may be used to increase understanding about other diseases and conditions that affect the performance of the upper limb.

Third, further research investigating the effects of other orthotic systems on upper limb function may be conducted. This may include other orthoses systems besides wrist hand orthoses This knowledge will assist therapists and orthotists in their understanding and prescription of orthotic intervention.

LIMITATIONSAND RECOMMENDATIONS FOR FUTURE STUDIES

This study was limited to researching the effect of wrist immobilisation on the proximal joints of the upper limb. It is suggested that further analysis be performed on the data to include the movement patterns in the distal joints of the hand. This will give a fuller and more detailed picture of the effect of wrist immobilisation on the upper limb.

Only the absolute degree of motion occurring at the proximal joints of the upper limb was monitored (e.g. wrist extension/flexion, ulna/radial deviation are quantified as an absolute value). The aim of the study was to determine in a general sense if there is a difference in the proximal three-dimensional upper limb movement between the free and immobilised condition, and the relative angles of the upper limb segments were not studied. More indepth analysis of the data may allow the functional range of motion occurring at the upper limb joints during activities of daily living to be quantified.

The wrist hand orthoses applied to the subjects were not custom fit. This may have reduced the ability of the orthosis to fully immobilise the wrist. To address this problem, careful balance was struck by tightly strapping the orthosis to minimise wrist motion without inflicting pain or discomfort to the subjects. Future studies may want to explore the use of other orthotic devices that can fully immobilised the wrist, such as casting, or the gauntlet system

Due to time and resource constraints, the sample has been restricted to nine subjects. By establishing conservative significance levels for statistical test (0.05 or less) and controlling extraneous variables, unfounded generalisations to the larger population is controlled. The results however, do highlight the variability of upper limb movement and its compensatory patterns. Further research in this area is definitely warranted using larger samples to substantiate the findings. Alternatively, multiple replication of research carried out on small sample sizes may also further the investigations in this area.

Finally, in any kinematic study utilising motion analysis systems and skin markers, there are errors in the data that have to be taken into account. These include inaccuracy in calibrating the ExpertvisionTM system, marker obstructions, skin movements and idealisation error. Although all efforts were taken by the researcher to reduce these errors, future replication studies could serve to validate the accuracy of the data obtained using this measurement system.

CONCLUSION

Based on the results of the study, wrist immobilisation appears to affect both the timing and range of motion of the upper limb in elderly males during performance of the Jebsen Hand Function Test. The differences in time for the elderly sample were comparatively higher than past studies on younger populations, suggesting wrist immobilisation may affect elderly to a greater extent. In general, there were compensatory increases of motion at the shoulder and decreases motion at the elbow during wrist immobilisation. The study also validated the use of the upper limb measurement system that was developed in this study using the ExpertvisionTM. It has the ability to diffferentiate between the movement patterns of the upper limb during free and immobilised wrist condition and could have numerous applications in future occupational therapy research on the performance of upper limb occupations.

ACKNOWLEDGEMENTS

The authors acknowledge the contributions made by the nine voluntary participants; Richard Smith and the Biomechanics Department of The Faculty of Health Sciences; to John Balla, for his statistical advice and to the School of Occupational Therapy, The University of Sydney, for partially funding the resources required for completing the study.

REFERENCES

Backman, C., Mackie, H., & Harris, J. (1991) Arthritis hand function test: Development of a standardized assessment tool. TheOccupational Therapy Journal of Research. 11(4), 246-255 Barr, N.R., & Swan, D. (1988)The hand: Principles and techniques of splintmaking. (2nd. Ed.). Sydney: Butterworths

Brand, P.W., (1985) External stress: Forces that affect joint action. In P.W. Brand (Ed.). Clinical mechanics of the hand. (pp.105-112). St. Louis: C.V. Mosby Co. Carlson, J.D., & Trombly, C.A. (1983) The effect of wrist immobilization on performance of the Jebsen Hand Function Test. American Journalof Occupational Therapy, 37(3), 167-175

Carr, J. & Shepherd, R. (1987) Upper limb function. In Carr, J. & Shepherd, R. A motor relearning programme for stroke. (2nd Ed.). (pp.43-72). Rockville: Aspen Systems Chan, W., & Chapparo, C. (1997). The effects of wrist

immobilisationon upper limb function in elderly males. OT Australia, AAOT. The 19th Federal Conference. Perth, April.

Chapparo, J. & Ranka, J. (1996) The occupational performance

model(Australia). Draft manuscript. (Available from The School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney. Lidcombe. 2141. NSW) May.

Charness, A.C., (1988) Stroke head injury: A guide to functional outcomes inphysiotherapy management. MD: Aspen Publishers Inc.

DeLozier, G.S., Alexander, I.J., & Narayanaswamy, R. (1991) A method for measurement of integrated foot kinematics. Proceedings of theInternational Symposium on #-Dimensional analysis of human movement.Montreal: Canada, 79-82.

Feldon, P. (1988) Wrist fusions: Intercarpal and radiocarpal. In

D.M. Licktman (eds.). The wrist and its disorders (pp. 446-463) Philadelphia: W.B.Saunders

Fess, E.E. (1986) The need for reliability and validity in hand

assessment instruments. The Journal fo Hand Surgery, 11A(5), 621-623

Gant, R. (1993) The accuracy and reliability of a method

measuringthe three-dimensional kinematics of the foot during the stance phaseof walking, and its application to patients with osteoarthritis ofthe knee. Unpublished Masters Thesis. (Available from The Faculty of Health Sciences, The University of Sydney, Lidcombe, NSW 2141)

Hackel, M.E., Wolfe, G.A., Bang, M.S., & Canfield, J.S. (1992)

Changes in hand function in the aging adult as determined by the Jebsen Hand Function Test. Physical Therapy, 72(5), 373-373

Jebsen, R.H., Taylor, N., Trieschmann, R.B., Trotter, M.J., &

Howard, L.A. (1969) An objective and standardized test of hand function. Archives of Physical Medicine and Rehabilitation, 50(6), 311-319

Kraft, G.H., & Detels, P.E., (1972) Position of function of the wrist. Archives of Physical Medicine and Rehabilitation, 53, 272-275

Kreighbaum, E., & Barthels, K.M. (1985) Biomechanics: A

qualitativeapproach for studying human movement. (2nd Ed.). Minneapolis: Burgess Publishing Co.

Lehmkuhl, L.D., & Smith, L.K. (1983) Brunnstrom’s clinical

kinesiology.(4th ed.). Philadelphia: F.A. Davis Co.

Linscheid, R.L. & Beckenbaugh, R.D. (1976) Total arthroplasty of the wrist to relieve pain and increase motion. Geriatrics, 4. 48-52

Magee, D.J. (1987) Thoracic (dorsal) spine. In D.J. Magee:

Orthopedicphysical assessment. (pp. 142-169). Philadelphia: W.B.Saunders

Malick, M.H. (1988) Upper extremity orthotics. In H.L. Hopkins & H.D. Smith (Eds.). Willard & Spackman’s occupational therapy. (7th Ed.). (pp. 308-316). Philadelphia: J.B. Lippincott Co.

Millender, L.H. & Nalbuff, E.A. (1973) Arthorodesis of the

rheumatoid wrist. Journal of Bone and Joint Surgery, 55A, 1026-1034

Motion Analysis Expertvision System TM (1989) Motionalanalysis corporation. 3650 North Laughlin Rd., Santa Rosa. California. USA.

Moseley, L (1992) Three dimensional kinematics of the rear foot during thestance phase of walking at three dirfferent velocities. Unpublished Honours Thesis. (Available from The Faculty of Health Sciences, The University of Sydney, Lidcombe, NSW.)

Perry, J. (1975) Pathomechanics. In American Academiy of

Orthopedic Surgeons, Atlas of orthotics: Biomechanical principles andapplication (pp. 57-64). St. Louis: C.V. Mosby.

Perry, J. (1978) Normal upper extremity kinesiology. Physical

Therapy,58,(3), 265-278

Polgar, S., & Thomas, S.A. (1991) Introduction to research in thehealth sciences. (2nd Ed.). Melbourne: Churchill Livingstone

Rossi, J. (1988) Concepts and current trends in hand splinting.

OccupationalTherapy in Health Care. 4(3/4), 53-67

Sarrafian, S.K. (1975) Functional anatomy of the upper limb. In American Academy of Orthopedic Surgeons. Atlas of orthotics: Biomechanicalprinciples and application (pp. 33-56) St. Louis: C.V> Mosby Co.

Stern, E.B. (1991) Wrist extensor orthosis: Dexterity and grop

strength across four styles. American Journal of Occupational Therapy,45,(1), 42-49

VanderLinden, D.W., Carlson, S.J., & Hubbard, R. (1992)

Reproducibility and accuracy of angle measurement obtained under static conditions with the Motion Anlysis System.Physical Therapy, 72, 300-305

Marker Number Site
1 2 cm below clavicle at left mid clavicular line.
2 Perpendicular intersection of 1 and 3, approximately at sternal angle.
3 Body of sternum
4 15 centimetres above Marker 6, along lateral border of arm.
5 10 cm above Marker 6, along medial border of the arm.
6 Lateral epicondyle of elbow.
7 Styloid process of radius.
8 Head of ulna.
9 MCP joint of thumb.
10 IP joint of thumb.
11 MCP joint of index finger.
12 PIP joint index finger.
13 DIP joint of index finger.
14 MCP joint of little finger.

Table2: Descriptive and statistical data: performance time (in seconds)during JHFT in free (F) and immobilised (I) conditions

&nbsp; Mean S.D. Mean of difference (F-I) S.D. One tailed t-value

(df= 8)

Test 1: writing F:

I:

16.00

17.95

2.56

3.20

-1.95 1.93 -6.06 **
Test 2: turning over cards F:

I:

8.51

10.52

2.52

2.61

-2.62 3.77 -4.18 *
Test 3: picking up small objects F:

I:

6.79

7.50

0.92

1.10

-0.62 0.83 -4.34 *
Test 4: simulated feedingF:

I:

9.52

12.91

1.24

2.61

-.3.39 2.71 -7.52 *
Test 5: stacking checkersF:

I:

5.82

6.71

1.05

1.42

-0.89 1.00 -5.32 *
Test 6: picking up light cansF:

I:

5.54

6.06

0.73

0.78

-0.51 0.84 -3.64
Test 7: picking up heavy cans F:

I:

7.34

8.55

1.05

1.40

-1.21 0.72 -10.08 ***

* Significant at 0.05 level

** Significant at 0.01 level

*** Significant at 0.001 level

Table3: Mean of total degree of motion of each component (in degrees) +standard deviation for Test 1-7 in free (F) and immobilised (I)conditions

&nbsp; Mean Standard

deviation

z-value 2-tailed p value (df=8)
Rotation of trunk F:87.48

I: 107.18

19.89

27.14

-1.68 0.09
Side flexion of trunk F:78.99

I: 83.44

25.18

33.50

-0.70 0.48
Shoulder F:76.63

I:83.79

14.11

15.94

-2.03 0.04*
Elbow F:133.74

I: 114.97

13.63

4.66

-2.37 0.02*

* Significant at 0.05 level

Table4: Mean of degree of motion (in degrees) + standard deviationin the free (F) and immobilised (I) condition

&nbsp; Components of the upper limb
Test no. Rotation of trunk Side flexion of trunk Shoulder Elbow
1: writing F:

I:

12.80+2.99

12.65+4.65

9.15+4.32

10.08+4.74

7.19+3.99

6.74+3.17

6.35+2.59

6.74+1.74

2: turning over cards F:

I:

14.95+3.97

21.75+10.63

26.54+11.57

27.18+12.42

12.97+2.60

15.20+3.74

18.55+7.31

12.84+4.45

3: picking up small objects F:

I:

10.28+2.51

12.54+4.70

8.55+4.75

8.77+3.53

10.27+2.48

12.36+2.89

10.25+3.60

11.50+4.32

4: simulated feedingF:

I:

12.37+3 52

15.24+5.68

9.39+3.61

10.53+3.58

9.48+3.69

13.29+7.73

43.96+9.11

37.69+10.19

5: stacking checkersF:

I:

14.74+3.89

15.99+7.23

7.61+2.24

9.30+6.84

14.82+3.35

18.22+3.48

14.39+2.99

12.80+1.66

6: picking up light cans F:

I:

15.78+5.20

20.29+5.84

11.27+4.59

13.62+4.98

8.77+2.46

9.61+2.05

20.51+4.01

20.46+3.70

7: picking up heavy cans F:

I:

18.18+7.91

22.17+5.50

13.25+4.99

13.22+4.83

9.79+1.88

9.29+1.18

18.89+4.84

18.73+3.56

Table5 : Mean of free minus immobilised degree of motion in trunk rotationand side flexion, standard deviation, z-value and 2-tailed p-value

Test no. Mean+ Standard deviation z value 2-tailed

p-value

1. Writing Rotation: 0.14 + 4.58

Sideflex: – 0.93 + 6.15

Shoulder: 0.45 + 2.16

Elbow: -0.39 + 2.47

-0.30

-0.41

-0.77

-0.30

0.76

0.68

0.44

0.77

2. Turning over index cards Rotation: -6.80 + 11.15

Sideflex: -0.64 + 8.84

Shoulder: -2.15 + 30-.84

Elbow: 5.48 + 6.13

-1.40

-0.14

-1.82

-2.37

0.16

0.89

0.18

0.02

3. Picking up small objects Rotation: -2.27 + 5.95

Sideflex: -0.21 + 4.82

Shoulder: -2.09 + 2.54

Elbow: -1.25 + 2.49

-0.65

-0.06

-1.82

-0.98

0.51

0.95

0.07

0.33

4. Simulated feeding Rotation: -2.87 + 6.58

Sideflex: -1.14 + 4.51

Shoulder: -3.81 + 6.80

Elbow: 6.27 + 6.18

-1.24

-1.01

-1.40

-2.10

0.21

0.31

0.16

0.04 *

5. Stacking checkers Rotation: -1.25 + 9.71

Sideflex: -1.69 + 6.93

Shoulder: -3.40 + 2.82

Elbow: 1.59 + 2.83

-0.18

-0.06

-2.55

-1.60

0.86

0.95

0.02 *

0.11

6. Placing light cans Rotation: -4.51 + 6.96

Sideflex: -2.35 + 2.82

Shoulder: -0.82 + 2.72

Elbow: 0.05 + 3.92

-1.71

-2.07

-1.24

-1.18

0.09

0.04 *

0.21

0.86

7. Placing heavy cans Rotation: -3.98 + 7.23

Sideflex: 0.53 + 4.46

Shoulder: 0.49 + 2.13

Elbow: 0.16 + 3.98

-1.60

-0.30

-0.89

-0.41

0.11

0.77

0.37

0.68

Significant at 0.05 level

Wrist casting to improve control of the wrist and hand during the performance of occupational tasks

Kirsty Stewart, Christine Chapparo

This paper is derived from a presentation at the OT Australia AAOT-NSW, 6th State Conference, Mudgee, NSW, (1993, October)

KirstyStewart, MAppSc(OT), is a lecturer in the School of OccupationalTherapy, The University of Sydney, NSW.

ChristineChapparo, MA,DipOT,OTR,FAOTA, is a senior lecturer in the School of Occupational Therapy, The University of Sydney.

INTRODUCTION

Combinations of spasticity, dyskinesis and reduced isolated control are found in almost every child with cerebral palsy. This abnormal tone and movement can seriously interfere with upper limb motor performance in young children. The resulting malalignment of joints and abnormal pattern of muscle action affect the quality of fine motor control required for prehension and bilateral use. This in turn reduces the repertoire of reach, grasp and release patterns available to the child for everyday occupational performance tasks.

Occupational therapists who provide direct service to young children with cerebral palsy seek to improve the quality of upper limb movements during the performance of occupational tasks. As an adjunct to play and work related modes of intervention, therapists often apply various upper limb orthotic systems to encourage the carryover of gains made in therapy.

Controversy has existed for many years over the use of casting as an orthotic system to manage young children with cerebral palsy. Therapy literature reveals little support for upper limb casting, reflecting instead, occupational therapists preference for the use of thermoplastic orthoses. Few articles exist to support the clinical impression that casting of the wrist improves active wrist and hand control in children who demonstrate active and functional motion.

The purpose of this paper is to present case studies that illustrate the results of a serial inhibitory casting program for two preschool children with cerebral palsy.

LITERATURE

Serial inhibitory casting, when used as a treatment approach for people with cerebral palsy, has two main aims. One aim is that of reducing and preventing contractures for positional or health reasons and the other is to improve active upper limb occupational performance. Casts may also be applied as a pre-surgical trial ( Tonkin, 1995) or to increase the use of the affected upper limb by casting the unimpaired arm (Yasukawa, 1990).

Inhibitory casting to reduce contractures caused by abnormal tone is no longer a novel treatment and occupational and physiotherapists frequently apply casts to the upper and lower limbs for this reason (Barnard, Dill, Eldredge, Held, Judd & Nalette, 1984; Booth, Doyle & Montgomery, 1983; Cherry & Weigand, 1981; Cruickshank & O̓Neill, 1990; Hill, 1994; King, 1982; Kitson, 1991; Smith & Harris, 1985; Steer, 1989; Tona & Schneck, 1993). However, the use of serial inhibitory casting to improve active wrist and hand control in children who demonstrate active and functional movement is not as well supported in the literature (Chapparo & Stewart, 1993).

A study by Yasukawa (1990) found that ‘the use of inhibitory upper extremity casting can enhance function and improve arm-hand position” in a child with hemiplegic cerebral palsy. Law et.al. (1991) also found that serial casting, in combination with intensive therapy, improved hand function in children with cerebral

palsy. At the Spastic Centre of NSW, occupational therapists have also found that serial inhibitory casting is most effective in improving upper limb function in children with cerebral palsy (Chapparo, 1992).

RATIONALEFOR CASTING

Disturbances of active wrist and hand function in children with cerebral palsy occur as a result of four primary problems:

1.Muscle spasticity commonly pulls the upper limb into a posture of flexion. the muscular tension produced by the spasticity increases when the muscle groups are stretched during the performance of occupational tasks.

2. Abnormal synchronous activity or cocontraction occurs between specific muscle groups during rest or when the muscles are acting as antagonists. A typical finding is the persistent activity of the flexor muscles of the wrist, particularly flexor carpi ulnaris when finger and wrist extension is attempted.

3. Hyperactivity of the stretch reflex mechanism is produced byfailure of the normal muscle lengthening reaction to elongation by sudden stretching. This causes a stereotypic flexion patterning of the wrist during hand function.

4. To a lesser extent in children with active wrist motion, myostaticcontracture occur.

We have found that wrist casting is effective in altering this pattern of dysfunction within a short space of time. It has many advantages over more traditional orthotic devices. Yasukawa (1990 & 1992) outlined four main advantages of the use of serial inhibitive casting to improve function in the upper limb. The first is that joint stability can be improved, encouraging the client to use the affected arm during bilateral activities. Second, casting anatomically aligns the limb and thus may strengthen opposing muscle groups. Third, improvements in the overall balance of the flexor and extensor muscles may occur due to the additional proprioceptive input from the cast and fourth, the impaired upper limb may be trained to function more efficiently. Other benefits of casting include: the maintenance of a prolonged, gentle stretch to spastic or contracted muscles; 24 hour a day biomechanical intervention; the gradual increase in range of movement from the serial application of casts; and circumferential pressure and the warmth of the casted limb.

As with any intervention, the effectiveness of a casting program is based initially on the appropriate choice of child for casting. The majority of casting literature outlines the various criteria the researchers used in the selection of candidates for their casting programmes. Copley, Watson-Will and Dent (1996) presented indications and contraindication for casting selection based on the current literature by Booth, Doyle & Montgomery (1983); Cusick & Sussman, (1982) & Steer (1989). The indications for casting included: the existence of soft tissue contractures; limitations in active range of motion; difficulty in orthotic application for tone reduction and difficulty in achieving or maintaining weight bearing positions for tone reduction. The contraindications outlined included: the presence of rigid tone in the upper limb; the presence of fluctuating tone; medical instability; joint calcification and existing skin

conditions.

Candidates for casting can be classified according to a number of criteria. Chapparo and Ranka (1994) developed one classification system that grouped clients into two categories, Type 1 and Type 11 and the goals of the casting programs can be related directly to these groupings (See Table 1).

The type 1 casting candidates are generally the clients presenting with little or no active movement in the upper limb, poor or absent sensation and they tend to be fully dependent in activities of daily living. The abnormal upper limb patterns are usually well established and the clients often have an intellectual disability together with the physical disability. The main goals of casting with the type 1 candidates are tone reduction, to gain biomechanical and musculoskeletal changes, for health and hygiene reasons and to improve upper limb positioning. The casting program is generally non-functional and can be viewed as an annual or biannual upper limb management program.

Type 11 casting candidates are generally more functional, have some active range of movement and use their affected upper limb spontaneously. There is usually little or no sensory impairment. These clients are usually young, from 18 months to 8 years or the upper limb impairment is relatively recent. In most cases the clients are developmentally appropriate and are able to understand the goals and process of the casting program and participate in the program. The

main goals of casting with type 11 candidates

CRITERIA TYPE 1 TYPE 11
MOTOR little or no active motion significant to isolated active ROM, spontaneous use
SENSATION impaired or absent very mild impairment to normal
NEED positional, health & hygiene increased function
AGE / ONSET well established abnormal patterns young or soon after onset of abnormal pattern
CARE total or significant care parental care or independent
BEHAVIOUR/

COGNITION

decreased cognition/behaviour

increased agitation

developmentally appropriate

understand goals and process

able to engage in active program

Table1:Type I and Type II criteria

are to increase or improve active function in the upper limb, increase active and passive ranges of movement and reduce tone. Improved occupational performance is usually seen in the form of improved reach, grasp and release, improved bilateral usage and increased use of the affected upper limb as an assist.

The majority of clients will not fall completely into one or the other categories, but will have some aspects of both. Clients being cast for improvement in function will present with mainly type II characteristics and the clients being cast for contractures, health and positional reasons will have mainly type 1 characteristics.

THESELECTION OF TYPE 11 CASTING CANDIDATES – CASTING TO IMPROVEOCCUPATIONAL PERFORMANCE

In the absence of a well defined protocol for upper limb casting for function as an occupational therapy intervention, it was necessary to build upon well established existing allied protocols. The Spastic Centre of NSW applies similar criteria to those used for upper limb reconstructive surgery to casting candidates, as there is evidence that these prerequisites are appropriate when selecting candidates for casting aimed at promoting functional improvement. Upper limb surgery and serial casting can both be classified as biomechanical forms of intervention in that they are designed to change the structure and balance of musculoskeletal function of the wrist and hand and both aim to improve the function as well as the appearance of the limb. The following criteria are used to

determine appropriateness of clients for casting to improve wrist and hand function.

a.Voluntary Control: This refers to the amount of voluntary motor control at the joints to be cast. We propose that prognosis for improved wrist and hand function would be optimal for those children who demonstrate spontaneous use of their involved arm as well as wrist extensor strength of above 3.

b.Sensation: Sensory impairment may be a limiting factor for the functional motor outcome expected from therapy, surgery or casting. The general proposition is that the degree of spontaneous upper limb use parallels the degree of sensory awareness. If the arm is ignored, then sensation is usually poor. The best outcome from casting would therefore be found in children with good discriminatory sensation.

c.Age: Althoughcasting can be successfully implemented as young as 15 months, we believe the best candidates for casting would be between 3 and 5 years of age. At this age it is felt that the child is old enough to participate in their own programs and understand the procedure. Older children tend to have developed compensatory patterns and are less likely to be receptive to new ways of learning to use their upper limb.

d.Motivation and Need: Casting, as with other interventions, is most successful with those children who enjoy activities and demonstrate the ability to co-operate in performing motor activities on command. At the same time however, we believe that there has to be an

intrinsic functional need for improved motor control. If the child and parents do not identify a functional need they will probably not persevere with a casting program.

e.Informed Parents: Parents are an important part of a childÌ“s casting program and as such it is vital they have realistic expectations of the goals of casting. The main expectation for parents is that they will be able to encourage their child to continually use the casted limb in a manner that will enhance the outcome.

CASEDESCRIPTIONS

Two preschool aged children with cerebral palsy were selected as appropriate candidates for serial wrist casting, both presenting as Type II casting candidates. At the time of this intervention both children were attending a preschool support class and were being seen by therapists from the Spastic Centre of NSW.

Tahlia:

Tahlia has cerebral palsy with spastic quadriplegia, her left side being more affected than her right. She was first seen regularly for occupational therapy at the age of two and from the age of three was involved in a preschool early intervention program. She was independently mobile in a Kaye Walker, on a trike or by crawling. She had a right hand preference and full active range of movement in her right upper limb. Her sensation, when assessed, was within normal limits. Tahlia was functioning at an academic level slightly below her age and she also had some difficulties with her speech and language.

Upper Limb Status prior to Casting: Tahlia used her left hand as an active assist and stabiliser. She was able to grasp using a radial-digital pattern with her wrist in flexion and full ulnar deviation. She would spontaneously attempt bilateral tasks and was able to manipulate objects bilaterally. She had full passive range of movement in her left upper limb excepting some limitations at the end of her radial deviation and supination ranges. Her active range of movement was limited in all planes at the wrist and forearm, including: no active supination, limited wrist extension and no radial deviation. She did demonstrate some active wrist extension but was unable to use this during occupational

performance.

Tahlia was independent in most self care activities but had some difficulty with buttons, shoes, socks and laces. She was able to eat with a spoon or fork in her right hand only. When crawling she tended to weight bear on an open right hand and fisted left hand. She was able to access a keyboard with her right index finger.

Tahlia was assessed for upper limb casting when she was 4 years and 10 months using the criteria previously outlined. She had fair voluntary control, intact sensation, was a motivated child who would benefit from functional hand improvement and had supportive and realistic parents. The general aims of wrist casting were to increase her active and passive ranges of movement and provide her with enhanced performance of her left upper limb.

Estelle:

Estelle was a five year old girl with spastic quadriplegia cerebral palsy. She was initially seen for occupational therapy at the age of 16 months. Estelle was unable to move independently, other than rolling, but was able to forearm prop or sit cross legged in order to play when on the floor. Independent mobility was aided through the use of a hand operated motorised bike or a right side hand controlled electric wheelchair.

Estelle had a right hand preference and used her left hand as an active assist or stabiliser. Increased muscle tone was evident in her left upper limb when she was engaged in any activity. Her sensation was within normal limits and she presented as a bright, interactive little girl.

Upper Limb status prior to casting: Estelle had limitations in both active and passive upper limb ranges. Her main limitations included: elbow extension, wrist extension, radial deviation and supination. When grasping she tended to hold her wrist in flexion and ulnar deviation, with her left index finger staying in extension. She also displayed some excessive upper limb movements when attempting to grasp (See Figure 1).

She was unable to form a pincer grasp or grasp small objects and used a palmer grasp and release pattern. She had underlying muscle weakness which also affected the quality of her

Figure1: Estelle, grasping pattern used pre casting

grasp. Estelle was dependent in most self care activities but was able to finger feed and help with some aspects of dressing. She accessed a keyboard with her right index finger.

Estelle also fitted the criteria for serial wrist casting and was initially cast at the age of 5. The main aims of her casting program were to increase active and passive ranges of movement,

improve the quality of her grasp and release, develop a pincer grasp and improve overall functional use of her left hand.

Method

Tahlia and Estelle both had a series of plaster wrist casts. Tahlia having three casts over a period of 19 days and Estelle having two casts over 14 days.

Cast number: Tahlia Estelle
1 5&deg; wrist flexion

5&deg; ulnar deviation

35&deg; wrist extension

5&deg; ulnar deviation

2 wrist neutral 50&deg; wrist extension

5&deg; radial deviation

3 60&deg; wrist extension

5&deg; radial deviation

&nbsp;

Table2:Position of the wrist during each cast

Prior to the application of the first cast active and passive upper limb ranges of movement measurements were recorded using a goniometer. Video was then taken of each child performing an identical set of grasp and release exercises with a variety of different sized cubes and pellets as well as completing a set of bilateral tasks that included bead threading and opening a bottle. Video was also taken of each child performing individual activities that related directly to their individual goals. These final activities included drawing, crawling, eating and dressing activities.

Each plaster cast was applied with the wrist placed in a position that still enabled the child to actively extend her fingers (See Table 2 and Figure 2).

This positioning was important as active use of the hand while in the cast is an essential part of the casting programme. The casts were left on for between 5 and 7 days as serial inhibitory casting is most effective over shorter periods as further contractures due to immobilisation can occur if casting time is increased (Chapparo, 1992). Following the removal of one cast, the upper limb was cleaned, the skin checked and necessary ranges of movement noted. Another cast was then applied almost immediately.

Figure2: Position of wrist in the cast to allow finger extension

Additional support was required with all of Tahlias casts due to her crawling. This was provided in the application of additional plaster strips extending the length of the cast on the volar surface. Another option in these circumstances can also be the use of fibreglass casting material.

While wearing their wrist casts both children

were seen twice weekly for occupational therapy. A home therapy program was also followed. The two children were encouraged to use the casted hand for as many activities as possible, including specific activities that targeted finger extension, grasp and release and use of a pincer grasp. Bilateral tasks were also encouraged.

Following the removal of the final casts in both children, a wrist extension orthosis was manufactured. These orthoses supported the wrist in approximately 20 to 30 of wrist extension.

Initially the orthoses were worn for the majority of the school day when the children were involved in their preschool program. The orthoses were not worn during rest periods or at night. Wearing of the orthoses was gradually reduced over a three month period as active strength in the wrist extensors was noted.

RESULTS

The immediate results of both casting programs was an increase in active and passive ranges of movement in the affected upper limb as well as an overall improvement in hand position and hand function (See Tables 3 and 4). The specific

ranges of wrist extension and wrist deviation were measured pre and post casting. Increases in active and passive supination ranges were also noted although these were not specifically targeted.

&nbsp; Pre casting Post casting
Wrist extension with finger extension Active: 0

Passive: 0 – 50

Active: 0 – 15

Passive: 0 – 90

Wrist extension with finger flexion Active: 0 – 15

Passive: 0 – 50

Active: 0 – 50

Passive: 0 – 90

Radial Deviation Active: 0

Passive: 0 – 10

Active: 0 – 5

Passive: 0 – 30

Table3:TAHLIA: Active and Passive Range of Motion Measurements pre andpost wrist casting

Tahlia:Changes in Performance of Occupational Tasks and Routines

Tahlia also made many functional gains, including:

*crawling on open left palm

*ablility to place left forearm flat on table surface

* ability to hold and use a knife and fork together

*ability to stabilise paper for writing more easily

*increases in dressing speed

*grasp and release with active wrist

extension

*improved grasp and release patterns with some active radial deviation

*overall improvement in hand positioning

(See Appendix 1, Figures 3 and 4 for pre and post casting grasp patterns: Tahlia)

&nbsp; Pre casting Post Casting
Wrist extension with finger extension Active: 0

Passive: 0 – 60

Active: 0 – 10

Passive: 0 – 90

Radial Deviation Active: 0

Passive: 0 – 15

Active: 0 – 10

Passive: 0 – 20

Table4:ESTELLE: Active and Passive range of motion measurements pre andpost casting

Estelle:Changes in Performance of Occupational Tasks and Routines

Estelle also demonstrated gains in range of movement and function. These included:

*ablity to grasp with wrist in slight extension with neutral to only slight ( 5 ) ulnar deviation

* ablity to pick up small objects using

a pincer or lateral pinch grasp

*ablility to clap and play finger games

*ability to hold a knife and fork in two hands but unable to use them functionally due to weakness

*ablility to stabilise objects more easily

*used her hands spontaneously and appropriately for bilateral tasks

(See Appendix 2, Figures 5 and 6 for examples of pre and post casting grasp patterns : Estelle)

CONCLUSION

Tahlia and Estelle were both preschool aged children with cerebral palsy who were appropriate for serial wrist casting. Both made significant gains in range of movement and in upper limb occupational performance. The gains made in range of movement were maintained for at least three months at which time only slight decreases were noted. These decreases had little impact on the girls functional ability. They were both cast again the following year and further gains in range and function occurred.

REFERENCES

Barnard, P., Dill, H., Eldredge, P., Held, J.M., Judd, D.L.M. &

Nalette, E. (1984). Reduction of hypertonicity in early casting in a comatose head-injured individual. Physical Therapy, 64(10), 1540-1542.

Booth, B.J., Doyle, M. & Montgomery, J. (1983). Serial casting for the management of spasticity in the head-injured adult. PhysicalTherapy, 63(12), 1960-1966.

Chapparo, C.J. (1992). Notes from: Upper limb casting course. The Spastic Centre of NSW, Occupational Therapy Department.

Chapparo, C.J. & Stewart, K.S. (1993). Wrist casting to improve functional control of the wrist and hand in cerebral palsy: A case study. Proceedings of the 6th State Conference of the NSWAOT. Mudgee, NSW, Australia.

Chapparo, C.J. & Ranka, J.L. (1994). Upper limb Orthotics. Course notes, Post graduate certificate in neurology, The University of Sydney, Faculty of Health Sciences, School of Occupational Therapy. PO Box 170, Lidcombe, NSW 2141.

Cherry, D.B. & Weigand, G.M. (1981). Plaster drop-out casts as a dynamic means to reduce muscle contracture: A case report. PhysicalTherapy, 61(11), 1601-1603.

Copley, J., Watson-Will, A. & Dent, K. (1996). Upper limb casting for clients with cerebral palsy: A clinical report. The AustralianOccupational Therapy Journal, 43, 39-50.

Cruickshank, D.A. & O̓Neill, D.L. (1990). Upper extremity

casting in a boy with spastic quadriplegia. The American Journal ofOccupational Therapy, 44(6), 552-555.

Cusick, B. & Sussman, M.D. (1982). Short leg casts: Their role in the management of cerebral palsy. Physical and Occupational Therapy inPediatrics, 2, 93-110.

Hill, J. (1994). The effects of casting on upper extremity motor

disorders after brain injury. The American Journal of Occupational Therapy, 48 (3), 219-224.

King, T. (1982). Plaster splinting as a means of reducing elbow

flexor spasticity: A case study. The American Journal of OccupationalTherapy, 36(10) 671-673.

Kitson, A. (1991). Inhibitive castings for the upper limb: A case

study. Australian Journal of Physiotherapy, 37, 237-242.

Law, M., Cadman, D., Rosenbaum, P., Walter, S., Russell, D. &

DeMatteo, C. (1991). Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy. Developmental Medicineand Child Neurology, 33, 379-387.

Smith L.H. & Harris, S.R. (1985). Upper extremity inhibitive

casting for a child with cerebral palsy. Physical and Occupational Therapyin Paediatrics, 5,(1), 71-79.

Steer, V. (1989). Upper limb serial casting of individuals with

cerebral palsy – A preliminary report. Australian Occupational TherapyJournal, 36(2), 69-77.

Tona, J.L. & Schneck, C.M. (1993). The efficacy of upper

extremity inhibitive casting: A single subject pilot study. The AmericanJournal of Occupational Therapy, 47(10), 901-910.

Tonkin, M.A. (1995). The upper limb in cerebral palsy.

Unpublished manuscript. (Available from, The Spastic Centre, Ryde, NSW).

Yasukawa, A. (1990). Upper extremity casting: Adjunct treatment for a child with cerebral palsy hemiplegia. The American Journal ofOccupational Therapy, 44(9), 840-846.

Yasukawa, A. (1992). Upper-extremity casting: Adjunct treatment for the child with cerebral palsy. In J. Case-Smith & C. Pehoski, (Eds). Development of hand skills in the child. (2nd ed.) pp.111-123. The American Occupational Therapy Association.

APPENDIX1: Pre and post casting grasp patterns: Tahlia

Figure3:Pre cast grasping

Figure4:Post cast grasping

APPENDIX2: Pre and Post cast grasp patterns: Estelle

Figure5: Pre cast grasping

Figure6: Post cast grasping

The Occupational Performance Model (Australia): Application to group intervention for children with hand writing problems

TheOccupational PerformanceModel (Australia): Applicationto group interventionfor childrenwith handwritingproblems

Traci-Anne Goyen, Sharon Doyle,

Christine Chapparo

Traci-AnneGoyen, BAppSc(OT) is an occupational therapist at Westmead Hospital’sGrowth and Development Clinic and operates her own private practice.

SharonDoyle, BAppSc(OT) is an occupational therapist at the New Children’sHospital, Westmead, NSW. Australia

ChristineChapparo, MA,DipOT,OTR,FAOTA, is a senior lecture in the School ofOccupational Therapy, The University of Health Sciences and aclinical consultant to Westmead Hospital, Department of OccupationalTherapy

In 1995, the Occupational Therapy Department at Westmead Hospital had an extensive waiting list for children with Perceptual Motor Dysfunction. Perceptual Motor Dysfunction is a term used to describe preschool and school-aged children of normal intelligence, with no identifiable neurological pathology, who may have difficulties in fine motor skills, general coordination, handwriting, perception and learning (Wallen & Walker, 1995).

Strategies were implemented to reduce the waiting time for intervention. One such strategy, group intervention, was trialled for children with handwriting difficulties as an alternate approach to traditional individual intervention. Handwriting was chosen as the focus for a group intervention because handwriting difficulty was one of the most frequent reasons that school-aged children were being referred to occupational therapy.

Services that were known to offer group intervention for children with handwriting difficulties were contacted. Suggestions and descriptions were sought regarding the best way to approach this type of intervention. A number of these services had established therapy groups based on ‘preventative intervention’, in which they addressed instruction in ‘good’ handwriting practices, such as preferred writing postures and pencil grasps, to improve handwriting performance. Others were more ‘prescriptive’, using a programmed sequence of activities that addressed skills associated with handwriting function, such as visual-motor and copying tasks.

In our view, these programs failed to address the assessment and intervention of handwriting in a wholistic manner and they appeared to lack a clear framework within which to examine the total routine of handwriting.

A flexible approach to group intervention for handwriting was developed by the authors to meet the individual needs of children within a group context. While a flexible and wholistic approach to intervention for handwriting was preferred, it was clear that this could not be achieved effectively without an overall framework to guide aspects of group intervention.

To allow for individual skills, abilities and attitudes of children to be addressed within the context of a group programme, a theoretical model was sought within which individual goals could be made to guide intervention. The Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) was used to develop a framework for the group program. This particular model was employed as it was viewed as allowing therapists to:

1) analyse and explain the impact of poor performance in handwriting on the child’s total occupational context;

2) identify and address both global and specific areas of handwriting difficulty for each child within a group context; and

3) provide therapists with a clear explanation of the role of the occupational therapy with children who have handwriting problems.

The purpose of this paper is to illustrate how the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996), can be used to direct assessment and a group intervention programme for children who have handwriting difficulties.

ANALYSISOF HANDWRITING USING OCCUPATIONAL PERFORMANCE

CONSTRUCTS

Problems in handwriting are characterised by a number of different features. Often, therapists concentrate onanalysis of the most common characteristic, poor legibility and speed (Cermack, 1991; Wallen, Bonney & Lennox, 1996). Alternatively, others focus on underlying component function without linking the disorder to handwriting difficulties (Doyle & Goyen, 1997). It is unusual, however, that difficulty with handwriting is not associated with other aspects of occupational performance. Handwriting is performed within a personal and environmental context. It is embedded in school and home occupational roles where there is demand for a particular level of performance. Poor handwriting may be a graphic symptom of a learning disability, and therefore linked to associated difficulties with perception, motor planning, motor memorymotor sequencing and language (Benbow, 1995; Cermack, 1991; Stott, Moyes & Henderson, 1985; Levine, 1985). Inadequate strength of the finger muscles or an imbalance between flexor and extensor muscle strength may cause poor pencil grasp and handwriting (Benbow, 1990). Alternatively, behavioural disorders may impact on handwriting performance (Wallen & Doyle, 1995). Long term difficulty with handwriting impacts negatively on self esteem and self efficacy in children of all ages (Benbow, 1995).

Once it has been determined that a child has a problem with handwriting, it is critical to successful intervention that the reasons for the existing problem, as well as the impact of the problem on other occupations are fully analysed. Using the constructs within the Occupational Performance Model (Australia), (Chapparo & Ranka, 1996), guidelines for the depth and scope of handwriting assessment as well as intervention within the group context were developed. This particular occupational performance model is based on a top-down approach (Chapparo & Ranka, 1993). Its constructs and structure emphasise the child’s performance in terms of roles and complex tasks (Chapparo & Ranka, 1996). Relative to this model, the focus of handwriting intervention is therefore linked to the promotion of occupational role mastery. Component assessment and intervention occurs only when occupational need is identified at role and task levels. To define what constitutes mastery of handwriting for a specific child, the therapists must have knowledge of the child’s educational and play environment. The demands of these environments will contribute to the child’s required role expectations.

OccupationalRoles

‘Student’ and ‘player’ roles were identified as the primary occupational roles for school-aged children which could be affected by handwriting difficulties. The ‘student’ spends the majority of the day involved in writing tasks at school (McHale, 1987), and as a ‘player’ the child may choose to engage in a variety of games and activities, many of which may involve writing.

Handwriting of group members is therefore analysed in relation to the occupational role demands of performance. As outlined in the Occupational Performance Model (Australia), (Chapparo & Ranka, 1996), occupational roles have three dimensions: one is personal (knowing what has to be done); one is environmental (what outside expectations exist of performance) and role satisfaction (feelings of satisfaction with role performance). Applying these concepts to handwriting analysis, each child’s personal idea of how he or she wants to use handwriting to express ideas is sought. Similarly, the classroom context has implicit and often explicit demands for the level of performance expected from the student group. Last, children within the group are given opportunities to express their satisfaction with their levels of overall performance (Doyle & Goyen, 1997). Individual handwriting performance is therefore analysed against this real world context using information about perceived, actual and expected levels of handwriting performance from the child, parents and teachers.

Handwriting intervention goals, as they relate to performance of chosen and needed occupational roles, became one of the first steps in the process that guided programme development.

OccupationalPerformance Areas

Within the roles of ‘student’ and ‘player’, the ability to write was considered relative to its place as a routine or task in the ‘productivity’ and ‘leisure’ occupational performance areas.

Leisure routines and tasks

Children frequently engage in writing routines as part of their leisure activities. This may include tasks such as writing letters to penpals or friends, writing stories, and ‘fun’ writing games (such as crosswords, find-a-words, hangman).

Productivity routines and tasks

At school the student is expected to participate in two types of handwriting routines, depending on the age of the child. First, in the early school years, up to about 3rd grade, children spend time in performance of formal handwriting routines that target adequate development of a specific style. Second, around the 4th grade, there is a marked increase in academic demand for written output that emphasises writing reports, stories and projects, and demonstration of knowledge (Levine, Oberkland & Meltzer, 1981).

Tasks that support these routines involve dimensions of the ability to structure handwriting and timing of performance (Chapparo & Ranka, 1996), and include presentation of work in a neat, orderly and timely fashion. In addition, manipulative tasks incorporating multiple tools, such as using a ruler, eraser and compass become integrated into complicated handwriting tasks that are required to complete work. For the student the ability to write legibly and at an appropriate speed is essential for success at school. Furthermore, the legibility of a student’s handwriting can be influenced by a number of factors, including their posture when writing, grasp of the writing implement, organisation of work on the page, and the formation and spacing of letters.

Although there are many handwriting assessments that contribute to information about handwriting difficulties at this level of performance (Doyle & Goyen, 1997), we have found that these should be supported by two additional forms of analysis.

1) Task analysis of routines, tasks and subtasks to identify specific errors or strengths in performance.

Analysisof handwriting routines involves analysis of several critical routines that are required for the child’s successful role performance as student or player. For example, the routine required for writing a short story involves creating a story image in the mind, converting it to words, converting the words to written words, maintaining legibility of writing mode and memorising what is to be written. Often, we see that children are able to write when they can fully concentrate on the mechanical aspects of writing, but not when they have to attend to the information that is in their mind. Similarly, the routine of copying information from a chalkboard requires the child to adaptively put together the performance of several handwriting tasks such as reading the board, remembering what is read, writing the words, finding the next place on the board, and continuing the routine until its close. The added demands of structure and time that are imposed on routines of handwriting are an important feature of any handwriting assessment and intervention programme, as routines often form the link between discrete tasks and role performance.

Specifictask and subtask analysis can further describe the observed errors in handwriting routines. This involves a more indepth analysis of specific steps in handwriting. For example, in one child, the routine of copying from the board may be compromised by difficulty with the specific subtask of visual relocation of words on the board. The key to initial intervention in this case therefore, will not be to practice handwriting, but to practice visually locating words to be written. Similarly, another child may have difficulty with the timing of the same routine due to poor pencil grip. For this child, intervention in the first instance will be directed towards reordering pencil grip. Ultimately, for both these children, the step in the task that is problematic will need to be practiced within the

context of the whole writing routine to ensure

carry through in the classroom (Snell, 1987).

2) There is support in the literature for handwriting analysis to contain a measure of the teacher’s assessment of the child’s handwriting (Cermack, 1991). The teacher, in a classroom full of children has the opportunity to view the child’s performance against other children who are performing the same tasks and routines. In addition, the teacher has the opportunity to look at multiple samples of the child’s work, produced under various personal and environmental conditions. Teachers develop a picture of the level at which the child is able to sustain handwriting routine performance and which environmental and personal elements impact most directly on its quality.

Similarly, it is important to consider information about the child’s handwriting from the parent’s perspective. For example, many parents can identify difficulties with children completing homework, or experiencing pain and aversion during writing which is not evident in the classroom.

Componentcontributions to handwriting

The child’s ability to perform writing routines and tasks at school and for leisure may be compromised by underlying components, including biomechanical, sensory-motor, interpersonal, intrapersonal or cognitive operations (Benbow, 1995; Carr, 1989; Cook, 1991; Dunn & Campbell, 1991; Powell, 1994).

Formal and informal analysis of component function provides information that can assist in clarifying the nature of the handwriting problem.

Assessment of strength and muscle tone provides information which may explain the presence of poor pencil grip, endurance and fatigue during writing tasks and routines. In this instance, part of an intervention programme would need to address increasing hand strength and endurance to support writing (Benbow, 1995).

Sensory motor processing using various standardised measures (Ayres, 1989; Bruininks, 1978; Stott, Moyes & Henderson, 1984; Beery, 1989; Miller, 1988; Royeen, 1990) or informal observations can give information about the presence of visual, kinaesthetic or other sensory

processing disturbances associated with poor handwriting. For example, some children who have poor handwriting have inadequate somatosensory perception (Benbow, 1995; Levine, 1985; Cermack, 1991). This may be manifested in tests of finger identification, or knowing the precise position of hands and fingers. Children who do not adequately process somatosensory information may try to compensate for inadequate sensory feedback by using undesirable pencil grips. These are usually characterised by increased pressure and stabilisation of the distal joints of the index finger and thumb. For longer writing routines, this may result in fatigue. Similarly, a general problem with motor planning may result in poor development of automatic movements that are needed for skilled and quick writing. The child must think about the mechanics of writing rather than the content of writing, thereby limiting the length of academic work produced.

For some children, specific perceptual and cognitive deficits may be the foundation for errors in writing tasks. For example, Levine (1985) suggested that there was a need to differentiate component physical problems with writing from component cognitive problems, specifically language operations such as word finding and sentence formation. For example, the child whose handwriting problems are mostly centered around letter reversals, is probably demonstrating primarily language deficits, rather than handwriting deficits of the motor type.

The extent to which children are able to experience positive intrapersonal elements of task performance contributes to general self esteem and confidence. Emotional stability, mood and motivation are all intrapersonal dimensions of a child that can impact on the consistency of handwriting performance.

Externalenvironment

Physical and sensory environments contribute to how well the child is able to structure and time handwriting routines. Sociocultural dimensions of the external environment play a major part in determining the level of mastery of handwriting performance (Orr & Schkade, 1996), as described previously. Authors have indicated that the environmental demands of the school setting, for example, can contribute to the identification of intervention needs (Brollier,

Shepherd & Markley, 1994; Griswold, 1994; Haley, et al, 1992). In developing a programme for children with identified handwriting problems, therapists are often responding to the environmental demands of the classroom, or family expectations, rather than the individual concerns of the child. Any intervention model that guides programmes for effective handwriting, must consider the environmental influence on performance. The Occupational Performance Model (Australia) (Chapparo & Ranka, 1996), is one model of practice that appears to consider the prominent place of the environment to occupational performance.

Timeand Space

Timing of role, routine and component functions contribute to the efficacy of handwriting performance and the space in which the writing task occurs can influence a child’s performance at any level of the model. Time, in the form of developmental expectations of handwriting at different ages is a major consideration in assessment and intervention.

Below, is a summary breakdown of how handwriting performance with its various elements are viewed in relation to constructs in the Occupational Performance Model (Australia), (Chapparo & Ranka, 1996). The constructs depict occupational performance areas that can be targeted for:

1)goal setting

2)intervention.

3)programme outcome measures

OCCUPATIONALROLES THAT REQUIRE HANDWRITING

Student

Player

OCCUPATIONALPERFORMANCE AREAS THAT INCLUDE HANDWRITING

Productivity

Examplesof Handwriting Routines

near and far point copying

dictation

projects

spelling lists

creative writing

exams

worksheets

Examplesof tasks and subtasks

1) legibility (structure) of handwriting

*spacing of letters and words

*formation of letters (including size, case and slope)

*organisation of written material (including alignment)

*grasp of writing implement (including type and consistency of grasp)

*posture when writing

*pencil and paper management (including positioning, manipulation of pencil in hand, stabilising paper)

*writing pressure)

2) speed (timing) of handwriting

*fluency

3)Manipulativetasks related to handwriting

*use of ruler

*eraser

*folding paper

Leisure

Examples of handwriting Routines

*correspondence

*writing for games

*poetry and creative writing

COMPONENTSOF OCCUPATIONAL PERFORMANCE

Biomechanical

Range of Movement

Muscle strength

Grasp

Biomechanical development of the hand and thumb

Body posture

Stabilisation of joints

Sensory-Motor

Postural control and stability

Regulation of muscle tone

Bilateral coordination

Gross motor coordination

Fine motor coordination and control

In-hand manipulation

Visual-motor integration and control

Awareness of body position and movement in space

Planning and organising movement sequences

Sensation including the presence or absence of pain and discomfort

Cognitive

Attention and concentration

Memory, recall, retention and sequencing of ideas

Thinking, perceiving, recognising and knowing

Problem solving, decision making, planning and judgement

Visual perception

Language skills

Thinking and doing simultaneously

Formulating and translating ideas

Intrapersonal

Self esteem and confidence

Intrinsic motivation

Perseverance with difficult tasks

Emotional stability, mood and affect

Self control (controlling anxiety levels and impulsivity)

Interpersonal

Group participation skills including cooperation, turn taking, sharing, awareness of personal space and boundaries, empathy, verbal and non-verbal communication

COREELEMENTS OF OCCUPATIONAL PERFORMANCE

TheBody, Mind, Spirit Unit

General well being

Intrinsic motivation

Appropriate muscle tension

Pain-free

Absence of muscle and soft tissue damage

Absence of neuromotor disorder

EXTERNALENVIRONMENT

Social

Individual/group/classroom/home environment and expectations

Writing styles, implements and expectations of peers

Teaching style and educational milieu

Sensory

Amount of light, noise, heat in environment

Colours, textures involved (eg. colour of chalk on blackboard)

Writing surfaces

Appropriate sensory cues within the environment to assist writing

Physical

Ergonomic considerations (eg. seat height, room set up, desk position in class)

Physical proximity to other students

Writing and copying surface (eg. near/far point copying, vertical or horizontal writing surface)

Variety of writing positions

Cultural

Use of modified writing implements at home/school

Multicultural mix in classroom

Individual/family cultural background and expectations

Space

Physical and felt space as positive or negative aspects of handwriting

Time

Past experiences of hand writing

Time of day of writing performance

USINGOCCUPATIONAL PERFORMANCE CONSTRUCTS TO PLOT A HANDWRITING PROFILE FOREACH CHILD IN THE GROUP

Once a child’s handwriting abilities are assessed,

the same constructs within the Occupational Performance Model (Australia), (Chapparo & Ranka, 1996) can be used to construct a complete individual profile for each child’s handwriting, demonstrating strengths and weaknesses of performance. From this information, individual goals are formulated and intervention strategies selected and tailored to meet the individual needs of group members.

INTERVENTION

When planning intervention, the model was used in two ways. First, the occupational performance profile for each child was used to determine the level of handwriting intervention needed at the routine, task and component level. Second, the identified areas of need were examined to select appropriate mode and level of intervention. In one group, children could be:

1)working to refine handwriting routines

2)working on specific tasks and subtasks of handwriting that need massed practice

3)working on the component skills or underlying abilities which may have been identified as major contributing factors to poor handwriting.

The art of therapy in a group context in this situation is to construct the task so that all members are working on the same group goal, but at different levels. Sharing, support and mastery can be encouraged as group norms, rather than competition, thereby facilitating confidence and social interaction in a ‘safe’ learning environment.

There is no one intervention mode to which the Occupational Performance Model (Australia) is linked. Two general directions for intervention are found in the structure and underlying assumptions of this model. First, that intervention be occupation centered and linked to an identified occupational need. Second, that the intervention mode chosen by individual therapists suit the level of identified difficulty within the model.

Congruent with this view, there are multiple interventions that are incorporated into this program. First, the program was centered on

handwriting occupations as they related to the identified occupational role need of children referred.

Second, intervention modes chosen matched the identified areas of occupational need within the model. For example, problems with handwriting routines prompt therapists to use systematic instruction that target sequencing and timing of the whole task through prompts and practice of handwriting projects. Often children engage in this level towards the end of treatment. One example of a routine is completion of a group newspaper project.

Specific difficulty with steps of the routine are treated with massed practice of the specific step until mastery is achieved, followed by practice of handwriting routines. For example, children practice graphic patterns with and without lines of decreasing size, followed by letters, finally leading to a motivating writing task. Each session is concluded with a ‘fun’ writing task.

Specific difficulties in the component areas prompt therapists to choose interventions that match the component disorder identified. For example, visual matching and visual memory tasks are used where problems processing visual information are identified; proprioceptive, kinaesthetic and tactile modes of intervention are used where processing in that aspect of sensory motor component function is poor; specific strengthening or orthotic procedures are incorporated into the program when children are identified as having particular difficulties with the biomechanics of writing; general sensory motor procedures are used where children have identified difficulties with body posture and tone when writing. All these component interventions, however, are finally related to the overall intervention goal: improved handwriting.

Profiles of two children are presented in this paper to illustrate how the constructs outlined above have been applied. Due to space available in this article, these case studies focus on assessment and goal setting only. For further information about specific interventions that have been used in the group setting, see Doyle & Goyen, 1996.

CASESTUDY 1 : CHRISTOPHER

Christopher (9 years) was referred to

occupational therapy by the Learning Difficulties Clinic at Westmead Hospital because of presenting concerns with writing at school. Poor writing performance affected his ability to perform effectively as a ‘student’. The performance area which seemed to be primarily affected was his productivity at school. Christopher had difficulty performing and completing writing tasks at school and home, due to fatigue, pain and discomfort in his hand and wrist. His posture during writing was flexedand he made frequent changes with his pencil grip throughout the task. In addition, Christopher had problems manipulating a ruler for writing tasks.

On examination of the underlying performance components which may have contributed to his performance, Christopher was found to have problems with the following biomechanical aspects of writing. He wrote with a flexed wrist which reduced the flow of his movement across the writing surface and contributed to pain when writing.

There was a cognitive component to his difficulty involving higher level language/cognitive skills such as abstract reasoning and inferential thinking abilities. These had been previously identified by the speech pathologist and neuropsychologist from the Learning Disabilities Clinic. Intrapersonal component difficulties that were noted by Christopher, his parents and his teacher, were his lack of confidence and motivation to perform writing tasks in all environments. Assessment revealed that there were no contributing sensory motor or interpersonal difficulties.Environmental considerations included his classroom, which was a grade 3/5 composite class, and that his parents were regularly involved with his homework.

CHRISTOPHER’SPROFILE

OccupationalRoles:student

OccupationalPerformance Areas:

Productivity

*performing and completing writing routines and tasks at school and home, due to fatigue, presence of pain and discomfort

*manipulating ruler for writing tasks

*frequent changes in pencil grip

*poor posture during writing

Componentsof Occupational Performance

Biomechanical:flexed wrist causing pain and reducing flow of movement

Cognitive:high level language/cognitive problems such as abstract reasoning and inferential thinking skills

Intrapersonal:reduced confidence in writing ability

not motivated to perform written

homework tasks

CoreElements

*increased muscle tension in arm

*difficulty relaxing if experiencing pain when writing

Considerationsof Environment/Space/Time:

*composite class 3 and 5

*parents involved in homework regularly

Aims/ Goals of Intervention

PerformanceArea Aims / Goals:

Productivity:

1. To perform and complete handwriting activities at home and at school (including dictation and completing projects) without fatigue or presence of pain and discomfort.

2. To manipulate a ruler so Christopher can rule a line adequately for writing tasks

ComponentGoals:

1. To reduce pain and writing pressure by encouraging more functional (neutral) wrist position during writing

2. To reduce fatigue when writing over a longer

period of time (1/2 page) by improving fluidity and control of movement across the page

3. For Christopher to maintain a more functional posture during writing

4. For Christopher to be motivated to participate in written homework tasks, as indicated by report and performance.

5. To improve confidence in handwriting ability, as indicated by rating scales

Intervention for Christopher was developed within a group structure to meet these goals.

KATE’SPROFILE

Occupational therapy was recommended for Kate (8 years) by her school counsellor due to difficulties with writing at school. This affected her ability to perform effectively as a ‘student’. In addition, her problems with writing also limited her ability and enjoyment when ‘playing’ with others. Her difficulty with handwriting was mirrored in her poor use of tools to complete self care skills. Two performance areas appeared to be primarily affected, including her self maintenance skills and productivity at school. In respect of her self maintenance skills, Kate had difficulty managing eating utensils, and turning taps and knobs carefully.

At school, her handwriting was below average compared to her peers and she experienced pain in her thumb when writing faster. School based fine motor tasks, such as cutting, folding, colouring and using rulers was also problematic.

Examination of the underlying components which affected her performance, Kate was found to have problems with the biomechanical aspects of writing, mainly her fixed, static grip on the pencil with restricted finger movement. Her sensory motor skills, particularly in relation to fine motor tasks were found to be below age expectations. Specific problems were noted with her in-hand manipulation skills and visual motor control, including inaccuracies in completing mazes, copying patterns and with cutting tasks.

KATE

OccupationalRoles:

student

player

self maintainer

OccupationalPerformance Areas:

Productivity

*legibility of writing is below class average

*experiences pain when writing faster

*difficulty with school based fine motor tasks (cutting, folding, colouring, rulers)

SelfMaintenance

*managing eating utensils

*turning taps and knobs carefully

Componentsof Occupational Performance

Biomechanical:

*fixed static grip on pencil restricting finger movement

SensoryMotor:

*below average fine motor coordination (including in-hand manipulation and visual motor control)

InterventionAims / Goals

PerformanceArea Aims / Goals:

Productivity:

1.To reinforce graphic movement patterns during a fun writing activity

2.To improve legibility when required to write faster, as indicated by rating scales

3.To reduce pain when required to write faster for 1 paragraph, as indicated by child report

ComponentGoals:

1.To maintain a functional pencil grip

whilst writing on a vertical surface, to allow controlled and fluent pencil movements for one sentence

2.To perform in-hand manipulation tasks, that will support handwriting and other tool use within the classroom, such as: stabilising 3 beads in the palm while placing beads on thread

Kate and her parents were given the opportunity to address specific self maintenance difficulties at the conclusion of the handwriting group program.

SUMMARY

This paper has illustrated how the Occupational Performance Model (Australia) can be used to structure the assessment and content of intervention for handwriting difficulties. Specifically, the article outlines how the model can be used to determine:

1)the scope required for adequate assessment of handwriting occupations

2)how handwriting can be analysed relative to different levels of occupational performance, including, role performance; routine performance; task and subtask performance; and component performance within environmental constraints.

3)individual handwriting profiles for each child, outlining areas of strengths and weaknesses.

4) goals for intervention

5)intervention options for individual and group intervention

ACKNOWLEDGMENTS

The authors wish to acknowledge the support of colleagues at Westmead Hospital during the development and initiation of this programme.

References

Ayres, A.J. (1989). Sensory integration and praxis tests. Los

Angeles: Western Psychological Services.

Benbow, M. (1990).Loops and other groups: A kinaesthetic

writingsystem. Tuscon AZ: Therapy Skill Builders.

Benbow, M. (1995). Principles and practices of teaching

handwriting. In A. Henderson & C. Pehoski (Eds.). Hand function in thechild. (pp. 255-281). St. Louis MO: Mosby

Beery, E. (1989). The developmental test of visual motor

integration.(3rd ed.). Cleveland: Ohio

Brollier, C., Shepherd, J. & Markley, K.F. (1994). Transition

from school to community living. American Journal of OccupationalTherapy, 48, 346-353

Bruininks, R.H. (1978). Bruininks-Oserestky test of motor

proficiencyCircle Pines. MN: American Guidance Service

Carr, S.H. (1989). Louisiana’s criteria of eligibility for

occupational therapy services in public school systems. American Journal ofOccupational Therapy, 48, 503-506

Cermack, S. (1991). Fine motor functions and handwriting. In

A. Fisher, E. Murray & A.Bundy, (Eds.), Sensory integrationtheory and practice. (pp. 166-170) Philadelphia: F.A.Davis

Cook, D.G. (1991). The assessment process. In W. Dunn (Ed.).

Pediatricoccupational therapy: Facilitating effective service provision (pp. 35-47). Thorofare: Slack

Doyle, S., & Goyen, T-A. (1997). Measuring the difference:

evaluatingchange for children with handwriting difficulties. OT Australia. 19th National Conference. Perth. WA. May.

Doyle, S., & Goyen, T-A. (1996). Group intervention for

childrenwith handwriting difficulties.. Allied Health Day. The New Children’s Hospital, Westmead, NSW. August. (Available from the authors).

Dunn, W., & Campbell, P. (1991). Designing pedicatric service

provision. In W. Dunn (Ed.). Pediatric occupational therapy: Facilitatingeffective service provision (pp139-160). Thorofare: Slack.

Griswold, L.A. (1994). Ethnographic analysis: A study of

classroom environments. American Journal of Occupational Therapy. 48,397-402

Haley, S.M., Coster, W.J., Ludlow, L.H., Haltiwanger, J.T., &

Andellos, P.J. (1992). Pediatric evaluation of disability inventory (PEDI). Boston: New England Medical Centre Hospitals

Levine, M.D., Oberklaid, F., & Meltzer, L. (1981). Developmental output failure: A study of low productivity in school aged children.Pediatrics, 67, 18-25

McHale, K. (1987). Integrating children with fine motor

difficulties into regular classrooms: An approach to identifying and solving problems. Unpublished master’s thesis. Rhode Island College, Providence, RI. In A. Fisher, E. Murray, & A Bundy, (1991) Sensory integration theory and practice. (p.166) Philadelphia: F.A. Davis

Orr, C., & Schkade, J. (1996). The impact of the classroom

environment on defining function in school-based practice. American Journal ofOccupational Therapy, 51, 64-69

Powell, N.J. (1994). Content for educational programs in school

based occupational therapy from a practice perspective. American Journalof Occupational Therapy, 48, 130-137

Miller, L. (1988). Miller assessment for preschoolers. San

Antonio: The Psychological Corporation

Royeen, C.B., & Fortune, J.C. (1990). TIE:Touch inventory for

school aged children. American Journal of Occupational Therapy, 44, 155-160

Snell, M. (1987). Systematic instruction of persons with severe

disability. (3rd ed.). Columbue: Merrill

Stott, D.H., Moyes, F.A., & Henderson, S.E. (1984). The test of

motorimpairment (Henderson rev.) San Antonio: The Psychological Corporation

Wallen, M., Bonney, M., & Lennox, L. (1996).The handwriting speedtest. Adelaide: Helios.

Wallen, M., & Walker, R. (1995). Occupational therapy practice with children with perceptual motor dysfunction: Findings of a literature review and survey. Australian Occupational Therapy Journal,42(1), 15-25

Occupational performance and sensory integration therapy: preliminary findings of a rating scale

Occupational performance and sensory integration therapy: preliminary findings ofa rating scale

Veronica Steer

This article is derived from a paper presented at the 5th State Conference of OT Australia AAOT-SA, Adelaide, SA (October, 1996)

VeronicaSteer, BAppSc(OT), has a private practice in Adelaide, SouthAustralia and is a member of the Sensory Integration Faculty(OTAustralia).

INTRODUCTION

Children with learning disabilities form a large portion of most general paediatric occupational therapy practices. The children are referred for assessment and intervention for difficulties with writing, coordination, perception, perceptual motor and self help skill development. For most of these children, the level of ability, independence and organisation in many areas of their life is effected by the pervasive nature of the disability.

Over the last twenty years, sensory integration theory and practice (Ayres, 1972a, 1972b; Fisher, Murray & Bundy, 1991) has been a major and evolving form of intervention used by occupational therapists for children with learning disabilities who also have sensory integrative dysfunction. Research investigating the effectiveness of therapy using sensory integrative procedures has concentrated on the gains made in coordination, learning and behaviour (see for example, Ayres, 1972a, l977, l985; Ayres & Mailloux, 1981; Ayres & Tickle, 1980; Grimwood & Rutherford, 1980; Humphries et al, 1990; Parham, 1990). There has been little documentation of research that measures the change to the overall adjustment in the day to day life of the child who is receiving sensory integrative intervention. It is well recognised clinically, however, that “sensory integration and the corresponding adaptive behaviours lead to organised and appropriate occupational behaviour, including self-care and self-management, play and academic skills” (Fisher, Murray & Bundy, 1991.p.22).

Rating scales were developed by the author in response to the motivation to start recording the changes that were being noted in the children during their therapy sessions and in their lives, by parents and teachers. The Occupational Performance Model (Australia) (Chapparo & Ranka, 1994; 1996) was used to analyse aspects of the scales. Selected constructs from the model were employed to categorise the occupational performance areas and derive a clearer picture of the trends of change that occurred in children’s lives, in response to therapy as well as in the components that are hypothesised to contribute to a child’s occupational roles.

The paper is a report of a pilot study and the findings are therefore considered preliminary to further development of useful rating scales to measure change.

SENSORYINTEGRATION

Sensory integration is based on the work of A. Jean Ayres (1972a) who recognised a common picture in some children with learning difficulties that related to difficulties in processing sensory information. Based on many years of research with these children, she formulated hypotheses about deficits in neuro behavioural processes that are thought to be associated with learning disabilities. These hypotheses led to the development of treatment procedures designed to enhance sensory integrative processing in children who demonstrate difficulties in that area (Ayres, 1964, 1968, 1974b, 1972a, 1972b; Fisher, Murray & Bundy, 1991). A theory of sensory integration was formed that resulted in an associated standardised assessment (Fisher, Murray, & Bundy) that identified sensory processing difficulties that were interfering with early academic learning.

These sensory integrative difficulties were hypothesised to reflect disorganisation of the central nervous system’s ability to process sensory information about the child’s body and environment. This, in turn, interferes with complex processing required for the child to perform during daily activities. This could be viewed as a basic adaptive response in play, physical interaction with other children through tasks, learning daily living skills involving coordination of body movements, or classroom learning.

Sensory integrative procedures are characterised by child directed, motivating, goal oriented and sensory enriched activities, which are used to stimulate more appropriate or mature adaptive responses in the child’s performance. The goal is not only better physical skills required for the performance of daily activities, but enhanced sensory and motor processing that occurs at a more fundamental level of performance. The benefit of therapy is viewed as a more efficient processing of body and environment factors upon which the higher, more complex processing required for formal learning can develop.

DEVELOPMENT OF RATING SCALES TO MEASURE CHANGE

Purpose

The Sensory Integration Rating Scales were developed by the author out of motivation to start recording the changes that were being noticed in therapy, at school and at home, in the everyday abilities of children undergoing therapy. These changes were not always assessed on other standard measures of change, and were not being recognised in recent literature. The aim of the rating scales was to qualify and quantify the benefits of therapy and to begin to build a bank of data that would contribute to research supporting occupational therapy and sensory integration specifically.

The group of children for whom the rating scales were developed were children seen in the author’s paediatric practice. They have learning, coordination and behavioural difficulties, are assessed as having sensory integrative dysfunction and receive weekly direct intervention based on principles of sensory integration.

Rating scales were chosen over other styles of measurement for two reasons. First, they were viewed as being easy to use in a busy practice.

Second, similar rating scales are currently being used in Adelaide by psychologists, paediatricians and others to measure children’s behavioural changes in response to medication trials, behaviour management and social skills training.

They are recognised and accepted as measuring trends of change only and their limitations include their subjectivity. Despite this, many investigations have employed rating scales to demonstrate meaningful empirical relationships between data and theoretical constructs (Kidder & Judd, 1986).

Content

The development of the items in the Sensory Integration Rating Scales were based on commonly recognised areas of concern noted by parents, teachers and the author. They were areas of difficulty that were common to children being seen by the author and reflected the areas of performance that usually responded to therapy. They were areas of performance that were thought to reflect improved organisation of behaviour.

These functional indicators of sensory integrative dysfunction were collated into two scales, one to be used by parents and one to be used by teachers. The items reflected measures of the child’s effectiveness in dealing with aspects of everyday life at school and at home. The scales aimed to measure children’s functional performance before and after treatment and consisted of items relative to broad areas of play, self maintenance, gross and fine motor coordination, basic academic and writing abilities and psychosocial, attention and sensory based behaviours.

A five point Likert rating scale was used to rate 52 measures on the Parent Rating Scale form and 32 on the Teachers Rating Scale form. The scale for each item ranged from :

15

significantno

concern/concern/

difficultydifficulty

ParentForm

Examples of items on the Parent Form are as follows:

Doesyour child:

playby self indoors

playon the computer

playby self outdoors

playon bike or other moving equipment

use a knife and fork

eat in a neat manner

remainseated at the table

organiseand complete dressing

getto sleep and stay asleep

have tantrums

have confidence in his abilities

follow instructions

Isyour child:

fussy with different textures of food

freefrom motion sickness

emotionallycontrolled during periods of high activity

sensitiveto noise

ableto cope with change

TeacherForm

The following are examples from items on the Teacher Form:

Isthe child:

coordinated in physical activities

positive in attitude to physical activities

ableto glue

using scissors

formingletters appropriately

using correct pencil grip

writingwithout frustration

independent in organising work

physically restless

talkative

usually playing alone

able to maintain friendships

The scales were trialed and modified over school terms 1, II and III. The following results are from results obtained from school terms II and III.

Administrationof the Rating Scales

The rating forms were given to parents and

teachers of 32 children who had been referred for occupational therapy for perceived difficulties with learning, coordination and behaviour. The rating scales were given to the parents and teachers, via the parent, at the time of the first treatment session. At the end of the term, or block of therapy (6 to 18 treatments), a second rating scale, identical to the initial scale was completed without the parent or teacher referring to the initial record. After the results were documented, they were invited to compare the two and comment.

The return rate from both ratings was 16 (50%) for parents and 7 (25%) for teachers. The 16 children (4 girls, 12 boys) were aged between 4.10 years to 12.5 years (mn age. 7.9). Fourteen children were in state schools and 2 attended private schools. The return rate possibly reflected the voluntary nature of the task and lack of adequate time to make personal and follow up contact with the teachers to ensure appropriate education about the child’s occupational therapy programme.

Parentand teacher knowledge of occupational therapy and sensory integration

The parents’ level of knowledge of sensory integration was variable. It was based primarily on what they gained from the initial occupational therapy assessment and report and initial reading of the Sensory Information Sheet (1991) as well as A Parent’s Guide to Understanding Sensory Integration (1986). Some parents also attended an information evening on sensory integration, signs of difficulties and treatment benefits and had readSensory Integration and the Child (1979).

The teacher’s knowledge was more limited, based on the assessment report, the Sensory Integration Information Sheet, (1991) and AParent’s Guide to Understanding Sensory Integration (1986).

RESULTS

Preliminaryanalysis

a. Parent Rating Scales

Total scores for each child were computed for the entire rating scale for both the pre and post parent ratings. The differences or improvements in performance of each of the children as perceived by their parents is graphed in Table 1.

Table1: Parent Rating Scale: Improvements

Analysis of the increments graphed indicated that the parent’s ratings of their children varied between 5.24% to 27.3%. The average percentage increase in perceived performance for the 16 children was 15%.

b. Teacher Rating Scales

The teachers’ ratings of perceived performance of 7 of the 16 children at school were similarly computed and graphed (Table 2). Of the 7 children reviewed by teachers, the rate of change varied from -6% (after 6 treatments) to 72% (after 18 treatments).

Table2: Teacher Rating Scale: Improvement

Analysisof results using occupational performance constructs

To gain further information about the specific areas of performance that improved, or did not improve after therapy, the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) was employed. Items on the teacher and parent rating scales were grouped relative to their perceived placement within various constructs within the model. Three constructs were utilised: occupationalroles,occupational performance areas of self-

Table 2

maintenance, productivity, play and rest; and five component abilities, biomechanical, sensorimotor, cognitive, intrapersonal,

Table3: Rating Scale Items Categorised by Occupational PerformanceConstructs

interpersonal. Table 3 outlines how items from both the scales were able to fit the constructs in this particular model. Some items tapped more that one area.

table 3

Total scores for the following occupational performance areas were derived from pre and post treatment scores of items assumed to depict performance in the targeted area.

Total incremental scores were converted to percentage scores which depict the total percentage of perceived improvement in each area. This process was completed for both the teacher and parent rating scales (Table 4).

OCCUPATIONALPERFORMANCE AREAS

Selfmaintenance

Parents identified an improvement in children’s performance of 18.5%. These items included those relating to mealtime, bedtime

Table4: Percentage of improvement in

occupationalperformance as rated by Parents and Teachers

routines, dressing routines.

Productivenessas a student

Data primarily from teacher’s information identified an average improvement of 17% in this area. Questions included those related to fine motor skills, scissor and pencil use, construction and letter formation, completing set work, following instructions, reading, spelling, maths, attention and maintaining emotional control and activity in the classroom.

Play

Parents (13.4%) and teachers (17%) noted improvements in this area through items that related to performance with different types of

Table 4

indoor and outdoor play in terms of fine motor, sensory motor, visual motor, independent and interactive play; as well as coordination and stamina.

Restand sleep

Parents registered the highest increment of improvement in this area (25%). Items related to the ability with which children were able to get to sleep and stay asleep and obtain the quantity of sleep needed for balanced daily activity.

COMPONENTPERFORMANCE

Biomechanical

Parents (15.5%) and teachers (13%) rated improvements in this area through items relating to how well the child managed fine motor skill, utensils, play on equipment, PE, classroom activity, pencil grip, drawing, writing and physical effort required for outdoor tasks.

SensoryMotor

Perceived improvements by parents (14.1%) and teachers (16%) was identified by items that related to vestibular/proprioceptive play on swings, trampolines, climbing equipment, motion sickness, PE and coordination in physical activities; tactile daily function including tolerance of hugs, textures in clothing, play and food, excessive touching behaviours as well as auditory and olfactory indicators.

Cognitive

Perceived improvements (parents, 11.9% and teachers, 18%) were derived from scores on items such as cognitive play such as puzzles, construction, computer, boardgames as well as dressing and following instructions; letter formation, completing set work, reading, spelling, maths, maintaining appropriate levels of attention.

Intrapersonal

Perceived improvements of parents (15.6%) and teachers (17%) were indicated through items such as being able to play alone without the need for adult direction, emotional control, frustration with self, self image, confidence in

abilities as well as basic tolerances to everyday touch and interaction. Teachers particularly noted improvements in positive attitude to physical activity and PE, decreased frustration with writing, being able to maintain appropriate emotional control and confidence in school work.

Interpersonal

Parents (17.6%) and teachers (16%) these rated percentages of improvements through items such as ability to play with others, being able to keep up with family activities, tolerance to being touched by others, emotional control in times of high environmental activity, maintaining friendships and following instructions.

Along with the interpersonal and intrapersonal perspective outlined above, several behaviours associated with the ‘core element’ (Chapparo & Ranka, 1996) diagnosis of attention deficit disorder were targeted for noted improvement. Parents (24.1%) and teachers (17.3%) rated improvements in being able to remain seated at the table, being able to get to sleep, emotionally in control, coping with changes and conflict, reduction in physical restlessness, being able to follow instructions and rules; being independent in organisation of work, completing set work, maintaining appropriate levels of attention, reduced fidgetiness and talkativeness.

DISCUSSION

Three implications arise from this pilot study. First, there is some empirical support for using sensory integrative procedures to improve occupational performance in children who have difficulties in everyday home and school tasks. Improvements, as perceived and rated by parents and teachers were variable across a number of children. Parents perceived the most dramatic improvements to be in the occupational performance areas of self maintenance and rest, and viewed the children as establishing functional roles in these dimensions. This is consistent with early claims made by Ayres (1972) who suggested that appropriate balance of excitation and inhibition of sensory processing is required for organisation of arousal and attention. As yet, however, few studies have looked at the relationships between rest and sleep occupations and sensory integrations that are seen clinically. Teachers noticed

improvements in most areas required by the children to establish functional occupational roles as students. Most noticeable improvements were in the cognitive skills required for the classroom. These findings are consistent with clinical reports of improvements that therapists notice as a result of sensory integrative procedures (Fisher, Murray, & Bundy, 1991).

Second, the rating scales, although in the early stages of development provide important information which can be used by therapists for planning further intervention, or documenting changes in performance. It is clear that the scales will require further development before they can be used as a sound research and clinical tool.

Third, the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) is an effective framework within which to demonstrate changes made in occupational therapy. The constructs within the model gave adequate scope to demonstrate the variability and complexity of individual gains made by these children.

CASESTUDY: K

To further illustrate how the rating scales can be used in practice guide intervention and to demonstrate performance outcomes for children who receive occupational therapy intervention, a case study of one child K will be discussed.

Backgroundinformation

K attended occupational therapy for an assessment of ability related to fine and gross motor coordination, attention and behaviour in the classroom. He presented as an active, inquisitive, and articulate boy, who needed firm expectations and a quiet environment to assist application to most tasks.

Assessment

A full sensory integration assessment was undertaken using the Sensory Integration and Praxis Test (Ayres, 1989). This assessment identified relative strengths in visual perception and visual-motor integration, but significant postural control, balance and bilateral coordination difficulties. He demonstrated good motor planning abilities, and only one low score on measures of tactile perception.

In view of his broad areas of difficulty, and a

family history of dyslexia, K was referred for psychometric assessment. This indicated that K, at 6 years 1 month, was underachieving by around a year below his intellectual potential in written language skills due to significant attention deficit disorder. This affected concentration, recall and work output, and some minor phonic confusions based on sequential memory weaknesses.

His parents were not interested in trialing psycho-stimulant medication to assist his attention, as suggested by the psychologist, but elected to proceed with her additional recommendation of occupational therapy utilising sensory integration therapy. The speech pathologist established that K was progressing well with his literacy skills, and that no intervention was required at this stage.

RatingScales

On the initial rating scales completed by the parents, two fifths of the measures were rated as a ’1′, primarily reflecting difficulties with dressing, sleep, soiling, and wetting, tolerance of touch from others, noise, self image, frustration with himself, coping with conflict and others and physical restlessness.

His teacher rated two thirds of K’s measures as a ’4′ or ’5′, with gross motor coordination, maths, construction and stamina being of no concern. Scores of between ’1′ and ’3′ reflected more concerns with fine motor skills using scissors and pencil grip, following instruction, attending, talkativeness and maintaining concentration for extended periods. Problems with K’s tendencies to harass and bully other children were of concern.

Therapy

In therapy, tasks were initially chosen to develop processing of movement as it related to postural motor control, balance and coordination. However, due to his overreaction to such tasks, therapy was modified to provide moderate amounts of proprioceptive and touch input with muscle resistance to develop postural tone, equilibrium and lower his levels of arousal.

K sought out large amounts of tactile based tasks in the first half of the total programme. Skills training with letter and number formation and tying shoelaces was undertaken with K firmly

wrapped or seated in rugs, cushions and other tactile environments that provided firm body pressure. Introduction of more dynamic forms of movement equipment was gradual.

Therapy concluded when he was accepted into an occupational therapy programme at a local public hospital.

The Rating Scales indicated that the biggest changes (of 3 or 4 points on the scale) occurred at home in his fine motor play, balance, stamina, sleep, being free from soiling and wetting, tolerance of touch from others, and reduction in motion sickness. Improvements of one grade included construction, playing by himself both indoors and outdoors, use of utensils and remaining seated at mealtime.

The teacher’s Rating Scale at the conclusion of treatment indicated a marked change in K’s abilities and adjustment at school with 29 of the 30 measures being a ’4′ or ’5′. Improvements of two points on the scale included letter and number formation, following group instructions, reading and spelling. Changes of one point included reduction in fidgetiness, maintaining appropriate levels of attention, writing without frustration and scissor and drawing skills. K was only occasionally harassing other children.

In K’s case, the Rating Scales clearly defined the changes that had occurred over many occupational performance areas of the child’s everyday life. It would be been impossible to define these changes based on any other formal clinical assessment.

SUMMARY

Preliminary use and interpretation of the Parent and Teacher Sensory Integration Rating Scales to measure trends of change in the lives of children undergoing sensory integration therapy has been encouraging. The results, when considered clinically, support the use of sensory integrative procedures to improve occupational performance. Interpretation of the results of the rating scales are made more meaningful by using the Occupational Performance Model (Australia). The use of the model enabled identification of both broad and specific areas of benefit which are regularly appreciated by parents and teachers, but are often not illustrated by formal reassessment procedures used. Further development of the scales will hopefully result

in a useful tool which can be used by therapists to illustrated the effectiveness of their programmes.

REFERENCE

Ayres, A.J. (1964) Tactile functions: Their relation to hyperactive and perceptual motor behaviour. American Journal of OccupationalTherapy, 18. 83-95

Ayres, A.J. (1972a) Improving academic scores through sensory

integration. Journal of Learning Disabilities5. 336-343

Ayres, A.J. (1972b) Sensory integration and learning disorders.

Los Angeles: Western Psychological Services.

Ayres, A.J. (1974b) Sensory integrative processes neuropsychological learning disability. In A. Henderson, L. Lorens, E Guilfoyle, C. Meyers, & S. Prevel (eds.). The development of sensoryintegrative theory and practice: A collection of the work of A JearnAyres. (pp. 96-113). Dubuque,IA: Kendall/Hunt.

Ayres, A.J. (1977) The effect of sensory integrative therapy on the coordination of children with choreoathetoid movements. AmericanJournal of Occupational Therapy. 31(5) 291-294

Ayres, A. J. (1978) Learning disabilities and the vestibular system. Journal of Learning Disabilities 11(1), 18-22

Ayres, A. J. (1979) Sensory Integration and the child. Los

Angeles: Western Psychological Services.

Ayres, A.J. & Mailloux, Z. (1981) Influence of sensory integration procedures on language development. American Journal ofOccupational Therapy 35(6) 383-388

Ayres, A.J. & Tickle, L. (1980) Hyperresponsivity to touch and

vestibular stimuli s predictor of positive response to sensory integrati on procedures in autistic children.American Journal of OccupationalTherapy. 34(6) 375-340

Fisher, A. G., Murray, E.A., & Bundy, A.C. (Eds.). (1991) Sensoryintegration theory and practice.. Philadelphia: F.A. Davis Co.

Kidder, & Judd, (1986) Methods in social relations. New York: Holt, Reinhart & Winston

Sensory Integration Information Sheet, (1991) Sensory IntegrationQuarterly, 19.1

The immediate effects of three occupational therapy interventions on specific play behaviours of three children with developmental disability

Kylie Wilkinson, Christine Chapparo

Kylie Wilkinson BAppSc(OT)(Hons), at the time of writing this paper was an occupational therapist working with the Commonwealth Rehabilitation Service. This paper contains work that was generated as part of her honours thesis, completed in the School of Occupational Therapy, The University of Sydney

Christine Chapparo MA,DipOT,OTR,FAOTA is a senior lecturer at the School of Occupational Therapy, The University of Sydney

Children with severe and multiple disabilities “constitute a substantial portion of the total occupational therapy population” (Clancy & Clarke, 1990,p.162). As members of most therapy and educational service delivery teams, occupational therapists are often asked to assume prominent roles in designing and implementing therapeutic programs for these children. Although they are often classified according to their sensory, motor or intellectual impairment, they are regarded by occupational therapists as first and foremost whole, multifaceted individuals with unique existence in the social and physical world (Nelson, 1984). Each child’s developmental needs are broad, deep and complex, radiating into all aspects of occupational performance. While improving performance of occupational tasks in areas of self-maintenance, school, play and rest are important concerns, establishing an occupational identity through occupational roles, is considered fundamental to occupational therapy intervention for children with multiple disability.

One proposition implicit in the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) is that the role of player, with its associated play behaviours and component elements, is a primary occupational role of children. Of the broad categories of occupational performance, play is particularly deficient in most children with developmental disability (Nelson, 1984). Reportedly, children with multiple sensory, motor and intellectual disabilities have difficulty developing and engaging in play behaviours due to a variety of deficits. Whereas school and self-maintenance tasks can be taught in a systematic fashion, play does not appear to change in response to similar instructional strategies. Nelson (1984) hypothesises that this is due to the nature of play itself, the essential component of which is that it is not directed by others. Similarly, various researchers have found that cognitive, sensorimotor and perceptual component deficits are not able to account for deficient play performance in populations of children with multiple developmental disabilities. Moreover, current assessment tools available to occupational therapists are unable to describe play patterns and play deficits in children with developmental disorders (Bundy, 1991; Parham, 1992). Behaviours which appear to interfere most often with their ability to perform play and school tasks include diminished attention to the environment, high levels of stereotyped or self-absorbed behaviour, passivity, lack of initiative and poor self expression (Nelson, 1984).

Given that play is a complex phenomenon and that occupational therapists consider play to be a primary occupational role of childhood (Reilly, 1974; Fisher, Murray & Bundy, 1991; Keilhofner, 1985; Pratt, 1989), few occupational therapy researchers or theorists have examined play in terms of the performance components that underlie it (Morrison, Bundy & Fisher, 1991). Fewer still have examined play deficits which exist in children with multiple disabilities, or have sought to determine styles of occupational therapy intervention that are effective in facilitating playfulness.

Therapists who work with children who have disabilities adopt three approaches to direct intervention to improve play responses. First, the most traditional form of therapy advocates the development of adaptive play skills through the use of play tasks that are directed by the therapist (Blanche, 1992; Demchak, 1990; Gallagher & Berkson, 1986; Geniale et al, 1986; Josefowicz, 1980; Penso, 1987; Riley, 1980; Sent & Marks, 1989; Vassallo, 1986). Second, therapists who work specifically with children who have visual and hearing impairments apply additional visual and auditory stimulation during play occupations to assist the child to be more aware of and responsive to the environment (Alice Betteridge School, 1988; Allard, 1983; Anderson et al, 1987; Armstrong & Rennies, 1986; Blanksby, 1992; Caplan & Caplan, 1974; Cummings, 1989; Erhardt, 1987; Freeman, 1975; Goetz & Gee, 1987; Lee, 1977; Michelman, 1971; Pratt & Allen, 1989; Snow, 1989; Stewart et al, 1991). Third, and more recently, therapists employ added touch and movement stimulation that is embedded in play occupations through the use of sensory integrative procedures (Ayres, 1979; Arendt et al, 1988; Clark, Mailloux & Parham, 1989; Fisher, et al, 1991; Kanter et al, 1982; Kimball, 1988; Nelson, 1984; Ottenbacher & Short, 1981; Pratt & Allen, 1989). Additionally, children seek play during solitary times and it is during this type of play that environmental properties are learned and mastery of the environment during play is reinforced (Lehrer, 1981).

These three models of intervention and as well as solitary play all lie within the following general principles of occupational therapy and occupational performance specifically (Christiansen, 1991):

The child is viewed as an active participant in developing an occupational identity
2) The occupational therapist is viewed as facilitator or teacher
3) The intervention setting is viewed as an environment for developing occupational performance skills and roles
4) Occupation is the preferred intervention medium

There is no consensus to be derived from research studying the effectiveness of any of these three therapy interventions for children with developmental disabilities. While some reports suggest that sensory integration is able to elicit better adaptive responses than control models (Chapparo, Hummell, Macmillan, & Rumble, 1991), other reports contradict these findings. Many of these studies have employed large numbers of children involving comparative groups research designs and reviews of these studies are commonly characterised by criticisms of methodology (Cermack & Henderson, 1990).

Suggestions for more appropriate directions for research have included tailoring research designs to reflect the individual nature of the therapy and to the development of methods to measure small changes in behaviour that are both relevant and important to the child’s occupational performance (Cermack & Henderson, 1990; Ottenbacher, 1991). Cermack and Henderson (1990), for example proposed that research into the effects of sensory integrative procedures involve assessment areas not traditionally measured such as play skills, attention, affect and exploratory behaviour.

PURPOSE OF THE STUDY

The purpose of this study was to determine:

1) The immediate effect of sensory integrative procedures; adaptive play; and play using additional auditory/visual stimulation during therapy on the following components of self-directed play responses in children with multiple sensory, motor and intellectual disabilities:

a. time spent and amount of vocalisation
b. duration of enjoyment
c. time spent in on-task play behaviour (attention)
d. time spent in non-participatory intermission behaviour (passivity)
e. time spent in self absorbed and stereotypic behaviour

RESEARCH DESIGN

This study used a repeated measures within subject single system design with multiple measures across multiple subjects (Ott, 1988; Ottenbacher, 1986). In this design, the intervention is introduced after a baseline has been established. Each participant is then randomly exposed to each of the treatments a set number of consecutive times. The random order controls for carryover effects where it is not possible to withhold treatment to allow washout of previous treatments. To best demonstrate effect, three children were studied. This allowed a maximum number of controls to be applied within the time constraints of the researchers.

METHODS

Subjects

Three children with visual, hearing, motor and intellectual deficits served as subjects (C1, C2, and C3). Two were aged 8 and one 7 years, all were male and attended the same special school for children with visual and hearing impairment. Each child had observable deficits in play behaviours relative to their age and school/family expectations that were characterised by poor attention span, poor initiation of play activity, stereotypic and self-absorbed behaviours. Two children communicated through words, although at low level, one child communicated primarily through vocalisations, eye gaze and other gestures. All three children were familiar with the therapist who carried out the interventions. Detailed descriptions of each child were constructed prior to beginning the study from therapy reports, and observations of therapy and classroom performance. The detailed descriptions were then used to determine the play variables that were to be studied.

Definition of variables

a. Sensory integration procedures.
Sensory integration involves receiving and processing of sensory information for use (Ayres, 1972) to promote the output of adaptive behaviour such as play. For the purposes of this study, sensory integrative procedures were operationally defined as play activity negotiated between therapist and child that incorporates sensory stimulation through the use of specialised therapy equipment such as swings, bolsters, and moveable surfaces.
b. Adaptive play procedures.
Play activity that involves the child playing with a number of familiar and liked activities with direction and help from the therapist. Direction and help is in the form of verbal direction and positioning. The procedures did not include sensory integrative equipment.
c. Play with additional auditory/visual stimulation.
Play activities with a set number of familiar and liked activities with additional visual and auditory stimulation provided by tapes of age appropriate music and videotaped moving pictures that changed format every 30 – 60 seconds. The treatment setting did not include touch and movement stimulatory equipment.
d. Solitary play.
Play activities with a set number of familiar and liked activities positioned so that the child could make an active choice. The therapist was not present to give direction, and the child was not able to interact with any specialised therapy equipment.

The following responses were measured and have been operationally defined as:

a. Vocalisation: (V)
Any available vocal sound produced from a single breath that was not characteristic of simple respiration. Excluded were coughs and hiccups. Included were words, work-like utterances, grunts, coos, squeals, and laughs (Hilke, 1987)
b. Attention to play as measured by on-task behaviour: (OTB)
The child actively attended to and worked on a task chosen, asked for , or given to them by the therapist. This may have been evidenced by looking at the task, looking at the therapist, manipulating objects, purposeful task related body movement, and seeking behaviours to extend play or prolong play.
c. Non-participatory intermission time behaviour: (NPIT)
Passive behaviour that was not purposefully task oriented, interacting with the therapist or actively seeking a new task to do. Self absorbed behaviour and enjoyment responses were not included as non-participatory intermission time.
d. Self absorbed or stereotypic behaviour:(SSB)
Responses of self-injurious behaviour such as head banging, eye poking, hand mouthing, slapping and head or hand shaking, rocking, swaying, posturing, and any other idiosyncratic repetitive, patterned, nonlocomotor movement.
e. Indications of enjoyment:(E)
isolated laughter, smiles and sudden glee.

ADMINISTRATION OF THE INTERVENTIONS

Sequence

The multiple baseline design consisted of 4 phases.

Phase 1 Baseline: The child was observed for up to six 20 minute sessions in solitary play with toys, without therapy involvement and no additional pieces of therapy equipment.
Phase 2: The child participated in adaptive play which was directed by the therapist for six consecutive 20 minute sessions.
Phase 3: The child participated in play activity that incorporated sensory integrative procedures for six consecutive 20 minute sessions.
Phase 4: The child participated in play activity that incorporated additional visual/auditory stimulation for six consecutive 20 minute sessions.

All children started with the baseline phase that involved solitary play, after which the children received the three interventions in varying order. This variation was used to control for changes being attributed to possible sequential effects of previously administered interventions. While it is recognised that there are 6 possible alternative intervention orders, only three have been used in this study due to time constraints of the children and the researchers. This was considered sufficient to demonstrate that a particular intervention had a consistent effect.

Therapist

One therapist administered all interventions. She was experienced in handling children with multiple sensory and motor disorders, and experienced in all the interventions offered. The therapist was not aware of the behaviours that were to be measured from videotaped records of the treatment sessions.

DATA COLLECTION SOURCES

Data was taken from two data sources at each treatment session. First, a videorecording was made of the session using simultaneous recording from two videocameras. This enabled the researchers to obtain close-up recording of the child’s face and body reactions as well as recording of the therapy events involving the therapist and equipment. Second, notes of each therapy session were kept, providing a description of any confounding events that occurred. In the opinion of the treating therapist, the effects of the presence of videocameras on the child’s reactions to intervention were unnoticeable and not confounding.

DATA CODING AND RECORDING PROCEDURES

As there are no standardised tests for the variables measured, data was collected using continuous recording of events (Mann, Have, Plunkett & Meisels, 1991). The rationale for choosing this specific technique is its record of acceptable interrater reliability (Eckerman et al, 1989). This method has been shown to be more accurate in reporting behaviours than time sampling with fixed intervals (Mann et al, 1991).

Validity and reliability of measures used

The recording methods used have established validity through their repeated use in research projects that measure or describe childrens’ play behaviours or the specific variables identified (Bright et al, 1981; Eckerman et al, 1989; Hilke, 1988; Mason & Iwata, 1990; Ottenbacher, 1983).

DATA ANALYSIS

Reliability of data analysis methods used

To enhance the reliability of data analysis, the following controls were imposed:

a) Information of target behaviours were identified and operationally defined (Ottenbacher, 1988).
b) To avoid pseudoconfirmation of results, reliability checks were performed by trained independent observers who also rated each child’s performance randomly for at least 1/3 of the data collected. This was equally distributed across experimental conditions to enable interrater reliability checks across the course of the investigation. Different raters were assigned to each phase to prevent bias over different phases.
c) To prevent observer drift (Kazdin, 1982), the independent observers did not receive feedback on the reliability of scoring and were unaware of the purpose of the research.
d) Intrarater reliability was conducted on 1/3 of the data. This was possible as all sessions were stored on videotape.

Interrater and intrarater reliability were obtained using SPSS (1990) intraclass correlation coefficient computer package. Total reliability measures were used for each corresponding session of treatment because continuous sampling was used. While this is not a conservative measure, it is considered appropriate where overall duration is used to measure the dependent variable (Lagrow & Prochnow-Lagrow, 1983). The results of this analysis ranged from .80 to .99, demonstrating high levels of interrater and intrarater agreement.

Validity

To enhance internal and external validity of the study, the following controls were imposed:

a) The repeated measure design across subjects allowed for the systematic replication of intervention effects.
b) Bias was reduced by independent data checks.
c) The threat of multiple intervention interference was minimised by changing the order of the intervention phases for each child.
d) Maturation was controlled for by using short term intervention phases, measuring immediacy of response and applying the interventions in different order for each child.
e) Novelty was controlled by using a therapist with whom all children were familiar.
f) Although inability to generalise findings is a weakness of this design, enough detail exists in this report for others to replicate the study (Hacker, 1980).
g) Although interpersonal interaction between therapist and child is assumed to be the same for all interventions, it was recognised that there may have been an unconscious occurring. McReynolds and Thompson (1986,p.202) state “it is essential that experimenters provide evidence that treatment was administered as described”. In this study, two sessions from each of the interventions were observed and described by independent raters. They were then asked to compare the definitions of the individual interventions to the descriptions of intervention observed and comment on the accuracy of treatment administration. The validity of the content of interventions was confirmed.

Data Analysis Methods

An autocorrelation coefficient of adjacent data points of less than .82 in all phases was obtained indicating the absence of significant serial dependency (Ottenbacher, 1986). Visual and statistical analysis was then applied to the data (Figures 1 – 5).

Initially, visual interpretation of the data was undertaken to determine whether differences occurred in behavioural outcomes due to immediate effects of the three interventions. Where appropriate, this consisted of looking at the level, variability, slope, mean and trend of the data.

Statistical analyses were then performed for the following reasons:

a) baseline data were found to be unstable
b) there was a large amount of intrasubject variability
c) small improvements not detectable by visual analyses alone may have been significant

Non-parametric tests were employed. As there were four levels of within subject measurements in the repeated measures design, a Friedman two way analysis of variance (ANOVA) using ranks was first computed to determine the presence of significant difference between the three interventions and the baseline phase (SPSS,1990). Two level Wilcoxon signed-ranks tests were then used to discover the source of significant difference between each of the four phases in comparison to the others (Tables 2,4,6,8 and 10).

RESULTS

In this paper, selected results of the visual and statistical analyses are outlined for each of five dependent variables: vocalisation, enjoyment, on task behaviour, non participatory intermission time and self absorbed behaviour. For each behaviour, visual analyses will be presented followed by statistical analysis. Although selected results only are highlighted and discussed, all data generated are available to the reader on figures and tables accompanying each variable result.

Vocalisation (V)

Visual Analysis

Across the four phases for each of the three children in the study, sensory integrative procedures produced the highest mean duration of vocalisation (Table 1). There was no consistency in the slope of the trend line for any of the interventions shown (Figure 1). Differences in levels, as listed in Table 1, were greatest in C1 and C2 for sensory integrative procedures in comparison to other procedures and greatest in C3′s adaptive play and sensory integrative procedures than the other two phases. Data was variable across the three children and across the four treatments as can be seen in Table 1. While it is optimal to achieve high variability scores (above 85%) to demonstrate consistent outcomes of treatment, the scores are still clinically useful in this study. All three children had multiple disabilities characterised by emerging behaviours and their behaviour in everyday situations as well as therapy was variable.

appeffects_001_large

appeffects_002_large

 

 

Statistical Analysis (Vocalisation)

As shown in Table 2, no consistent significant differences occurred between individual treatments across all three children when the Wilcoxon signed ranks tests were computed. For C1, sensory integrative procedures had a greater immediate effects on vocalisation than did adaptive play. Sensory integrative procedures also produced greater immediate effects in comparison to additional audio/visual sensory stimulation and baseline freeplay scores for C2. Additional audio/visual sensory stimulation produced a greater immediate effect on vocalisation than freeplay but less than the immediate effects of adaptive play. For C3, both adaptive play had greater immediate effects on vocalisation than additional audio/visual stimulation. All other differences noted visually were not statistically significant.

 

appeffects_003_large

 

Enjoyment (E)

Visual Analysis

Of the enjoyment measures for each of the four phases shown in Figure 2, sensory integrative procedures consistently produced the highest immediate treatment effects. This is depicted by the highest mean levels and the highest individual treatment value for enjoyment being found in sensory integrative procedures for C1, C2 and C3 (Table 3). Table 3 shows slope and trend to be inconsistent across phases and children, with all three children showing the greatest slope in different intervention phases.

appeffects_005_large appeffects_004_large

 

 

Statistical Analysis

For each child, sensory integrative procedures achieved an acceptable level of significance with a higher immediate effect on enjoyment than baseline freeplay for C1, C2 and C3 (Table 4). The Wilcoxon signed-ranks tests revealed sensory integrative procedures to be the intervention phase that facilitated the greatest amount of enjoyment in comparison to other treatments (Table 4), except for adaptive play (C2) and audio/visual stimulation (C1).

appeffects_006_large

 

 

On Task Behaviour (OTB)

Visual Analysis (Figure 3)

On task behaviour as shown in Figure 3 and Table 5, recorded the highest mean duration score during the sensory integration phase of intervention. For C1 and C2, this immediate effect on on task behaviour was almost 100% greater than all other interventions. Adaptive play for C2 and C3 and audio/visual stimulation for C1 produced the second highest immediate effects on on task scores. The lowest scores were consistently baseline freeplay phases in both children possibly showing the difference in therapist child interaction in comparison to a non-therapist situation.

Slope, as with other behaviours measured, is inconsistent. The level between sensory integrative procedures and all the other phases was always the highest at the beginning of sensory integration phases as seen in Table 5. 100% variability was scored for sensory integrative procedures for each of the three children, and scores show values close to the full twenty minutes time period for each child.

appeffects_008_large appeffects_007_large

 

Statistical Analysis (On task behaviour)

The only significant results from the ANOVA in Table 6 is for C3 with sensory integrative procedures resulting in a higher level of on task behaviour than baseline freeplay. C1 and C2 had similar results with levels approaching significance.

The Wilcoxon signed-ranks test presented in Table 6 supports the visual analysis whereby sensory integrative procedures produced the greatest immediate effect on on task behaviour in comparison to other treatments across all three children.

appeffects_009_large

 

 

Non Participatory Intermission Time

Visual Analysis (Figure 4)

Sensory integrative phase mean scores for immediate effects on non participatory intermission time was the lowest of all interventions across the four phases (Table 7).

Each of the three children achieved an optimal score of zero passivity (NPIT) during sensory integrative procedures. This score was not achieved during any other intervention.

appeffects_010_large appeffects_011_large

 

 

Statistical Analysis (NPIT)

The immediate effects of sensory integrative procedures were significant, producing the lowest level of non participatory intermission time across all three children in comparison to baseline phases (Table 8). After application of the Wilcoxon signed-ranks tests to the data, sensory integration was found to produce the lowest significant difference across all treatments in all children. Significant differences were found also in C2 between adaptive play and baseline freeplay.

appeffects_012_large

 

Self Absorbed and Stereotypic Behaviour (SSB)

Visual Analysis (Figure 5)

The lowest mean score of self absorbed and stereotypic behaviour (SSB) as seen in Table 9 was produced during the sensory integration phase of intervention. The most negative slopes were found in C1 and C2 during adaptive play and during the additional audio/visual stimulation phase for C3 (Figure 5). This shows beneficial trend lines for these interventions even though the interventions show higher means than the sensory integrative phase.

appeffects_014_large appeffects_013_large

 

Statistical Analysis(SSB)

A statistically significant lower amount of self absorbed and stereotypic behaviour was found in comparison to baseline freeplay in C1, C2 and C3 after application of Friedman’s ANOVA to the data.

The Wilcoxon signed-ranks test confirms these claims. Other significant differences between treatments included lower level of SSB during sensory integration when compared to adaptive play and audio/visual stimulation in C1 and lower SSB in C2 in comparison to audiovisual stimulation.

appeffects_015_large

 

SUMMARY

Visual analysis of the data suggested that sensory integrative procedures produced the highest mean scores for vocalisation, enjoyment and on task behaviour for C1, C2 and C3 in comparison to baseline freeplay. In addition, non participatory intermission time, and self absorbed and stereotypic behaviour scores were lowest during sensory integration phases of treatment for all three children.

Statistically, however, the superiority of the sensory integrative procedures was not consistently demonstrated.

Vocalisation scores were only significantly higher during the sensory integration phase for C1 than adaptive play and baseline freeplay.

Enjoyment scores were significantly higher during the sensory integration phase for C1 in comparison to adaptive play and baseline only; and for C2 in comparison to audio/visual stimulation. For C3, sensory integration achieved higher enjoyment scores than all other phases.

C1, C2 and C3′s on task behaviour was significantly higher than baseline freeplay scores, but not in comparison to other interventions.

Sensory integrative procedures produced non participatory intermission time scores that were lower than all other interventions indicating the least passivity occurred during this intervention phase across all children.

Finally, sensory integrative procedures produced significantly less self absorbed and stereotypic behaviour than all other interventions except adaptive play for C2.

DISCUSSION

The findings of this study are similar to other studies that have researched the link between sensory integration, vocalisation and language. Many of these studies, however, reportedly did not use sensory integrative procedures correctly (Ottenbacher, 1983; Brody et al, 1977; Magrun, et al, 1981; Delly, 1987; Reilly et al, 1983; Kanter, et al, 1982). Others were able to offer no empirical evidence (Behan, 1979). Both Carlsen (1975) and Kanter et al, (1982) found no significant difference between sensory integration and other types of treatment. This study provides some empirical evidence to support the use of sensory integrative procedures with children who have multiple disabilities. However, there are no significant differences between sensory integrative procedures and other interventions for C3′s vocalisation. C3 had a higher level of vocalisation before intervention was introduced than did C1 and C2. This may be why the effects for C3 were not as great. Brody et al, (1977) reported similar findings whereby a child made better gains as a result of sensory integrative procedures if the child had moderate levels of vocalisation. It would seem therefore, that the use of sensory integrative procedures is an appropriate form of intervention for early production of vocalisations and words. This type of communication is vital for social interactions that form a part of social occupations such as play.

It is reported that too much sensory input or too little can contribute to disorganisation which in turn disrupts occupational performance (Fisher, Murray & Bundy, 1991). Just the right amount of arousal is required for enjoyment. For this reason, it could be hypothesised that if a child derives pleasure from the intervention, then organisation occurring is adaptive (Fisher, Murray & Bundy, 1991). Enjoyment can be interpreted as a type of purposeful interaction with the environment that is an integral part of play. Fun, expressed through enjoyment, is therefore an important product of occupational therapy intervention that assists the child to initiate and maintain social interaction necessary for play occupations.

The positive effect of sensory integrative procedures seen in this study is possibly due to several aspects of the sensory integrative mode of treatment. First, the treatment offered challenge within supported equipment. Second, the therapist was involved as a co-player in all activities and could quickly grade them according to the child’s reactions. Third, while choice is inherent to all interventions that promote occupational performance (Chapparo & Ranka, 1996), with these children, sensory integrative procedures gave the child the greatest amount of control over choice during intervention. These findings are consistent with studies reported by Weeks (1979) and Leveille (1981) who found that sensory integrative procedures promoted enjoyment. In these two studies, however, Weeks (1979) had no control group and Leveille (1981) used descriptive case study methods. This study provides empirical support for the notion that sensory integrative procedures provide immediate enjoyment as part of the play response. This enjoyment, in turn, contributes not only to social interaction, but also to the child’s ability to modulate sensory experiences.

Appropriate balance of excitation and inhibition of sensory stimuli is required for the organisation of attention. Ayres (1972) stated that movement is one of the most powerful organisers of this balance. Movement is said to allow active involvement of the child with the visual and motor experience as opposed to a passive experience such as looking at pictures. It helps in the focussing of attention by integrating touch, movement and vision (Fisher, Murray & Bundy, 1991). That sensory integrative procedures have a beneficial effect on attention has been reported by many authors (Behan, 1979; Leveille, 1981; Scheider et al, 1991; Geniale, 1986; Wilson, 1979). In this study, all children benefited from the immediate effects of sensory integrative procedures on attention. It yielded statistically significant greater effects than baseline freeplay, but no consistent significant differences in comparison to other forms of intervention. From a clinical perspective, however, all the children achieved the greatest mean attention scores during the sensory integrative phase of intervention. Attention to task is necessary for social interaction, for imitating others and for inhibiting inappropriate behaviours. Attention is stimulated readily in a novel environment. This may explain why sensory integrative procedures are more effective than other interventions in gaining attention. In comparison to the other interventions used, sensory integrative procedures included novelty as an integral part of the treatment process. Although the continually changing audio/visual stimulation provided novelty, it resulted in poor attention to task. With these children, this type of stimulation appeared to act more as a distracter, causing an overload of input that could not be actively inhibited by the child.

Overload of excitatory input or underarousal may promote non participatory behaviour. Sensory integrative procedures in this study produced significantly less non participatory behaviour in comparison to all other interventions. This may be due to the co player role of the therapist, or the challenge of the treatment (Fisher, Murray & Bundy, 1991). Active participation was a requirement of the treatment. Other forms of intervention used in this study did not appear to offer the range of activities and supportively stimulating equipment to keep the children consistently actively involved in therapy.

Children with severe disabilities have a limited repertoire of play and movement skills (Nelson, 1984). The movements used by them during the course of everyday activities are stereotypic, rather than varied and purposeful. Purposeful occupational performance requires purposeful social interaction that demands self absorbed behaviours be kept at a minimum (Nelson, 1984). Sensory integrative procedures in this study resulted in significantly lower levels of self absorbed behaviour than any other intervention. Previous studies have also reported sensory integrative procedures to be effective in reducing self absorbed behaviour. One exception to produce consistent positive results was as study by Mason & Iwata, (1990), however, these researchers failed to demonstrate whether purposeful activity or therapist interaction was an integral part of the intervention applied.

Using single subject methodology, this study has demonstrated that occupational therapy interventions employing play occupations are useful for three children with severe multiple disabilities in increasing vocalisation, attention to task, and in decreasing self absorbed and stereotypic behaviour and passivity. When comparing the three interventions, the study demonstrated that the immediate effects of sensory integrative procedures within a play context were superior to other modes of intervention in decreasing self absorbed and stereotypic behaviour and passivity. Sensory integrative procedures also functioned to increase the amount of vocalisation, on task behaviour and enjoyment during play occupations, but with no consistent significant differences from other interventions. While not all changes were statistically significant, the immediate effects of sensory integrative procedures consistently produced the highest mean directions for vocalisations, enjoyment and on-task behaviour. Tentative conclusions that can be drawn from this study suggest that sensory integrative procedures are an effective form of intervention for this population of children to facilitate behaviours required for the occupational role of player.

The focus of this study was on immediate effects of occupational therapy intervention, as opposed to long term effects. Many therapists base long term treatment modes on the initial reactions obtained during short pilot periods of therapy. The assumption is that if a child can achieve observable improvement in a target behaviour in the short term, the child could achieve the same results with more consistency with further intervention of the same mode. This assumption has to be supported by further research into long term outcomes of a variety of interventions. The limitations of this study are recognised. Small sample size restricts generalisability. Further replication studies are required. The scope of play behaviours studied are limited. Increased numbers of behaviours that support the occupational role of player need to be investigated. Considering the variability in some of the results, it is evident that larger clinical trials are needed to identify those children who could be considered optimum candidates for various forms of intervention.

The broader significance of this study lies in its identification of sensory integration as a therapy mode that contributes to the development of the occupational role of player in children with multiple and severe disabilities.

ACKNOWLEDGMENTS

The authors wish to acknowledge the contributions of the following people to this study: the three children who participated in the study and their families; Jill Hummell DipOT,BA,MA; and the staff of the Institute for Deaf and Blind Children, Norths Rocks.

References

Alice Betteridge School (1988) Information pamphlet on audio vi sual stimulation. Speech Pathology Department, Alice Betteridge School, North Rocks Rd., North Rocks, 2151

Allard, J. (1987) New ways with lighting. Kidderminster: Alexander Patterson School, Unpublished paper.

Anderson, J., Hinoojosa, J., & Strauch, C. (1987) Integrating play in neurodevelopmental treatment. American Journal of Occupational Therapy, 41(7), 421-426

Arendt, R., Maclean, W., & Baumeister, A. (1988) Critique of sensory integration therapy and its application in mental retardation. American Journal on Mental Retardation, 92(5), 401-411

Armstrong, J.E., & Rennie, J. (1986) We can use computers too. The setting up of aproject for mentally handicapped residents. British Journal of Occupational Therapy, 49(9), 297-300

Ayres, A. J. (1979) Sensory integration and the child. Los Angeles: Western Psychological Services

Ayres, A. J. (1972) Sensory integration and learning disorders.. Los Angeles: Western Psychological Services.

Blanche, E. J. (1992) Creativity in sensory integrative treatment. Sensory Integration Special Interest Section Newsletter, 15(1), 3-4

Blanksby, D.C. (1992) Visual therapy: a theoretically based intervention program. Journal of Visual Impairment & Blindness, September, 291-294

Bright, T., Bittick, K., & Fleeman, B. (1981) Reduction of self-injurious behaviour using sensory integrative techniques. American Journal of Occupational Therapy, 35(3), 167-172

Brody, J. F., Thomas, J.A., Brody, D.M., Kucherway, D.A. (1977) Comparison of sensory integration and operant methods for production of vocalisation in profoundly retarded adults. Perceptual and Motor Skills. 44, 1283-1296

Caplan, F., & Caplan, T. (1974) The power of play. Garden City: Anchor Books

Carlsen, P. N. (1975) Comparison of two occupational therapy approaches for treating the young cerebral palsied child. American Journal of Occupational Therapy. 29(5), 267-272

Cermack, S., & Henderson, A. (1990) The efficiency of sensory integrative procedures. Sensory Integration Quarterly, XVIII(1), 1-5

Chapparo, C., Hummell, J., MacMillan, C., & Rumble, D. (1991) Effects of sensory integration on social interaction skills. Proceedings of the 14th Federal Congress of the Australian Association of Occupational Therapists. Adelaide: AAOT

Chapparo, C., & Ranka, J. (1996) The occupational performance model (Australia): Draft Manuscript. School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, East St., Lidcombe. NSW. Australia. 2141. May.

Christiansen, C. (1991) Occupational therapy. Intervention for life performance. In C. Christiansen & C. Baum (Eds.). Occupational therapy: Overcoming human performance deficits. (pp.3-43). Thorofare: Slack Inc.

Clark, F., Mailloux, Z., & Parham, D. (1989) Sensory integration and children with learning disabilities. In P.N.Pratt & A.S.Allen (Eds.). Occupational therapy for children. (2nd Ed.). (pp457-507). St. Louis: The C.V.Mosby Co.

Cummings, F. J. (1989) Children with communicative impairment. In P.N.Pratt & A.S.Allen (Eds.). Occupational therapy for children (2nd ed.). (pp.442-456). St. Louis: C.V.Mosby Co.

Demchak, A. (1990) Response prompting and fading methods: a review. American Journal of Mental Retardation, 94(6) 603-615

Eckerman, C.O., Davis, C.C., & Didow, S.M. (1989) Toddler’s emerging ways of achieving social coordinations with a peer. Child Development. 60, 440-453

Erhardt, R.P. (1987) Sequential levels in the visual-motor development of a child with cerebral palsy. The American Journal of Occupational Therapy, 41(1), 43-49

Fisher, A., Murray, E., & Bundy, A. (1991) Sensory integration theory and practice. Philadelphia: F.A.Davis Co.

Freeman, P. (1975) Understanding the deaf and blind child. London: Heinemann Health Books.

Gallagher, R.J., & Perkson, G. (1986) Effect of intervention techniques in reducing stereotypic hand gazing in young severely disabled children. (2), 170-177

Geniale, P., Graham, F. & Quee, B. (1986) Occupational therapy at the special school. Lantern Light. November/December, 6-7

Goetz, L, & Gee, K. (1987) Functional vision programming. A model for teaching visual behaviours in natural contexts. In L.Goetz, D.Guess & K.Stremmel-Campbell (Eds.), Innovative program design for individuals with dual sensory impairments (pp. 77-97). Baltimore:Paul Brooks

Hacker, B. (1980) Single subject research strategies in occupational therapy. Part 1. American Journal of Occupational Therapy, 34(2), 103-108

Hilke, D.D. (1988) Inant vocalisation and changes in experience. Journal of Child Language. 15, 1-15

Iwasaki, K., & Holm, M.B. (1989) Sensory treatment for the reduction of stereotypic behaviours in persons with severe multiple disabilities. Occupational Therapy Journal of Research. 9(3), 170-183

Josefowicz, A. (1980) Preparing the young handicapped child for school. British Journal of Occupational Therapy, 43(7), 230-232

Kanter, R.M., Kanter, B., & Clark, D.L. (1982) Vestibular stimulation effect on language development in mentally retarded children. American Journal of Occupational Therapy, 36(1), 36-41

Kazdin, A. E. (1982) Single case research designs: Methods for clinical and applied settings. New York:Oxford University Press.

Kelly, G. (1987) Occupational therapy for speech and language for disordered children: A sensory integrative approach. British Journal of Occupational Therapy. 50(4), 128-131

Kimball, J. (1988) The emphasis is on intergration, not sensory. American Journal on Mental Retardation, 92(5), 423-424

Lagrow, S. J., Prochnow-Lagrow, J.E. (1983) Consistent methdological errors observed in single case studies: Suggested guidelines. Journal of Visual Impairment & Blindness, December, 481-488

Lee, C. (1977) The growth and development of children. London:Longman Group Ltd.

Lehrer, A. (1981) An occupational therapy pediatric research project in community integration. Canadian Journal of Occupational Therapy. 48(3), 115-119

Leveille, J. (1981) Outline of a sensory integrative approach with a chronic tactile defensive schizophrenic. British Journal of Occupational Therapy.( ). 160-162.

Magrun, W. M., Ottenbacher, K., McCue, S., & Keefe, R. (1981) Effects of vestibular stimulation on the spontaneous use of verbal language in developmentally delayed children. American Journal of Occupational Therapy, 35(2), 101-104

Mann, J., Have, T.T., Plunkett, J.W., & Meisels, S.J. (1991) Time sampling: A methodological critique. Child Development, 62, 227-241

Mason, S., & Iwata, B. (1990) Artificial effects of sensory integrative therapy on self-injurious behaviour. Journal of Applied Behaviour Analysis., 23(3), 361-370

Michelman, S. (1974) Play and deficit child. In M. Reilly (Ed.), Play as exploratory learning (pp. 157-207). Beverly Hills: Sage Publications

Nelson, D. (1984) Children with autism and other pervasive disorders of development and behaviour. New Jersey: Slack Publications

Ott, L. (1988) An introduction to statistical methods and data analysis. (3rd Ed.). Boston: PWS-Kent Publishing Co.

Ottenbacher, K. (1991) Research in sensory integration: Empirical perceptions and progress. In A. Fisher, E. Murray & A. Bundy (Eds.). Sensory integration theory and practice. (pp. 385-399) Philadelphia: F.A.Davis Co.

Ottenbacher, K. (1988) Sensory integration: myth, method and imperative. American Journal on Mental Retardation. 92(5), 425-426

Ottenbacher, K. (1986) Evaluating clinical change: Strategies for occupational and physical therapists. Baltimore: Williams & Wilkins

Ottenbacher, K. (1983) Developmental implications of clinically applied vestibular stimulation: a review. Physical Therapy. 63(3), 338-342

Ottenbacher, K., & Short, M. (1985) Sensory integration dysfunction in children: a review of theory and treatment. In D. Routh & M. Wolrich (Eds.). Advances in Development and Behaviour; Pediatrics. Vol.6. (pp. 286-329). Greenwich: JAI Press

Parham, L.D. (1992) Strategies for maintaining a playful atmosphere during therapy. (1), 2-3.

Penso, D.E. (1987) Occupational therapy for children with disbilities. London:Croom Helm

Pratt, P.N., & Allen, A.S. (Eds.). (1989) Occupational therapy for children (2nd Ed.). St. Louis:C.V.Mosby Co.

Reilly, C., Nelson, D. L., Bundy, A. G. (1983) Sensoimotor versus fine motor activities in eliciting voclalisation in autistic children. Occupational Therapy Journal of Research, 3(4), 199-212

Schneider, B.E., & Marks, H.E. (1989) Changes in preschool children’s IQ scores as a function of positioning. American Journal of Occupational Therapy, 43(10), 685-687

Sents, B.E., & Marks, H.E. (1989) Changes in preschool children’s IQ scores as a function of positioning. American Journal of Occupational Therapy, 43(10), 685-687

Snow, B. (1989) Children with visual or hearing impairment. In P.N.Pratt & A.S.Allen (Eds.). Occupational therapy for children (2nd Ed.) (pp.535-562). St. Louis: C.B.Mosby Co.

SPSS Inc. (1990) SPSS reference guide. Illinois: SPSS Inc.

Stewart, H.A., Ormond, C., & Seeger, A. (1991) Toy control program evaluation. American Journal of Occupational Therapy, 45(8), 707-711

Weeks, Z. (1979) Effects of the vestibular system on human development. Part 2. Effects of vestibular stimulation on mentally retarded, emotionally disturbed and learning disabled individuals. American Journal of Occupational Therapy. 87(6), 664-666

Wilson, E. B. (1979) Some impressions on the effect of sensory integrative therapy for children with learning disabiilties. Australian Occupational Therapy Journal. 26(1), 12-20

Using The Occupational Performance Model in practice: Developing intervention aims for a child with acute burns, and her mother.

Roman Weigl is an occupational therapist in the Department of Paediatrics at the Hospital of St. Pölten, St. Pölten, Austria, Europe.

INTRODUCTION

I am the sole occupational therapist in the department of paediatrics. There are three wards, one neonatal intensive care unit; one for children up to three years and one for children three to eighteen years. My role involves the assessment and management of children and their families. The children have various diagnoses, typically they have chronic illness, or they have had severe accidents, but also included are children with psychiatric, learning and developmental disorders.

PURPOSE

The purpose of this paper is to demonstrate how the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) has been applied within this setting to guide the scope and the focus of planned intervention.

This will be accomplished through examination of one case study. Using selected constructs within the model, discussion of the case will include an outline of:

1. Occupational role assessment of a child and her mother
2. Developing aims and setting goals for the child and her mother

CASE STUDY: ELKE AND MRS. R.

Elke is a five year old only child in a family with two working parents. She regularly attends kindergarten and spends time with her grandmother.

While at her grandmother’s house, Elke pulled a pot of boiling water from the stove and received severe scald burns to 25% of her body. Particularly affected were her right upper extremity, both shoulders and back, her right ear and neck.

Medical treatment consisted of cleaning of her wounds, wound debridement and plastic surgery to cover burned areas with Amnion and Xenotransplants. She was immobilised and positioned in an air bed and isolated to reduce the risk of infection. Her mother, Mrs. R. was able to room-in with Elke.

ASSESSMENT

Elke

This assessment was based on clinical observation of aspects of occupational performance, in response to a request for occupational therapy to assist in adjustment to hospitalisation.

Environment

The initial occupational therapy assessment of the child took place in her room in the Burn unit with the child positioned in supine in the air bed. Thick bandages covered all burned surfaces. Elke, her mother and therapist were the only people present. For hygienic reasons, there were a limited number of toys available. Assessment focussed initially on the perceived occupational roles of the child and her mother as well as their reactions to the injury and hospitalisation.

Occupational Role

Prior to her injury, Elke’s primary occupational roles were those of self maintainer and player. When seen, Elke showed no desire to interact with any other person, or objects, apart from her mother. Her primary occupational role performance was related to that of self maintainer - surviving this life threatening situation. To do this she sought constant emotional support and nurturing from her mother. Elke also fought against the often painful medical treatment. This behaviour too, related to Elke’s perception of survival in a sensory world that to her, was uncomfortable and threatening.

Elke showed no inclination to engage in play behaviours, even those that did not require physical activity. Three dimensions of her player role could be described relative to her perception of control, source of motivation to play and suspension of reality (Bundy, 1991; Ellis, 1973; Neumann, 1971). All three dimensions can be viewed from whether the locus of control is internally directed by the child or externally directed by others. The more the control is directed by external forces, the less the child is likely to show playfulness.

Perception of control refers to the child’s freedom to decide how to play, choose what and whom to play with (Neumann, 1971). This relates to the ‘doing’ aspects of occupational roles in the Occupational Performance Model (1996). Relative to play, Elke perceived she had no internal control. Much of her day was organised by the required medical treatments which, for the child, were frightening and painful.

The source of motivation relates to the child’s perception of the reward associated with the play. This aspect of play relates to the ‘knowing’ dimension of role in occupational performance. In Elke’s case, she knows that engagement in her usual play behaviours brings pain. There is no rewarding pleasure.

Suspension of reality refers to whether the child is able to temporarily suspend aspects of the real world situation to engage in an imagined situation. This relates to the ‘being’ dimension of role performance in occupational roles. Elke was forced by circumstances of pain, illness and the hospital environment to be constantly aware of all of the constraints of reality. It was not possible for her to even momentarily suspend reality to engage in imagined player roles – to ‘be’ anything other than a child who is burned.

Mrs. R.

Mrs. R., Elke’s mother, used her vacation time to stay with Elke 24 hours a day. Observations of her interaction with Elke over time showed that she had taken over every part of the child’s self maintenance tasks and routines. She rarely took a break to rest, or to engage in tasks and routines to maintain herself. Despite this, she still did not perceive that she was giving enough support to her child. Running through the interview were statements relative to her role as a mother, such, as “I’m not doing enough. I can’t help my child, I’m not a good mother to my child”. For Mrs. R., engagement in the occupational role performance of mother, by assisting her child with her daily care fulfilled the ‘doing’ aspects of role performance, but did not meet the ‘knowing’ aspect of the present role demands (“I don’t know what to do for my child”), and did not fulfil the satisfaction or ‘being’ dimensions of mothering (“I’m not a good mother to my child”). In addition, she voiced conflict between various cognitive and intrapersonal operations relative to her view of future occupational performance, thereby confounding her perceived ability to remain stable and supportive. For example, “It could have been worse” (cognitive) and “This is the worst thing that has happened to me” (intrapersonal).

Mrs. R. expressed a perceived lack of control in her role as a mother in the hospital situation. She verbalised need for additional personal support to maintain herself. They received visits from Mr. R. after his daily work, which was perceived as supportive, but there was no other self maintaining resource available to her. The grandmother’s visits were not viewed as supportive as she was dealing with her own severe feelings of guilt over the accident which had occurred at her house.

AIMS OF INTERVENTION

Severe burns cause major disruptions to a variety of elements of human function. The resulting disordered occupational performance can only be partly explained by the existing biomechanical and sensory motor damage. Children and their families have very individual reactions to the injury and each family unit requires individual consideration of the complex situation that exists.

In this case, the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996) was used to plan and prioretize occupational therapy aims and goals of intervention for Elke and her mother. This model is used as it offers the scope required for planning assessment and intervention for children with severe burns and their families. In this hospital, it has been useful in assisting the therapist to obtain a systematic overview of the child and the family and to determine in the acute stage of intervention, what would be the most useful therapeutic action.

The Process of Reasoning Using Occupational Performance

As explained by Chapparo (1996), use of the model in practice starts with determination of chosen or needed occupational roles.

Elke

a. Roles

Elke’s existing roles as determined by interview, history and observation were those of:

Player
Self-Maintainer
Kindergartener
Friend
Daughter

Through observation and talking with Elke and her mother, three of these occupational roles were prioretised and targeted for the focus of occupational therapy intervention: self-maintainer, rester and player. Self maintenance was necessary for the child to survive and begin to participate in her own care. Rest was required so that she could develop some daily rhythms of rest and activity, that were lost after the injury. Play is the prominent occupational role of childhood (Pratt & Allen, 1989), and one of the fundamental childhood occupations through which Elke could learn to cope with the prolonged physical and psychological pain experienced during hospitalisation. Participation of the mother and child together in each of these roles supported the integrated roles of daughter and mother.

b. Tasks and Routines required to support these targeted roles

The following tasks and routines were targeted for focus in occupational therapy intervention, as they related to the role performance, and became the aims for Elke’s occupational therapy.

Self maintainer

* to survive
* to develop healthy strategies for enduring intrusive medical procedures
* to become familiar with hospital routine and staff
* to develop strategies to cope with pain
* to eat and drink independently

Rester

* to develop usual routines of staying awake during the day and sleeping at night in preparation for going home

Player

* to have the desire to play
* to develop satisfying play strategies within the confining conditions, such as bandaging and skin grafting
* to have contact with a play partner
c. Components of occupational performance that are critical to the targeted roles and tasks

Biomechanical component

* to encourage movement in those joints and body segments that are not immobilised.

Intrapersonal component

* to develop the intrinsic motivation to move and participate in tasks and routines
* to develop a sense of control through self-maintenance, and play occupations.
* to develop a feeling of security within the hospital setting

Interpersonal component

* to find support through interaction with mother and others in the hospital environment

Cognitive component

* to build a knowledge store of medical and hospital procedures to reduce her fear of the unknown
* to assist Elke to rehearse and prepare cognitive strategies to cope with her daily medical routines in the form of games, counting, verbalisation and visualisation.
d. Core elements of occupational performance

Body

* to reduce the biomechanical constraints on everyday activity to the minimum
* to reduce pain and itching caused by burned tissue and grafting procedures

Mind

* to use the mind to imagine and visualise past and future events and temporarily suspend the reality of trauma

Spirit

* to support a sense of the will to live, and a purposefulness to daily activity
e. External Environment

The major difficulty faced at this point in care is the risk of environmental deprivation. This can be reduced by:

* increasing the opportunities for social contact with other children
* increasing the sensory stimulation by access to an increased variety of toys, wall murals, photos
* increasing the opportunities for pleasurable physical contact and movement through adapted equipment, positioning and handling that facilitate nurturing touch, as opposed to the touch generated by medical procedures

Goal Examples

The following are examples of measurable goals that were developed from a number of the stated aims.

* Elke will initiate play with a chosen toy (facilitation of playfulness)
* Elke will continue playing with the therapist without her mother for 30 minutes without stress (reduction of fear)

Mrs. R.

Tiffany (1978) noted that occupational therapists in acute paediatric settings could expect to spend 50% of their time working with adults under stress – the client’s families. This percentage probably increases when family members are rooming-in. In using a family centered approach, occupational therapy must consider, not only the injured child, but also the participating family members: in this case Elke’s mother.

a. Roles

Mrs. R’s existing roles as described by her were:

mother
partner and wife
self maintainer
worker

The interview revealed the role of mother to be the most pressing issue for Mrs. R. Repeatedly, the theme of “How can I be a good mother to my child now?” was raised. It became obvious during the observations of mother and child interactions that Mrs. R. needed some assistance with her own self-maintenance, so that she could be in a position to support her child in a mother role. It was equally obvious that her perception of her ability to carry out her mother role as being “not good enough” needed to be transferred into a more emotionally satisfying state. After talking with Mrs. R. the prioretised role performance that was targeted included:

Self maintainer and Rester
Mother
Partner and wife
b. Tasks and routines that are required to support identified roles

Self maintainer and rester

* to be able to develop routine periods of rest

These sleep/rest/activity cycles will be linked to Elke’s sleep/wake daily routines.

* to find and develop family and hospital resources that will assist with the time required for looking after Elke
* to develop routine ‘time away’ strategies that can be used by Mrs. R. for personal recuperation

Mother

* to give guidance about how to support her child physically and emotionally under the changed conditions (hospital) of mothering
* to give assistance in how to cope with a child who is under severe stress
* to give assistance in the form of adaptations to assist in handling Elke during routine daily tasks
* to support and affirm her skills as a mother
* to support playfulness between mother and Elke

Partner

* to develop strategies and routines which will support Mrs. R.’s need to engage in her valued role as a partner
c. Components of occupational performance that support the targeted role

Cognitive Component

* to build a knowledge store of hospital routines and procedures to alleviate fear of the unknown
* to develop a image of Elke’s future roles and function which supports a realistic but positive outcome
* to know that she can leave Elke for short periods with another person

Intrapersonal Component

* to feel competent in her role as mother of a child with an acute, and severe medical disorder
* to be able to separate from Elke for short periods without feeling anxious
* to feel a sense of fulfilment and mastery in her ability to nurture Elke and meet her needs

Interpersonal Component

* to establish social networks that enable her to find support through specific hospital staff, other parents and partner
e. Body/Mind/Spirit
* reduction of exhaustion
* to develop a sense of control within the hospital environment
* to develop a sense of hope and meaning for herself, Elke and the family unit

Goal Examples

Examples of how some of the aims were amalgamated and operationalised into measurable goals are as follows:

* Mrs. R. will be able to leave Elke’s room for 1 hour to complete a self-maintenance, leisure or social task. (self maintainer role and tasks)
* Mrs. R. will learn to position Elke so that she is comfortable during self maintenance routines (mother role, security with role functions for a child with severe disability)

INTERVENTION

Short term goals such as these were gradually developed and met over time, until Elke developed some independent self maintenance and play skills. Similarly, Elke’s mother gradually became more secure in her role as a mother of a child who has severe burns, and began to balance her various chosen and needed roles.

One intervention example

During one therapy session which aimed at the facilitation of play, finger puppets were introduced to Elke by the therapist. The puppets had to be frozen for several hours before the session for infection control. Finger puppets were chosen in respect of the biomechanical component constraints imposed on Elke, including immobilisation of proximal parts of the limb, finger motion and supine positioning. Thick bandaging and fragile skin made regular contact with many toys impossible.Finger puppets gave Elke the opportunity to physically play using the minimum of body movement. Initially, she directed the puppet’s actions as they were worn by the therapist, fulfilling both the ‘knowing’ and ‘doing’ dimensions of playing. Using puppets, the Elke came to realise that it was possible to engage in play without feeling pain and discomfort.

While imagining and acting out conversations between the puppets, the child was free to suspend reality and choose various play themes. Through play, Elke began to explore self initiated activity, to direct her environment and experience rewarding social contacts with someone other than her mother (Fazio, 1997; Oaklander, 1992).

SUMMARY

This paper has briefly outlined how the Occupational Performance Model (Australia) was used to construct an framework of intervention for a child who had sustained severe burns and her mother. Constructs within the model were used to develop a picture of the individual and associated occupational performance needs of both mother and child as a beginning to intervention.

REFERENCES

Bundy, A. (1991) Play theory and sensory integration. In A. Fisher, E. Murray, and A. Bundy, (Eds.). Sensory integration theory and practice. pp.46-68. Philadelphia: F.A.Davis.

Chapparo, C.J. (1996) Occupational performance: Expanding the concept of performance. Erster Osterreichischer Ergotherapiekongress. Wien. Austria. August.

Chapparo, C.J. & Ranka, J. (1996) The Occupational Performance Model (Australia). Draft manuscript. (Available from The School of Occupational Therapy, Faculty of Health Sciences. Lidcombe. 2141.NSW, Australia) May

Ellis, M.J. (1973) Why people play. Englewood Cliffs. NJ: Prentice-Hall

Fazio, L.S. (1997) Storytelling, storymaking and fantasy play. In D.L. Parham & L.S. Fazio (Eds.). Play in occupational therapy for children. (pp. 233-247). St. Louis: Mosby

Neumann, E.A. (1971) The elements of play. New York: MSS Information

Oaklander, V. (1992) Gestalttherapie mit kindern und jugendlichen (7th Ed.). Stuttgard: Klett-Cotta. Original title: (Oaklander, (1978) Windows to our children. Moab: Real People) Press

Pratt, P.N., & Allen, A.S. (1989) (2nd Ed.). Occupational therapy with children. St. Louis: C.V.Mosby

Tiffany, E.G. (1978) Psychiatry and mental health. In H.L. Hopkins, & H.D. Smith (Eds.). Willard and Spackman’s occupational therapy. (5th Ed.). Philadelphia: J.B. Lippincott Co.

Social experiences of children with fragile X syndrome: An occupational performance perspective.

Kristan Baker, BAppSc(OT) (Hons), is an occupational therapist working at The Rozelle Hospital, NSW, Australia. At the time of this study, he was a student in the Undergraduate Honours Program, School of Occupational Therapy, The University of Sydney.

In practice, the majority of occupational therapists concern themselves with activities of daily living and productivity-related issues (Graham, 1990; Gregory, Fairgrieve, Anderson & Hammond, 1992; Powell, 1994). Occupational performance is often viewed in limited terms of self-maintenance and productivity. Additionally, therapists place emphasis on: a) the biomechanical, sensory motor and cognitive components of performance; and b) the physical environment. Less emphasis is placed on: a) leisure and rest aspects of performance; b) the interpersonal and intrapersonal components of performance; c) the social, sensory and cultural environments; and d) the body/mind/spirit core elements of human existance, all of which, at least theoretically, influence a person&#146;s occupational performance (Chapparo & Ranka, 1993). These restricted views of occupational performance do not mirror the profession&#146;s holistic theoretical and philosophical foundations (See for example, Meyer, 1922).

This paper explores an area often neglected by occupational therapists, friendship and social interaction, from the perspective of four children who have fragile X syndrome. In schools, no single profession has addressed the social needs of children, especially those with disabilities (Damon & Phelps, 1989). This is a significant omission considering that, both quantitatively and qualitatively, children with disabilities have few, if any, friendships with children without disabilities (Alper & Ryndak, 1992; Kishi & Meyer, 1994; Sabornie, 1985; Zetlin & Murtaugh, 1988). Perhaps this situation could be rectified by school-based occupational therapists actively working to identify and support children&#146;s social needs.

In doing so, occupational therapy could implement a broader service with the adoption of practices that focus on social needs across a variety of practice settings. As Bonder (1993, p. 211) stated, ?for occupational therapy to provide a holistic view of meaningful activity, we must understand the relationship between physical, psychological, and social variables.? At present however, the nature of the relationship between social variables and occupational performance in children (particularly those with disabilities) is unknown and needs to be investigated. This paper begins to explicate this relationship through examination of the occcupational nature of social experiences of four children with fragile X syndrome as explained by constructs contained in the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996).

THE STUDY

The data for this examination is obtained from an ethnographic study (Baker, 1996) that explored the social experiences of four children with fragile X syndrome, a genetic disorder causing a range of physical, intellectual and behavioural disabilities (Reiss & Freund, 1990). The four children attended four different schools, with two attending regular schools. They all lived within family units of differing configurations, but consisting of at least one parent. Single in-depth interviews were conducted with each child&#146;s parents, teachers and two occupational therapists, as well as three half-day participant observation sessions at each child&#146;s school, making a total of ten interviews and twelve observation sessions. The empirical data yielded detailed case studies of each child&#146;s social experiences. Grounded theory method (Strauss & Corbin, 1990) was used to analyse interview transcripts and observational fieldnotes.

Social experiences were composed of two dimensions – social interaction and friendship – and of the interrelationship between them. The dimension of social interaction was indicated when children who were not friends played together. This dimension was characterised by: a) reliance on social skills and a social medium, b) minimal emotional content, c) non-restrictive involvement of children, d) spontaneity, and e) the fostering of a sense of belonging. The dimension of friendship was uniquely characterised by: a) free will and selection; b) mutual satisfaction of social needs; c) disobedience of authority; d) similar ability, interests and personality; e) an emotional bond; and f) an inherent mystery that was more than the sum of the parts identified here. The dimensions of social interaction and friendship were also interrelated when friends participated in social interaction as an overt display of their friendship.

The study supported previous research by finding that the four children&#146;s social experiences were lacking when compared to children without disabilities, particularly out-of-school activity and involvement with children without disabilities. However, in contrast with previous research, each child still valued and enjoyed a diverse range of friendships and social interactions. The study identified numerous personal and environmental factors contributing to the quality of each child&#146;s social experiences which are summarised progressively throughout this paper.

The following sections are devoted to exploring the children&#146;s social experiences from an occupational performance perspective relative to the eight primary constructs of the Occupational Performance Model (Australia) (Chapparo & Ranka, 1996): space, time, external environment, components of occupational performance, occupational performance roles, occupational performance areas and finally occupational performance.

SPACE

All the social experiences of these children occurred within the infinite boundaries of their internal and external domains. Body structures necessary for social interaction were housed in each child&#146;s body – their internal space. Of greater significance to social experiences was the area surrounding the child - external space - in which all friendships and social interactions took place. The corporeal area around a social experience - physical space (Chapparo & Ranka, 1996) – was not a great influence. Nevertheless, it ultimately determined the type of social interaction possible within its physical boundaries. Of greater influence was the child&#146;s perception of this corporeal area - felt space (Chapparo & Ranka, 1996). The children typically had negative perceptions of felt space when an area was unfamiliar, small, cluttered, loud or populated with other children. Similarly, positive views of felt space usually occurred where environments were familiar, spacious, more ordered, not overly loud and with fewer children. However, not all children adhered to this pattern. One child had entertaining social experiences in a positive felt space that was small, enclosed by oddly shaped buildings and with many teachers about. In fact, his neighbourhood was deemed by him to be a negative felt space (probably because of a detrimental social history with neighbourhood children), despite it being larger, quieter and unpopulated when compared to his school. Generally, the children avoided negative felt spaces, subsequently reducing opportunities for social experiences. Positive felt spaces, on the other hand, were usually preferred and contributed to the creation of opportunities for social experiences.

TIME

The children’s social experiences were influenced by time - physical time (Chapparo & Ranka, 1996) – and restricted to certain times throughout the day. Some biological rhythms (eg, sleep), determined by physical time, restricted opportunities for social experiences in the twenty-four hour day. Opportunities to engage in social experiences were further restricted by the child&#146;s, and the immediate sociocultural context’s, interpretations and manipulations of physical time - felt time (Chapparo & Ranka, 1996). This resulted in the greatest opportunities for social experiences being at school. Even there however, felt time imposed restrictions. Children only attended school five days a week and did not attend at all during school holidays. The school ?day? itself was also subdivided by felt time, beginning just before nine o&#146;clock in the morning and finishing just after three o&#146;clock in the afternoon. Still further, social opportunities at school were decreased during educational periods and increased during recess and lunch periods. These leisure periods ran no more than ninety minutes each day and time still had to be allocated to eating in these periods.

Social experiences were influenced by space and time in both physical and felt senses, as defined by Chapparo & Ranka (1996). These findings correspond to the postulations made in the Occupational Performance Model (Australia) regarding the impact of space and time on occupational performance. Social experiences, as observed in these children, are partly explained by notions of space and time that are central constructs of occupational performance.

EXTERNAL ENVIRONMENT

Social Environment

Each child&#146;s relationships (if any) with other children - social environment - were particularly important with regard to social experiences. There are several layers to the social environment, of which the most exterior is society. Society is discussed in the section on Cultural Environment in this paper, since it was the mechanism through which societal beliefs and ideals were transmitted from person to person that affected social experiences. Of more relevance to the social environment was the presence of other children and the child&#146;s family and school, as part of the neighbourhood/community layer of the social environment.

a. Presence of Other Children.

Other children existed within the children&#146;s social environment, some of whom were friends and others who were not. Two social situations involving the presence of other children mitigated against engagement in social experiences in these children: a limited number (quantity) and restricted range (variability of personal attributes) of other children present. Generally, a social environment with few children and/or a low degree of variability between children decreased opportunities for social experiences, and vice-versa. However, this trend was not always observed. The children&#146;s preferences for particular children was an important factor, in that each child chose with whom they interacted or became friends. This choice depended upon the number and range of children present, where a larger number and range increased the chances of meeting their personal preferences, and vice-versa. For example, many social experiences of children attending segregated schools (for only children with disabilities) were limited by an inadequate number and range of other children. In contrast, the potential for social experiences at regular schools (for children with and without disabilities) was enhanced by a larger number and range of other children.

b. Family

The family was a nucleus for social experiences – a crucial foundation upon which social opportunities were provided and removed. Sound familial relationships allowed the child to venture from the family unit and explore their social environment. Informants gave examples of tense or estranged family relations that removed this exploratory foundation. As one teacher said, “if there is a problem happening at home it does surface, often, in the playground.” Informants went on to describe how, subsequently, social experiences were damaged by the child getting “into fights or … not playing with anyone … just standing out as being different.” The influence of parents on social experiences was particularly significant considering that the children were largely dependent on their parents for out-of-school social experiences. Parents used a variety of techniques to facilitate social experiences. Indirectly, parents provided advocacy, increased exposure to social environments, and overcame barriers to community integration. Directly, parents facilitated social experiences with encouragement, social engineering, education, social identity development, and activity arrangement. However, parents occasionally interrupted social experiences with disciplinary action and separation of friends. Parents sometimes prioritised other occupational performance tasks and routines that rendered their child&#146;s social needs to a secondary concern.

c. School

School was an incredibly dense social environment that greatly affected social experiences. School staff created and removed opportunities for social experiences. There were instances where executive staff decisions (that were sometimes economically derived) disrupted close friendships. Attitudes of school principals partly determined the behaviour of staff and students and dramatically impacted upon social experiences, both positively and negatively. Autocratic teaching or therapy styles, emphasising strict discipline and one-on-one teaching, quelled social behaviour. Egalitarian styles, emphasising fair and flexible discipline and groupwork, supported social behaviour. Many teachers and therapists created social opportunities using some of the following facilitation strategies. On some occasions, formal facilitation strategies were adopted that included direct instruction, social engineering, social skills training, buddy systems, education and peer tutoring. On other occasions teachers preferred to use informal facilitation ? an active, sensitive and cooperative process relying on natural social processes with minimal professional interference.

The existence of school policy that guided professional conduct had a tremendous impact on social experiences. Several professionals stated that they were “bound” by general school policies, even though they knew it to be detrimental to friendships and social interactions. Policies regarding socially appropriate (especially age-appropriate) behaviour lead teachers to restrict certain social interaction and punish children for behaving inappropriately on the basis that, as one teacher said, “it is for their own good.” Policies relating to the standard transition from primary to secondary school disrupted some children’s social experiences. One parent stated that “the concept of going to a new school is so frightening for him because it is a new social situation.” Policy regarding the enrolment of children into schools and classes determined with whom the child could interact. Policies outlining the integration of children with disabilities into regular schools had differing effects on social experiences. On the one hand they supported social experiences with their socially oriented purpose. Many professionals commented that “a lot of (integration) is done purely … to increase social interaction.” Enrolment policies determined the number and range of other children with whom the children could interact or make friends. On the other hand, some integration policies were criticised because they “singled out” children with disabilities and subsequently impaired their social experiences. Such stigmatising integration policies pertained to special education programs, academic curriculums, and the procedures for integration into regular schools.

Cultural Environment

a. Society

Social experiences were influenced by Australian culture, or “society,” and the beliefs and practices therein: the cultural environment (Chapparo & Ranka, 1996). The effect was twofold. First, certain people within society believed and practiced a reluctance to accept children with disabilities. Second, this reluctance meant that some children with disabilities perceived children without disabilities as intimidating and were therefore reluctant to approach them. However, at one of the children&#146;s schools these societal beliefs and their negative effect on social experiences were rarely observed. This school&#146;s belief system contrasted that of ?society? in that it was based on principles of equality and acceptance. Subsequently, the child at this school had many enjoyable social experiences.

b. Ethos

Ethos was defined as the underlying and distinctive climate or spirit of a group. Two significant factors in determining the school&#146;s ethos were student-teacher relationships and discipline. There were two types of ethos observed across the four schools: an ethos of clemency and one of tyranny. An ethos of clemency was observed to be conducive to social experiences. Student-teacher relationships were characterised by: empathic emotional regard, propensity to care, mutual respect, frequent displays of affection, discipline that considered social experiences, and infrequent misbehaviour by children. The style of discipline comprised: minimal aggression and greater assertion (sharp and clear tone of voice, low volume, minimal physical manipulation), egalitarian treatment of children, rationality, explanation of the wrong committed and an indication of how to correct it. An ethos of tyranny was observed to be deleterious to social experiences. Student-teacher relationships were characterised by: apathetic emotional regard, lack of concern and respect, frequent displays of hostility, discipline that did not consider social experiences, and periodic misbehaviour by children. The style of discipline comprised: aggression, authoritarian treatment of children, irrationality, and minimal explanation of the wrong committed and how to correct it.

An investigation of occupational role performance in men over sixty years of age following a stroke

Anne M. Hillman, Christine J.Chapparo.

This paper is a copy of an article published in the Journal of Occupational Science: Australia, Vol. 2, No 3. (pp. 88-99), 1996. Reprinted with permission of the authors.

Anne Hillman BAppSc(OT) is a lecturer in the School of Occupational Therapy, Faculty of Health Sciences, The University of Sydney.

Christine ChapparoMA,DipOT,OTR, FAOTA, is a senior lecturer in the School of Occupational Therapy, The University of Sydney.

INTRODUCTION

This paper is an introduction to research which investigates the occupational role performance of men who have had a stroke and are living at home. It contains a discussion of the nature of life roles and of their occupational roles in particular. The conceptual framework for this research is a person centred occupational performance model. The rationale for using this approach is given and the data collection methods are briefly described. Preliminary findings are presented, together with a case history to illustrate these findings.

OCCUPATIONAL ROLE

Life roles can be described as social, cultural and occupational roles. These divisions are not intended to be absolute, however, and involve considerable overlap, such that social cultural roles also have an occupational or doing element to them, while occupational roles can be seen to have social and cultural elements.

One model of occupational performance, developed by Chapparo and Ranka (Chapparo & Ranka, 1993, October), describes occupational roles as patterns of behaviour composed of self maintenance, work, leisure and rest activities. Occupational role performance refers to the way these activities are carried out. Occupational roles are established through need and/or choice and are modified with age, ability, experience, circumstance and time (Chapparo & Ranka, 1994). It follows that occupational roles are one means by which daily activities are determined and organised.

It has long been assumed that occupational role performance has a direct influence on lifestyle and health issues (Barris, Kielhofner & Watts, 1988). More recent research has demonstrated such links (Bränholm & Ful-Meyer, 1992). Elliott & Barris, (1987) have established a relationship between the number of roles performed, the degree of meaningfulness of such roles and overall life satisfaction. Although the depletion of occupational roles that occurs following the onset of major disability may be assumed to lead to a corresponding decrease in overall lifestyle or role performance satisfaction, nobody has investigated this specifically in relation to people who have had a stroke. Indeed, very little is known about the specific occupational roles of the elderly, or about the way elderly people who have had a stroke organise their daily activities following resettlement at home.

The saying that reality is only what individuals perceive of the world around them can be applied to people’s perspectives of their roles in life. People’s perceptions about their roles are coloured by their own life experiences and beliefs and attitudes. In describing role performance, health professionals often make assumptions about the meaning and balance that is ascribed by clients to their own life roles (Kielhofner, 1995; Oakley, Kielhofner, Barris & Reichler, 1986). For example, the initial focus of many rehabilitation programs is on the development of specific self care skills determined by the institution. These are seen as underpinning general performance at the role level (Culler, 1993; Levine & Brayley, 1991) as well as enabling the continued performance of self maintenance roles such as personal carer and home maker (Foster, 1992; Hill, 1993). The researchers believe this process often reflects the meaning and importance that the health care team attributes to a self maintainer role rather than the meaning and priorities of the client (Chiou & Burnett, 1985). In order to reduce the bias that these assumptions may introduce, this study adopted a person centred interview approach whereby the participants were invited to identify their own roles, give reasons for performance that relate to occupation, and talk about meaning in terms of value and satisfaction.

Although role assessment instruments have been developed for adults and the elderly, they have limitations in the scope and type of information they provide. Principally, they either rely upon interpretation of information by the investigator to determine role performance, like The Occupational Performance History Interview (Kielhofner & Henry, 1988), or, like The Role Checklist (Oakley, 1981), provide the person with a list of assumed roles and ask them to indicate participation and value. Satisfaction with performance is not always considered. Assessments like The Role Change Assessment (Jackoway, Rogers & Snow, 1987) also reflect an assumption that everyone views a named role in the same way. For instance, that everyone would see the role of household cook as self maintenance. The researchers adopt Chapparo & Ranka’s (1994) view that a given role can be given a different meaning by different people. For example, the role of cook may be self maintenance to one person, productivity to another, and leisure to a third. Indeed, the same person may view such a role in different ways in different circumstances. For example, preparing Sunday breakfast may be seen as a family activity, while cooking the regular evening meal could be seen as work.

Heard (1977) developed a model of role acquisition which illustrated how internal and external expectations affected roles that were acquired. As a conceptual basis for this study, the researchers have proposed an extension of Heard’s model to highlight the place of perceived external and internal expectations on role choice, role performance and role satisfaction (see table 1).

This model shows that reasons for role performance are individually determined and depend upon the person’s own perceptions of what is expected of them by others, what they expect of themselves and what resources are available to them for achieving performance. Based on this model, it is clear that there is a need to investigate people’s own perceptions of their performance at the role level, rather than make decisions based on indirect information given. Role assessments such as The Occupational Performance History Interview, while based on the self-reporting of interviewees as their primary source of information (Kielhofner & Henry, 1988; Moorhead, 1969), do not ask them questions about their own perceptions of their performance at the role level. Instead, questions are asked about past and present behaviour and from this the interviewer interprets and rates that person’s role performance.

This study represents a starting point for a line of research that investigates self perceived occupational role performance following stroke. It describes what occupational roles are carried out post stroke, the nature of that role performance, and what satisfaction is derived as a result. If there is an overall depletion in role performance satisfaction, as distinct from the number of roles performed or the nature of role performance, then this will have an impact on the nature of health and community service provision for people who have had a stroke.

The purpose of this study, therefore, is to gather information about the self-perceived occupational role performance of elderly men who have had a stroke and are living at home. The study was restricted to men, as it was felt that the issues they face following a major life event such as a stroke differ in many ways to those faced by women.

Research design

Qualitative research methodology was employed utilising in depth interviewing. This was done for two reasons. First, it permitted explanation of questions and further probing of responses, thus facilitating a greater depth and quality of information than could be obtained by other means. Second, from the participant’s point of view, it allowed the interviewer to understand the meanings attributed to particular role performance.

Participants

18 participants so far have been interviewed. Selection criteria included the following. Participants were men over 60 years of age who had had a stroke requiring admission to hospital, and who were discharged home three to six months prior to interview. They were not engaged in paid work and lived in the Sydney metropolitan area. People were excluded from the sample if they were female, were under 60 years of age, still worked in a paid capacity, lived in an institution, had a serious handicap resulting from a chronic condition unrelated to their stroke, were discharged from hospital less than three months or more than six months ago at the time of the interview, spent less than two weeks in hospital, did not receive rehabilitation while in hospital, had more than one stroke, or required an interpreter while in hospital.

The occupational therapy departments of a number of major teaching hospitals and rehabilitation units in the Sydney metropolitan area were used in order to obtain the participant sample. Ethics committee requirements did not permit the researchers to actively engage in the selection process or in inviting potential participants to take part. Occupational therapists who agreed to assist with this study selected potential participants from their own case load or by obtaining nominations from other therapists, according to the criteria set down by the researchers. These people were then contacted by the therapist who nominated them. The researchers provided therapists with material to distribute to potential participants. This consisted of a letter containing information about the study and inviting participation. If people indicated they were interested in participating, permission was obtained by the therapist to forward their contact details to the researchers. Where people were still attending an occupational therapy outpatient program another therapist in the department who had not worked with them made the contact in the same way.

Data Collection Procedures

Of the eighteen interviews conducted so far, seven were carried out by one of the researchers of this study and eleven by people trained by that researcher. Interviewers were trained in the following way: a series of tutorials culminated in a one day workshop which included audio and videotaping of practice interviews. Following this workshop, interviewers were required to submit an audio tape of an interview, using the procedures they had been taught, with someone of their acquaintance who was over 60 years of age. This tape was evaluated by the researcher and feedback was given. If the tape was unsatisfactory, interviewers were required to do another interview and submit a second tape. No-one proceeded with interviewing for the study until they had submitted a satisfactory tape.

Participants were contacted by the researchers and an appointment was made. Interviews were held in the participants’ own homes. In most cases there was no third party present. The length of interview varied from 45 minutes to 2 1/2 hours and ended when the participant tired or saturation of information occurred. Permission was obtained to tape the interview and a tape machine and microphone were placed in full view but in a non-intrusive way on any convenient surface nearby. Participants commented more than once that they had forgotten they were being taped.

The interview process had six parts:

1) Explanation of purpose of interview.

2) Recording demographic information.

3) Gathering information about role performance.

4) Participant identification and confirmation of roles.

5) Sorting roles under performance area and sociocultural headings.

6) Participant rating of roles.

The technique of ethnographic semantics (Spradley, 1979) was used to discover the way participants categorised their own immediate roles, role performance and role needs. This involved asking questions of three orders: descriptive, structural and contrast. The form of these questions changed with the understanding of the participant. The whole process commenced with a “grand tour” question such as: “Can you tell me about your roles now?” The purpose of this question was to find out what meaning the participant ascribed to the general term of role. The strong emphasis on open ended questions in this part of the interview ensured that the comments of participants were spontaneous and self-generated.

Descriptive questions yielded information about what the daily roles, functions and activities actually were for the participants. An example of a common stimulus question was “how do you spend your time?”. Further probes consisted of questions such as: “do you do anything with other people?”, “what sort of things do you do with your children?” and “what sort of things do you do around the house?” These types of questions yielded a list of tasks and activities that were later consolidated to form role patterns.

Structural questions in the form of role sorting enabled the researchers to determine how participants ascribed these role patterns into major role categories. This occurred in two stages. First, during the interview, the interviewer listed what (s)he perceived the participant’s roles to be. At the end of the interview the participant was asked to either confirm the role titles or suggest changes. The interviewer then privately sorted these roles under the major headings of productivity, self maintenance, leisure and sociocultural roles. The second stage of role sorting followed. Role titles were written by the interviewer on stickers. These were handed to the participant one by one and they were invited to sort the roles by placing each one under the heading that best described the reason for its performance. Participants were asked why they placed roles where they did and were usually able to give clear reasons for their decision.

During this second stage, a role sorting board was employed to help participants decide which role heading best described particular patterns of activity. The board was made of cardboard with a whiteboard surface and measured 610 mm x 440 mm. It carried simple definitions of each of these major role headings in large bold print for easy reading, often with clarification from the interviewer. The definitions were as follows:

Productivity: work, giving a service, doing something that can be used by others.

Self Maintenance: what you need to do to get by and get on with the rest of your life.

Leisure: fun, enjoyment.

Social Cultural: relationships, being with others, beliefs and values.

Other (no definition given).

Contrast questions were used to help participants identify what they would like to do that they were not able to do and to describe their perceptions of the frequency, value and satisfaction of role performance. Frequency was discussed in terms of how often the participant did things in that role. Value was considered as relative to the importance they ascribed to it. They were asked to consider satisfaction in terms of how they felt about their own performance in the role. Examples of contrast questions were: “if you could spend your day doing anything you wanted, what would you do?”, and “what is it that stops you doing this?”. Contrast questions of this type were used to assist participants to focus on immediate role performance needs rather than role performance prior to their stroke. Contrast questions led ultimately to participants being able to rate their role performance.

When rating their role performance, participants were asked to rate, as a single unit, the roles in each of the categories for frequency of performance, value of role, and satisfaction with performance. They were shown a five point scale represented on a large piece of card measuring 360 mm x 240 mm and asked to rate by pointing. Each scale had polar descriptions, with 1 as the lowest rating and 5 as the highest. For example, the value scale read:

“I consider this role to be:

In summary, the interview yielded both quantitative and qualitative data to describe aspects of self perceived roles. Information gathered related specifically to the participants’ own perceptions of their current role performance in the areas of productivity, self maintenance and leisure, as well as their sociocultural role performance. Perceived frequency of performance; perceived role value and degree of satisfaction with role performance were discussed and evaluated for each of these areas.

Data Analysis

Seven sets of data have been analysed at this stage of the study and form the basis of the findings reported in this paper.

Truthfulness of Data

Several checking measures were used to determine trustworthiness of the data collected. First, member checking was employed by ensuring that judgements on role identification and role categorisation were made by the participant rather than the interviewer.

This process establishes credibility of the data whereby the truth value is determined by how well the researcher is able to represent the participant’s experiences rather than the defined a priori of the researcher (Sandelowski, 1986). Second, comparisons were made between the qualitative information obtained in the interview section and the quantitative ratings made by the participants at the end of the interview. This process allowed the researchers to determine the consistency of the data and to track where variability in the data occurred. Third, another researcher reviewed a number of transcripts and role ratings made by the interviewers. Comparisons were made between the findings of the first researcher and the findings of the second (Minichiello, Aroni, Timewell & Alexander, 1990). Following this, additional questions relative to the style of questioning used in interviews and interpretation of the data were proposed. This process assured a certain freedom from bias in interpretation of the data that came from the natural biases, motivations and perspectives of the researchers themselves (Guba, 1981). This resulted in constant modification and refinement of the interview technique.

Data analysis procedures

All taped recordings of interviews were converted to written transcripts (Miles & Huberman, 1984). After each transcription was complete, the notes were edited by researchers for accuracy. The data set from each interview was read and researchers identified the possible scope of the data. Topics and themes that occurred and re-occurred were identified and assigned preliminary codes that subsequently became the initial content label discussed under ‘preliminary findings’ in this paper.

The level of detail of coding was multi-sentence ‘chunks’ rather than word or sentence coding (Miles & Huberman, 1984). Multiple copies of the transcribed and reduced data were made and passages of text were coded using descriptive terms according to the thematic interpretation made by the researcher as outlined below. Specifically, texts were examined for information relating to roles that had been identified by that participant. The text was then further examined for statements of frequency, value and satisfaction relating to performance of each of the roles identified. The entire data set of seven participants was double coded (Miles & Huberman, 1984) to determine the internal consistency of the researcher’s interpretation of the text. For this reason, the preliminary findings presented below will focus on interpretations of these seven participants.

Preliminary Findings

The preliminary findings are presented according to the themes that emerged. As each theme is discussed, narratives will be included to demonstrate similar and contrasting thematic perspectives as identified by the researchers.

These are preliminary findings. They will be discussed relative to the following four aspects of the analysis:
1) statements that relate to specific role performance,
2) commonly occurring roles that were identified,
3) findings related to role sorting, and
4) findings related to role rating.

Role Statements

As described previously, the interview commenced with a “grand tour” role question. Participant responses to this question were often revealing, in that they summed up the nature of that person’s focus or outlook on life.

Participant 16 was asked “can you tell me what your roles are now?

He responded:

“My main idea is to get out of the wheelchair and able to walk, that’sthe main thing I want to do. That’s why I will do whatever therapy they’ve got for me to do. They can tell you what you’ve got todo. They can’t make you do it. You’ve got to do it yourself”.

A great deal of his conversation and responses revolved around this theme. He explained at length how he managed his wheelchair, how he transferred and many other issues. Managing the after effects of his stroke was a major role for him, which he discussed with a passion.

Next, Participant 2:

Interviewer:”How do you see yourself? I mean we all have a lot of different roles in life…”

(Pause – Bursts into tears) “/…/ I got six kids … /…/ andfourteen grandchildren. /…/ So I’m just Grandpop to them.”

This gentleman was quite labile. His sociocultural roles were of particular importance to him and he discussed at length his relationships – good and bad – with those around him. Again, there was passion in his responses on this theme that was absent when discussing other areas of his life.

Participant 15 was different:

He was asked:”What are the roles that you have in life?”

“ Well,I’m just looking forward to the time when it foldsup, and somebody else has got to look after the problem then. /…/It doesn’t worry me. /…/ I’ve got a limited time I know, and Ijust keep on going.”

It subsequently became clear that this person had no particular focus to his life. His roles were identified, but there were none that appeared to be of particular significance to him, and there was no passion in his responses.

Commonlyoccurring roles

Role names were given by the interviewer and the participant on the basis of what seemed to best describe the role. The roles most frequently identified by participants were as shown in table 2:

Table2: Roles most commonly identified by the seven participants.

Role Sorting

Comparing Interviewer Sorting With Participant Sorting

The interviewer made sorting errors in every case and averaged 2.5 errors per interview.

Examination of Participant Role Sorting

Under the heading of productivity, four people identified a total of seven roles, while three could identify no productivity roles. All seven participants placed roles under each of the other headings. A total of eleven roles were placed under self maintenance, sixteen under leisure and twenty-four under social cultural.

There was an idiosyncratic placement of some commonly occurring roles (see table 3). For example, the role of father was placed by three people under the social cultural heading, giving it the meaning of being something the person did because of his beliefs and values and/or his relationships with others. This placement corresponds with the general view of father as primarily a social role. However, three people placed the role of father under another heading. Participant 18 placed father under leisure, saying:

“They’re my children and all that caper. Tremendous good looking children as well/…/It’s a lifetime’s pleasure really”.

Participant 17 placed the role under the productivity heading, explaining that he saw his role as a father in terms of ensuring his children were financially secure. He said:

“But we’ve got eight children. Right? /…/ What are you going to do/…/ to fix them up, without it distressing the others? Ah, itgives you something to think about.”

Participant 15 placed the role of father under self maintenance. He lived with his daughter, and seemed to be saying that, although his children cared for him, he did not reciprocate by doing anything for them. Their relationship with him seemed to focus on checking on his ability to care for himself successfully.

“I seem to have more of a relationship with them than I have with them. Do you understand?

Interviewer:”No, say that again.”

“Well,they’re always … seeking to see how I am … and I haven’t bothered about them!

Interviewer:”Oh I see what you mean. So you think the relationship’s a bit one way?

“Well,it is…Because after all, they’ve got their own relationships Participant 16, although a father, preferred to includethe role under the larger heading of family member.

Table 3 also groups together roles that appeared to go together, such as father and grandfather, and day care attender and health maintainer. The nature of some of these roles will now be explained.

Day Care Attender: In every case the person received therapy as part of a larger program.

Person with a Disability: The person carried out a remedial program at home and disability directed much of his attention and time.

Time Passer: Passive leisure, for example, television, radio, reading, talking books and street watching. This role was characterised by the statement that it “passes the time”.

These variations in sorting and placement would seem to indicate that the same role has different meanings to different people, supporting the contention that meaning cannot be arbitrarily ascribed to roles by others.

Other roles that were identified followed more closely the pattern that might expected, although there were still some surprises such as Home Maintainer and Pet Owner (see table 4).

Role Rating

The Ratings Sheet

Participants were asked to rate on three different five point scales for frequency of role performance, how much they valued the role, and how satisfied they were with their performance of that role.

Two participants completed role sorting, but did not rate their roles, leaving a total of five participants who undertook role rating.

Internal consistency between interview and ratings

Using a subjective comparison of the ratings with statements made by the participants in the text, it was estimated that approximately 75% consistency was achieved.

Preliminary consideration of role ratings for the seven participants analysed so far indicate certain themes. A total of fifty-four ratings were made overall, for frequency, value and satisfaction in the four areas of productivity, self maintenance, leisure and social cultural. When all the ratings are viewed together, the majority of participants rated at the top end of the five point scale. 63% rated five for any given rating, 18.5% rated 4, 16.5% rated 3 and 2% rated 2. No participant rated one, the lower end of the scale, for any rating.

Overall performance area ratings for the five participants were totalled using a weighted score. A rating of 5 was given five points, a rating of four was given four points and so on. This meant that if all five participants rated five for a given rating, the maximum possible score was 25. If no-one had rated it at all, the lowest possible score was 0. All five participants who completed ratings identified roles in the performance areas of self maintenance, leisure, and social cultural. Only three identified roles in the productivity area. For this reason the productivity ratings were further adjusted so that ratings for each area could be compared on the same level of five respondents.

From figures 1 to 4, it can be seen that social cultural roles and self maintenance roles were performed most frequently, with leisure roles being performed least. Social cultural roles were valued most highly, with productivity roles being valued least. Finally, social cultural roles produced the highest rating for satisfaction with performance, with productivity roles being valued the least. It must be emphasised that these results represent preliminary analysis only on a small number of participants. Data will be presented in a more meaningful way when the study has been completed.

CASE EXAMPLE – Participant 16

Findings are illustrated by the following case example:

Table 5 shows role distribution for participant 16. The role of Stroke Manager (person with a disability), ascribed as a self maintenance role, was one that took up most of this man’s time and was very involving for him.

The stroke had changed his life and had become the focus for him. A great deal of what he had to say related to how he was now dealing with his disabilities:

“The wife gives me therapy twice a day. Iget it once a week over at the day care centre. What I learn there, I’ve been able to tell the wife. We try to carry that out as further therapy. Because Ilook at this way – what you learn on Wednesdays, if you don’t get anymore done till the following Wednesday, you go backwards./…/So you’ve got to have it continuous./…/ That’s what we do./…/I go inon Wednesday and have full therapy, for walking. I walk with an aidbut can’t walk without. Because I can’t stand alone. Then I come home and tell the wife what’s been doing. Then we put the actual therapy into practice./…/ We got two hours a day doing it. First thing of a morning. Then afternoon, say about two o’clock. Then just before going to bed at night.”

This is an expression of the nature and frequency of role performance.

It is interesting to note that he had no personal carer role. It seems that for this man, Personal Carer was subsumed by Person With a Disability and had become part of that larger role.

He had successfully achieved the transition from active to passive participant in a number of roles, despite the fact that he is a man who, from the interview, seemed to need active involvement. For example, in his role as a Hydroponic Gardener, he sat

in his wheelchair at the top of the back step and directed his wife. This was his expression of satisfaction with this role:

He was asked: “The way that you carry out that role now, – do you get some satisfaction out of that?”

“Oh yes, knowing that it is going to be still done. /…/ I’ve got it in my computer, which is the brain box. /…/ And what’s got to be done is there and can be done. Somebody carries it out with the instructions, and that’s done satisfactorily so I don’t worry about it now.”

This man’s family seemed happy to participate in his roles on this basis.

Role ratings for participant 16 are shown in table 6. He rated five for satisfaction with all areas of role performance, and the researchers judged that there was agreement between this rating and what he said in the interview. However, this is what he said in relation to the role of Person With a Disability:

“Because when you get a stroke, well you are in it. And, as I say, it’s a nightmare and … you can’t get out. It’s like … going through atunnel and you can see the light at the end of it and you’re clawingand clamouring to get to it, but you can’t”.

When discussing his performance as a Person With a Disability, he said:

“Well,if you carry that out together it’s not so bad. But you feel …left alone at times. You wonder what it’s all about … whether it’sworth it or not because sometimes you can see you’ve progressed andother times you don’t have progress. /…/You don’t seem to cotton onto it. That’s how the … stroke leaves you. You don’t comprehendalways what you’ve got to do. /…/Just one of these silly damnthings. It’s aggravating and frustrating. You see things you wantto do and you can’t. When I was in hospital, with the therapy theywere giving me -it was all right. Then they asked me about what sortof therapy I thought would be the best and I told them home therapy,being in your own home. Here in your own surroundings, you do whatyou want to do.”

When asked to rate satisfaction with his performance he said:

“Oh yes, I’m contented. Everything’s moving along the way I want. I am satisfied all the time with what I am trying to do and the things that have been done for me. I work very hard.”

From this it appears that he was satisfied with his performance in this role, but derived no pleasure from it, and performed it through need rather than choice.

Discussion and Implications for Further Research

Preliminary analysis has revealed a number of interesting points:

When a general question about role performance is asked, such as “tell me how you see your roles now”, the response can sometimes reveal the overall focus of that person’s life. For instance, participant 16 responded to this question by saying he wanted to get out of his wheelchair and overcome the effects of his stroke. Participant 2 spoke of his relationships with those around him. Participant 17 spoke at length about his advocacy activities. In each case, the response to this initial question revealed a theme that was returned to many times throughout the rest of the interview, indicating that it was of primary importance to that person. For others, such as participants 15 and 18, responses to this role question were general and diffuse and no such theme was revealed. Further questioning also failed to reveal any particular focus and these men appeared to participate in a more passive way in what was going on around them.

Results so far seem to show that it is not possible for one person to accurately to ascribe meaning to the roles of another. For example, comparison of the two stages of role sorting in this study demonstrated that the interviewer made errors in every case, despite feeling confident, from what had been said in the interview, of how the participant would view that role.

It appears that a role sorting process can enable the principle meaning ascribed to particular roles to become clearer to both the interviewer and the participant. Role sorting required the participant to choose the main reason they performed the role in terms of the headings of productivity, self maintenance, leisure, and social cultural. While they were all able to make this choice, some did indicate that there was more than one reason for performance. For instance, participant 18 placed his advocacy role under productivity, but discussed how it also gave him great pleasure and could therefore have been viewed as leisure. Sorting allowed the discussion and clarification of the meaning roles had for individuals.

Most of the people interviewed, when asked to rate their roles, rated them positively for frequency, value and satisfaction with performance. For example, not one person rated 1 (the lowest rating) on the five point scale for any role. When the ratings for all participants for all ratings (frequency value and satisfaction) were looked at together, 63% of the responses were at 5 (the highest rating). There could be a number of reasons for this. For example, from a cultural perspective, Australian men in this age group expect and are expected by their peers to confront life events and be stoic about them (Job, 1994). This could lead to more positive ratings. Also, giving a low rating for frequency, value or satisfaction could be viewed by the participant as too self-revealing or too challenging to their own perceptions of how they are performing overall in their life roles. Again, older people are sometimes reluctant to reveal too much in case there are consequences in terms of loss of control and the imposition by others of restrictions to their autonomy (Russell, 1981). Finally, the selection method for participants meant that participants were selected and invited to participate by the occupational therapist who had worked with them during their rehabilitation. It is possible that therapists may have selected people whom they considered had a positive outlook and could give a good account of themselves. The ratings may accurately portray people who were actively participating in valued roles to a level that they found satisfying overall. The researchers estimated that there was approximately 75% agreement between the ratings and the content of the interview transcripts, indicating consistency in responses.

This study is not yet finished and further investigation of satisfaction with role performance is planned.

Summary

In summary, this paper has presented preliminary findings of research into the occupational role performance of elderly males who have had a stroke. The conceptual framework for this research is a person centred occupational performance model. The rationale for using this approach was given and data collection and analysis methods described. A case history was presented by way of illustration, and results were given and discussed.

With the established link between occupational role performance, meaningfulness of roles and positive health and well being, it is important that we do not ignore this aspect of occupation. It is hoped that further research into role performance that is person centred will enable us to develop a better understanding of the meaning ascribed to role performance by individuals.

ACKNOWLEDGEMENTS

The authors acknowledge the contributions of the participants and their families to this study, as well as the School of Occupational Therapy, The University of Sydney for partially resourcing the study.

References

Barris, R., Kielhofner, G., & Watts, J. H. (1988). Occupationaltherapy in psychosocial practice. Thorofare, NJ.: Slack Inc.

Bränholm, I., & Fugl-Meyer, A. R. (1992). Occupational role preferences and life satisfaction. Occupational Therapy Journal of Research,12(3), 159-171.

Chapparo, C., & Ranka, J. (1993, October). Occupational performance: Apractice model for occupational therapy. Paper presented at the 6th State Conference of the New South Wales Association of Occupational Therapists, Mudgee, NSW.

Chapparo, C., & Ranka, J. (1994). Occupational Performance: Definitionof Terms, : Available from School of Occupational Therapy, The University of Sydney, PO Box 170, Lidcombe, NSW Australia 2141.

Chiou, I. L., & Burnett, C. N. (1985). Values of activities of daily living: A survey of stroke patients and their home therapists. Physical Therapy, 65(6), 901-906.

Culler, K. H. (1993). Home and family management. In H. L. Hopkins & H. D. Smith (Eds.), Willard and Spackman’s Occupational Therapy, (8th ed., pp. 207-226). Philadelphia: J.B. Lippencott.

Elliott, M. S., & Barris, R. (1987). Occupational role performance and life satisfaction in elderly persons. The Occupational TherapyJournal of Research, 7(4), 215-224.

Foster, M. (1992). Life skills. In A. Turner, M. Foster, & S. E. Johnson (Eds.), Occupational therapy and physical dysfunction: Principles, skills andpractice., (3rd ed., pp. 210 – 222). Edinburgh: Churchill Livingstone.

Guba, E. (1981). Criteria for assessing the trustworthiness of naturalistic inquiries. Educational resources information centre annual reviewpaper, 29, 75-91.

Heard, C. (1977). Occupational role acquisition: A perspective on the chronically disabled. The American Journal of OccupationalTherapy, 31(4), 243 – 247.

Hill, J. (1993). Activities of daily living. In H. L. Hopkins & H. D. Smith (Eds.), Willard and Spackman’s Occupational Therapy, (8th ed., pp. 192-206). Philadelphia: J.B. Lippencott.

Jackoway, I. S., Rogers, J. C., & Snow, T. L. (1987). The Role Change Assessment: An interview tool for evaluating older adults. Occupational Therapy in Mental Health, 7(1), 17 – 37.

Job, E. (1994). The experience of ageing: Men grow old too. Armidale, NSW.: The University of New England Press.

Kielhofner, G. (1995). A Model of Human Occupation: Theory and Application. (2nd ed.). Baltimore: Williams & Wilkins.

Kielhofner, G., & Henry, A. D. (1988). Development and Investigation of the Occupational Performance History Interview. The American Journalof Occupational Therapy, 42(8), 489 – 498.

Levine, R. E., & Brayley, C. R. (1991). Occupation as a therapeutic medium: A contextual approach to performance intervention. In C. Christiansen & C. Baum (Eds.), Occupational therapy: Overcoming human performance deficits, (pp. 590-631). Thorofare, N.J.: Slack.

Miles, M. B., & Huberman, A. M. (1984). Qualitative data analysis: Asourcebook of new methods. Newbury Park, Calif.: Sage Publications.

Minichiello, V., Aroni, R., Timewell, E., & Alexander, L. (1990). In-depthinterviewing: Researching people. Melbourne: Longman Cheshire.

Moorhead, L. (1969). The occupational history. The American Journal ofOccupational Therapy, 23(4), 329-334.

Oakley, F. (1981). Role Checklist. Unpublished: Available from Fran Oakley, 9103 Autoville Drive, College Park, Maryland 20740.

Oakley, F., Kielhofner, G., Barris, R., & Reichler, R. K. (1986). The Role Checklist: Development and empirical assessment of reliability. Occupational Therapy Journal of Research, 6, 157-170.

Russell, C. (1981). The aging experience. Sydney: George Allen & Unwin.

Sandelowski, M. (1986). The problem of rigour in qualitative research. Advancesin Nursing Science, 8, 27-37.

Spradley, J. P. (1979). The ethnographic interview. New York: Holt,