published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Thesis (MSc)--Stellenbosch University, 2001. / ENGLISH ABSTRACT: Although the neurodevelopmental therapy (NDT) treatment approach is used extensively in the management of children with cerebral palsy, there is currently very little documented research to support its efficacy. The purpose of this study was to evaluate the efficacy of NDT in terms of its effect on motor function in a group of 10 cerebral palsy children. A multiple simple single-subject design was used in which the children each acted as their own controls. A 5 week baseline period, during which no intervention was received by the children, was followed by a 5 week intervention phase during which the children received twice weekly NDT treatment. The children were assessed at the beginning and end of each phase using the Gross Motor Function Measure (GMFM), and an assessment tool, which allowed the establishment of individualised outcome measures, called TELER. The group of children demonstrated no statistically significant gains in motor function on either of the outcome measures during the baseline phase of the study. However during the intervention phase the overall improvements demonstrated by the group on both the GMFM and TELER were statistically significant. Nine out of the ten children achieved greater improvements in their goal total GMFM scores during the intervention phase than during the baseline phase. Similarly all of the children achieved a greater number of clinically significant improvements on the TELER outcome measures. NDT was beneficial and useful in promoting motor function in this group of cerebral palsy children. / AFRIKAANSE OPSOMMING: Alhoewel die Neuro-ontwikkelingsterapie (NOT) behandelingsbenadering wydeverspreid gebraik word in die behandeling van kinders met serebrale verlamming, is daar huidiglik baie min gedokumenteerde navorsing om die effektiwiteit daarvan te staaf. Die doel van hierdie studie was om die effektitiwiteit van NOT te evalueer met betrekking tot die impak daarvan op die motoriese funksie van ‘n groep van 10 kinders met serebrale verlamming. ‘n Veelvuldige eenvoudige enkeling -subjek raamwerk is gebruik waarvolgens die kinders elk as hul eie kontrolegoep ageer het. ‘n 5-weke basislyn fase, waartydens die kinders aan geen intervensies onderwerp is nie, is gevolg deur ‘n 5-weke intervensie fase waartydens die kinders twee keer per week NOT behandeling ontvang het. Die kinders is geevalueer aan die begin en einde van elke fase met die Oorhoofse Motoriese Funksie Maatstaf (OMFM)/Gross Motor Function Measure (GMFM), asook ‘n evalueringsmaatstaf genaamd TELER, wat die bepaling van geindivualiseerde resultate moontlik gemaak het. Die groep kinders het geen statistics bewese vordering in motoriese fiinksies getoon volgens beide die evalueringsmaatstawwe tydens die basislyn fase van die studie nie. Daarteenoor het die groep tydens die intervensie fase oorhoofs gesproke statistics bewese vordering getoon met betrekking tot beide die OMFM en die TELER. Nege uit die 10 kinders het groter vordering getoon met hul totale OMFM resultate tydens die intervensie fase as gedurende die basislyn fase. A1 die kinders het tegelykertyd ‘n groter hoeveelheid substantiewe kliniese verbeterings getoon met betrekking tot hul TELER uitkomste. NOT was voordelig en nuttig in terme van die verbetering van motoriese funksie in die groep van serebraal verlamde kinders.

This study utilised a qualitative interpretive approach to investigate the subjective / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2009.

This study utilised a qualitative interpretive approach to investigate the subjective experiences of six children with cerebral palsy who participated in a therapeutic horse riding intervention programme over a two-year period. Data was collected through a triangulation of methods and sources of data in the form of proxy reports from teachers, parents and therapists, and participant observations on my part. Research in the field of disability and rehabilitation remains largely ungrounded with respect to formalised theorising around concepts such as strengths, capabilities, and well-being. In attempting to address this gap, the nascent sub-discipline of positive psychology was identified as a field that holds significant research utility. Arguably, its keynote contribution entails directing researchers and practitioners in the field of disability and rehabilitation to the aim of building, reinforcing and extending disabled individuals' strengths in order to optimise their functioning. Consistent with existing work, this study found that the participants' lives were characterised by experiences of difference and marginalisation in relation to non-disabled individuals. More striking, however, was the finding that they were subject to experiences of difference and othering in relation to their disabled peers. This group dynamic seemed to be accounted for in terms of a hierarchy of similarities and differences with respect to their capabilities for communication and motor functioning. Further, the findings suggested that the participants tended to utilise their bodies, the site of their impairments, to engage with their environments and social others in their own idiosyncratic and agentic ways. By virtue of the tendency to negotiate and at times transcend their impaired physicalities, the participants were perceived as functionally autonomous, which worked to challenge prevailing stereotypes with regard to individuals with profound forms of physical disability. Importantly, such features impacted upon the degree and quality of their engagements with their physical and psychosocial environments in significant ways. In addition, in terms of the therapeutic riding activities engaged with during the course of this study, the participants came to experience their bodies as bodies that work. This seemed to have had positive implications for how they felt about their bodies and themselves. An enhanced sense of personal worth also tended to minimise their experiences of their bodies as impaired and dis-abled. In this way, their participation in therapeutic horse riding facilitated the children's experiences of themselves as more than disabled, thereby indicating the emancipatory potential of participating in this form of intervention. Moreover, it was noted that the limited body of existing, largely quantitatively oriented research in the field of therapeutic horse riding has often been methodologically wanting. As disconcerting was the noticeable absence of theorising around the mechanisms and processes by which therapeutic horse riding effected changes. It was therefore fitting to draw on theoretical frameworks within psychology to delineate possible mechanisms and processes by which participation in therapeutic horse riding could potentially effect subtle, meaningful shifts in the everyday functioning and psychological well-being of children with disabilities. This study contributed to existing research within the field of disability and rehabilitation through its efforts to yield "thick descriptions" and "thick interpretations" in combination with the theory-laden validation of findings around the everyday subjective experiences of children with disabilities. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2009.

[Truncared abstract] Introduction: The assessment of any therapy requires not only an understanding of how that therapy works but also how it affects health related quality of life (HRQOL). Botulinum Toxin A(BoNT-A) therapy for upper limb spasticity management in children with hemiplegic cerebral palsy(CP) is currently under trial. Despite its use for over a decade for lower limb spasticity, little is known about the mechanisms involved in improving motor function and the effect on the child and their familys HRQOL. Both central and peripheral mechanisms are hypothesised[1]. Whilst evidence of improved quality of movement and ability to perform tasks is emerging[2-4], this cannot be directly correlated with an improvement in HRQOL. In addition, the traditional method of assessing child HRQOL by parent proxy reports has come under question[5, 6]. The World Health Organisation now recommends the collection of both parent proxy and child self-reports[7]. Aims: 1. Investigate the corticomotor projections to the upper limb in school aged children with hemiplegic CP and the changes that occur with BoNT-A therapy by transcranial magnetic stimulation (TMS). 2. Investigate the effect of upper limb BoNT-A therapy on HRQOL of school aged children with hemiplegic CP by completion of the PedsQL 4.0 Generic Core Scales and 3.0 CP Module. 3. Determine the concordance between Child Self-Report and Parent Proxy Report scores for the PedsQL 4.0 Generic Core Scales and 3.0 CP Module. 4. Determine the concordance between PedsQL scores and function as assessed by the Melbourne Assessment of Unilateral Upper Limb Function (MUUL). Methods: Design: Prospective randomised pilot study. Setting: Department of Paediatric Rehabilitation, Princess Margaret Hospital, and Centre for Neurological and Neuromuscular Disorders, Perth. Participants: 22 school aged children with hemiplegic CP aged 7yr 0mth-13yr 11mth (12 treatment, 10 control). 3 Treatment: One episode BoNT-A injections (dose 1-2U/kg/muscle) into the upper limb for treatment group. The control group received usual care. ... Conclusion: This pilot study provides preliminary evidence of the effects of upper limb BoNT-A therapy at both a central physiological and a broader quality of life level in school aged children with hemiplegic CP. At a central level, corticomotor pathway reorganisation occurs in the setting of BoNT-A. However the reorganisation is not limited to the affected side pathways suggesting a systemic BoNT-A effect or developmental changes. Similarly, in this pilot study, there was no statistically significant effect of upper limb BoNT-A on the childs HRQOL as assessed by the PedsQL although positive trends were observed 4 for a number of physical and psychosocial domains. The collection of both child self-report and parent proxy reports when assessing HRQOL is recommended, and function needs to be assessed independently. Larger studies across the broader CP population, the design of CP specific HRQOL tools appropriate for use in the higher functioning CP cohort, and alternative better tolerated methods of investigating the motor system in children with movement disorders are recommended.

[Truncated abstract] This thesis consists of five experimental studies from seven data collection periods. The first two studies quantitatively analyse children with and without cerebral palsy using upper limb three dimensional (3D) motion analysis. Upper limb angular kinematics and sub-structures were measured and analysed, both of which were utilised during subsequent studies. The final three studies assess the efficacy of lycra® arm splints using clinical assessments, 3D dimensional upper limb kinematics and 3D sub-structures. Study 1 analysed 3D movement sub-structures in children with and without cerebral palsy ... The aim of the study was to quantitatively analyse movement sub-structures in children with and without cerebral palsy during four functional tasks taken from the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment - Randall, Johnson & Reddihough, 1999) ... Results demonstrated significant differences in angular kinematics in children with and without cerebral palsy, while the methodology developed in this study provided improved insight into the movement of the upper limb and trunk during functional tasks. Study 3 reported a randomised controlled trial of lycra® arm splints in children with cerebral palsy across all levels of the International Classification of Functioning Disability and Health (ICF) ... Lycra® arm splints were shown to have a statistically significant impact at the level of participation, whereas no significant difference was seen at the level of impairment and activity. Study 4 reported a randomised controlled trial of the effects of lycra® arm splints on 3D movement sub-structures during functional tasks in children with cerebral palsy ... This research demonstrated that movement sub-structures (including movement time) can be quantified and are amenable to change with intervention. Study 5 reported a randomised controlled trial of the effects of lycra® arm splints on angular kinematics (thorax, shoulder and elbow) during functional tasks in children with cerebral palsy ... The benefits of the splint on angular kinematics were only apparent when worn for the 3 month period, as minimum evidence was established for the short-term (1hour) and long term (3 month post splint wear) carry-over effects.

Whilst literature exists describing prevalence and theories about mechanisms of development of deformity, there is a distinct lack of research that examines how deformity can be measured despite it being an area of identified need. This study established the inter- and intra-rater reliability of the Goldsmith Index of Body Symmetry and examined the relevance of the information it provides within the context of a comprehensive postural assessment for individuals with cerebral palsy in conjunction with a commonly used clinical assessment ... Results demonstrated that high index levels were not exclusively associated with people with windswept deformity. Postural patterns of windsweeping, frog leg (abducting) and scissor (adducting) postures and hip extension were found to occur in all categories, suggesting that asymmetry is not confined to one particular postural pattern. Clinically observable changes were identified through comparison of the supine evaluation and index scores. The flexibility of postural components (or the ability to correct asymmetry) in a supine position for the SD categories demonstrated wide variation. However, subjects in the 3+SD groupings had fixed scoliosis and the majority (83%) also had fixed pelvic obliquity and rotation. All other subjects up to the 3SD category had flexible pelvic obliquity and rotation. No definitive differences in postural components between groups were identified in sitting positions, which was attributed to the influence of gravity on the body in an upright posture. Examination of sitting ability and index level did not demonstrate any relationship, suggesting that greater independence in sitting is not necessarily associated with a lower Goldsmith Index. The study highlighted that assessment of posture is complex, and that no single tool provides the answers required to manage a person’s posture. It demonstrates the need for clinicians to be aware that subjective clinical assessment may not be sufficient to adequately assess and detect changes in posture, and that the Goldsmith Index of Body Symmetry provides objective data that can be used as a powerful adjunct in interpreting clinical assessment and supporting the evaluation of clinical interventions.