Original Article
341
Activities of Daily Living in Children with Hemiparesis: Influence of Cognitive Abilities and Motor Competence Markus Rauchenzauner2
Martin Staudt1,3
1 Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center
for Children and Adolescents, Schön Klinik Vogtareuth, Germany 2 Department of Neuropediatrics, St. Vinzenz Krankenhaus, Zams, Austria 3 Department Pediatric Neurology and Developmental Medicine, University Children’s Hospital, Tübingen, Germany
Steffen Berweck1
Address for correspondence Caroline Adler, MscOT, Schön Klinik Vogtareuth, Department of Neurorehabilitation, Epilepsy Centre for Children and Youth; Occupational therapy, Krankenhausstr. 20, 83569 Vogtareuth, Germany (e-mail: [email protected]).
Neuropediatrics 2014;45:341–345.
Abstract
Keywords
► hemiparesis ► cognition ► activities of daily living ► quality of performance ► hand motor function
Purpose The aim of the article is to investigate whether motor competence and cognitive abilities influence the quality of performance of activities of daily living (ADL) in children with hemiparesis. Patients and Methods A total of 20 children with hemiparesis (age, 6–12 years; 11 congenital, 9 acquired during childhood) were studied. Motor competence was assessed with the Assisting Hand Assessment, cognitive abilities with the German version of the Wechsler Intelligence Scale for Children IV, and the quality of ADL performance with the Assessment of Motor and Process Skills (AMPS). Results The motor skills scale of the AMPS correlated with motor competence, and the process skills scale of the AMPS correlated with cognitive abilities. Conclusion The quality of ADL performance is influenced not only by motor competence but also by the cognitive abilities of a hemiparetic child. This suggests that, in addition to motor-oriented training programs, an optimal therapy for hemiparetic children should also consider cognitive approaches.
Introduction Unilateral spastic cerebral palsy (USCP), formerly termed “congenital hemiparesis,” is a common cause of disability in childhood, with an incidence of 0.6 to 1 per 1,000 live births.1 Children with this disorder show various functional disabilities in the sensorimotor domain, such as muscle weakness, spasticity, reduction of range of motion, reduced amount of movements and precision of the movements, motor planning, and tactile dysfunction.2,3 Not surprisingly, most children with USCP have difficulties in the performance of activities of daily living (ADL),4,5 and it has been shown that singular “body functions” as defined in the international classification
received March 19, 2014 accepted April 22, 2014 published online July 15, 2014
of functioning, disability and health child and youth6 such as reduced speed, grip force, tone, and weakness of distal muscles, as well as tactile dysfunction influence the ADL performance and their quality.7–10 This phenomenon is, of course, not specific for USCP: Similar problems are also encountered in children with hemiparesis caused by brain lesions acquired after the neonatal period, for example, traumatic brain injuries or stroke.11 Sensorimotor deficits are, however, not the only problem in hemiparetic children: Impaired cognitive functions have been described in children with USCP12–14 and even more so in hemiparetic children with lesions acquired later in childhood.15,16 But despite the high prevalence of these problems
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1382824. ISSN 0174-304X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Caroline Adler1
Activities of Daily Living in Children with Hemiparesis
Adler et al.
Table 1 Diagnosis, age, and MACS level of the participants Participants
Age (y)
Sex
Side
MACS
Onset of hemiparesis (years ago)
Diagnosis
1
10.3
M
Right
1
3.11
Hemiparesis after traumatic brain injury
2
9.9
F
Left
3
6.2
Hemiparesis after ischemia during resection of dysembryoplastic neuroepithelial tumor (DNET) right temporal lobe
3
11.6
M
Left
2
2.1
Hemiparesis and aphasia after traumatic brain injury.
4
9.6
M
Left
3
1.4
Hemiparesis after resection of a pilocytic astrocytoma middle brain stem to right hemisphere
5
11.3
F
Left
2
Congenital
USCP
6
7.5
M
Right
3
Congenital
USCP
7
11.3
F
Left
3
4.2
Ischemic MCA infarction
8
7.6
M
Right
2
Congenital
USCP
9
11.7
M
Right
2
Congenital
USCP
10
10.8
F
Right
2
Congenital
USCP, hemispherotomy
11
7.7
F
Right
1
5.2
Hemiparesis after viral encephalitis (herpes simplex)
12
12.3
F
Right
1
Congenital
USCP
13
10.8
F
Right
2
Congenital
USCP
14
10.8
F
Left
3
7.2
Ischemic MCA infarction
15
8.0
F
Left
2
Congenital
USCP
16
12.2
F
Right
1
Congenital
USCP
17
8.8
F
Left
2
Congenital
USCP
18
12.5
M
Left
2
Congenital
USCP
19
10.6
M
Left
2
0.6
Hemiparesis after partial resection of pilocytic astrocytoma right thalamic
20
11
M
Right
3
2.7
Ischemic MCA infarction after clipping a giant aneurysm
Abbreviations: MACS, manual ability classification system; MCA, middle cerebral artery; USCP, unilateral spastic cerebral palsy.
in hemiparetic children, little is known in how far these factors can also influence the performance of ADLs—in addition to the well-described impact of sensorimotor dysfunctions. This was the scope of our study.
Approval from the ethic committee of the LudwigMaximilians-University of Munich and informed written consent from all participants and their caregivers were obtained.
Assessments
Patients and Methods Participants In total, 32 consecutive patients with hemiparesis were identified from our inpatient and day clinic service. Inclusion criteria were age between 6 and 12 years, USCP or acquired hemiparesis for at least 6 months, and eligibility for all assessments of the study. Of these 32 patients, 3 did not wish to participate, and 9 could not complete the whole assessment. Therefore, 20 children (average age, 10.3 years; standard deviation, 1.6) could be included in this study, 11 with USCP, and 9 with hemiparesis following lesions acquired later in childhood as seen in ►Table 1. Neuropediatrics
Vol. 45
No. 6/2014
Motor competence was measured using the Assisting Hand Assessment (AHA). The AHA is a sensitive, reliable, and valid tool to assess bimanual performance and use of the affected hand during play in hemiparetic children. After videotaping a play situation of 15 to 20 minutes duration, 22 items are scored on a 4-point ordinal scale. These raw scores are then converted by Rasch analysis into interval scaled from 0 to 100 AHA units (1 AHA unit ¼ 0.19 Rasch measurement logits).17–20 Quality of performance of ADL, which includes the physical effort, efficiency, safety, and independence of a person while performing the ADLs, was measured using the Assessment of Motor and Process Skills (AMPS). The AMPS is a cultureindependent, sensitive, reliable, and valid tool to assess the
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
342
Activities of Daily Living in Children with Hemiparesis
Statistical Analysis Correlations between AHA, WISC, and the two scores of the AMPS (motor skills and process skills) were calculated using Pearson product moment correlation. In addition, a multivariate model analysis was applied. All statistical tests were performed one tailed, with a significance level of p < 0.05.
Results The motor scale of the AMPS correlated strongly with motor competence (r ¼ 0.600; p ¼ 0.003), but not with cognitive abilities (r ¼ 0.111; p ¼ 0.321 not significant [n.s.])). For the process scale of the AMPS, we found a reciprocal correlation. A significant correlation was found with the cognitive abilities of the children (r ¼ 0.518; p ¼ 0.010) but not with their motor competence (r ¼ 0.320; p ¼ 0.085 n.s.). This finding can be seen in ►Fig. 1.
343
This finding was confirmed in the multifactorial analysis. The two variables AHA and WISC together explained 36.9% (corrected r square) of the variance of the AMPS motor scale and 22.4% (corrected r square) of the AMPS process scale. The AHA had an effect on the AMPS motor scale (sum square, 0.91; p ¼ 0.002), but it had no significant effect on the AMPS process scale (sum square, 0.13; p ¼ 0.353). The WISC showed a significant effect on the AMPS process scale (sum square, 0.72; p ¼ 0.039) but no significant effect on the AMPS motor scale (sum square, 0.16; p ¼ 0.151).
Discussion This study shows that, in hemiparetic children, the quality of ADL performance is not only influenced by their motor competence but also by their cognitive abilities. The influence of motor competence on quality of ADL performance has, to our knowledge, not yet been demonstrated formally for hemiparetic children. This correlation is, on the contrary, not unexpected, because impaired body functions such as increased tone or weakness of the paretic arm have been reported to influence not only motor competence but also the functioning in ADL and quality of ADL performance.5,14,23 In the treatment of children with hemiparesis motor-focused interventions are very common, for example, modified constrained-induced–movement therapy (mCIMT). mCIMT and hand-arm bimanual intensive therapy, for example, are well-established therapeutic interventions
Fig. 1 Correlation between motor competence and the Assessment of Motor and Process Skills (AMPS) scales and cognitive abilities and the AMPS scales.
Neuropediatrics
Vol. 45
No. 6/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
quality of ADL performance in persons of 2 years of age and older. For this assessment, two standardized ADLs are chosen in a patient interview, which are then performed in a familiar context and observed by the therapist. The AMPS consists of two separate scales: the motor skill scale with 16 items, and the process skills scale with 20 items. A 4-point ordinal scale is used to score each item, and a multifaceted Rasch analysis is used to transform the raw scores into interval-scaled logits.21 Cognitive abilities were measured using the German version of the Wechsler Intelligence Scale for Children (WISC) IV.22
Adler et al.
Activities of Daily Living in Children with Hemiparesis
Adler et al.
to overcome the nonuse and improve children’s hand functioning. Therefore, such motor-based interventions are useful because they can improve not only body functions but also the ADL performance.24–26 A correlation between cognitive abilities and ADL performance has not yet been reported for hemiparetic children either. These findings are in line with Naygard et al,27 who found that cognitive abilities define 25% of variance of quality of ADL performance in patients with Alzheimer disease. Similarly, Lindén et al28 detected a parallel improvement of AMPS process skills and results of neuropsychological tests during the rehabilitation of adult patients with acquired brain injuries. An association between cognitive abilities and motor skills to neuropsychological assessments in patients after stroke was also described.29 Our results have important implications for therapeutic approaches in hemiparetic children. As we could show that quality of ADL performance correlates not only with motor competence but also with cognitive abilities, we propose that not only motor-focused but also cognitive-based interventions such as the “Cognitive orientation to daily occupational performance (CO-OP)”30 should be applied for improvement in the quality of ADL performance in these children. This aspect seems especially important when hemiparetic children present with a relatively good motor competence but impaired cognitive functions. These children often do not use their motor abilities efficiently, and a training of motor competence alone will not lead to a better quality of ADL performance. In such patients, cognitive-oriented interventions during therapy might make a very important contribution to improve the use of the paretic hand in ADL. The effectiveness and combination of motor approaches with cognitive approaches to improve ADL performance is not described yet.
Acknowledgments We thank all the children and their parents who made their contribution to this research. Also, many thanks to the team of psychologists, who administered the WISC assessments, and to the occupational therapists of the Schoen Klinik Vogtareuth, for doing all the AHA and AMPS assessments. Finally, we thank Hemihelp Deutschland e.V. and the Schoen Klinik Vogtareuth for financial support. The authors report no further declaration of interest.
4 Rice J, Russo R, Halbert J, Van Essen P, Haan E. Motor function in 5-
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
References
21
1 Surveillance of Cerebral Palsy in Europe. Surveillance of cerebral
palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE). Dev Med Child Neurol 2000;42(12):816–824 2 Steenbergen B, Gordon AM. Activity limitation in hemiplegic cerebral palsy: evidence for disorders in motor planning. Dev Med Child Neurol 2006;48(9):780–783 3 Steenbergen B, Verrel J, Gordon AM. Motor planning in congenital hemiplegia. Disabil Rehabil 2007;29(1):13–23 Neuropediatrics
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22
year-old children with cerebral palsy in the South Australian population. Dev Med Child Neurol 2009;51(7):551–556 Van Zelst BR, Miller MD, Russo R, Murchland S, Crotty M. Activities of daily living in children with hemiplegic cerebral palsy: a crosssectional evaluation using the Assessment of Motor and Process Skills. Dev Med Child Neurol 2006;48(9):723–727 WHO ICF-CY. Internationale Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit bei Kindern und Jugendlichen. Bern: Verlag Hans Huber, Hogrefe AG; 2011 Auld ML, Boyd RN, Moseley GL, Ware RS, Johnston LM. Impact of tactile dysfunction on upper-limb motor performance in children with unilateral cerebral palsy. Arch Phys Med Rehabil 2012;93(4): 696–702 Arnould C, Penta M, Thonnard JL. Hand impairments and their relationship with manual ability in children with cerebral palsy. J Rehabil Med 2007;39(9):708–714 Braendvik SM, Elvrum AK, Vereijken B, Roeleveld K. Relationship between neuromuscular body functions and upper extremity activity in children with cerebral palsy. Dev Med Child Neurol 2010;52(2):e29–e34 Kim WH, Park EY. Causal relation between spasticity, strength, gross motor function, and functional outcome in children with cerebral palsy: a path analysis. Dev Med Child Neurol 2011;53(1): 68–73 Steinlin M. A clinical approach to arterial ischemic childhood stroke: increasing knowledge over the last decade. Neuropediatrics 2012;43(1):1–9 Bodimeade HL, Whittingham K, Lloyd O, Boyd RN. Executive function in children and adolescents with unilateral cerebral palsy. Dev Med Child Neurol 2013;55(10):926–933 Weierink L, Vermeulen RJ, Boyd RN. Brain structure and executive functions in children with cerebral palsy: a systematic review. Res Dev Disabil 2013;34(5):1678–1688 Russo RN. Congenital hemiplegia and the neglected upper limb [dissertation]. Adelaide: Flinders University School of Medicine; 2011:181 Everts R, Pavlovic J, Kaufmann F, et al. Cognitive functioning, behavior, and quality of life after stroke in childhood. Child Neuropsychol 2008;14(4):323–338 Kuhtz-Buschbeck JP, Hoppe B, Gölge M, Dreesmann M, DammStünitz U, Ritz A. Sensorimotor recovery in children after traumatic brain injury: analyses of gait, gross motor, and fine motor skills. Dev Med Child Neurol 2003;45(12):821–828 Krumlinde-Sundholm L, Eliasson AC. Development of the Assisting Hand Assessment: a rasch-built measure intended for children with unilateral upper limb impairments. Scand J Occup Ther 2003; 10:16–26 Krumlinde-Sundholm L, Holmefur M, Kottorp A, Eliasson AC. The Assisting Hand Assessment: current evidence of validity, reliability, and responsiveness to change. Dev Med Child Neurol 2007; 49(4):259–264 Krumlinde-Sundholm L. Reporting outcomes of the assisting hand assessment: what scale should be used? Dev Med Child Neurol 2012;54(9):807–808 Holmefur M, Aarts P, Hoare B, Krumlinde-Sundholm L. Test-retest and alternate forms reliability of the assisting hand assessment. J Rehabil Med 2009;41(11):886–891 Lange B, Spagnolo K, Fowler B. Using the assessment of motor and process skills to measure functional change in adults with severe traumatic brain injury: A pilot study. Aust Occup Ther J 2009; 56(2):89–96 Schmidtendorf S, Christmann N, Heinrichs N. The performance of children with AH(H)D according to the HAWIK-IV. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie 2012; 40: 191–199; Petermann, F.,Petermann, U. Hamburg-Wechsler- Intelligenztest für Kinder- IV: Manual pp. Bern: Verlag Hans Huber, 2007
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27 Naygard L, Amberla K, Bernspang B, Almkvist O, Winblad B. The
nual capacity and bimanual performance in children with congenital hemiplegia. Dev Med Child Neurol 2010;52(9):811–816 24 Sakzewski L, Ziviani J, Abbott DF, Macdonell RA, Jackson GD, Boyd RN. Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Dev Med Child Neurol 2011;53(4):313–320 25 Hoare BJ, Wasiak J, Imms C, Carey L. Constraint-induced movement therapy in the treatment of the upper limb in children with hemiplegic cerebral palsy. Cochrane Database Syst Rev 2007;(2):CD004149 26 Eliasson AC, Krumlinde-sundholm L, Shaw K, Wang C. Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model. Dev Med Child Neurol 2005;47(4):266–275
relationship between cognition and daily activities in cases of mild Alzheimer’s disease. Scand J Occup Ther 1998;5:160–166 28 Lindén A, Boschian K, Eker C, Schalén W, Nordström CH. Assessment of motor and process skills reflects brain-injured patients’ ability to resume independent living better than neuropsychological tests. Acta Neurol Scand 2005;111(1):48–53 29 Kizony R, Katz N. Relationship between cognitive abilities and the process scale and skills of the Assessment of Motor and Process Skills (AMPS) in patients with stroke. OTJR: Occupation, Participation and Health 2002;22:82–92 30 Missiuna C, DeMatteo C, Hanna S, et al. Exploring the use of cognitive intervention for children with acquired brain injury. Phys Occup Ther Pediatr 2010;30(3):205–219
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23 Sakzewski L, Ziviani J, Boyd R. The relationship between unima-
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341
Activities of Daily Living in Children with Hemiparesis: Influence of Cognitive Abilities and Motor Competence Markus Rauchenzauner2
Martin Staudt1,3
1 Clinic for Neuropediatrics and Neurorehabilitation, Epilepsy Center
for Children and Adolescents, Schön Klinik Vogtareuth, Germany 2 Department of Neuropediatrics, St. Vinzenz Krankenhaus, Zams, Austria 3 Department Pediatric Neurology and Developmental Medicine, University Children’s Hospital, Tübingen, Germany
Steffen Berweck1
Address for correspondence Caroline Adler, MscOT, Schön Klinik Vogtareuth, Department of Neurorehabilitation, Epilepsy Centre for Children and Youth; Occupational therapy, Krankenhausstr. 20, 83569 Vogtareuth, Germany (e-mail: [email protected]).
Neuropediatrics 2014;45:341–345.
Abstract
Keywords
► hemiparesis ► cognition ► activities of daily living ► quality of performance ► hand motor function
Purpose The aim of the article is to investigate whether motor competence and cognitive abilities influence the quality of performance of activities of daily living (ADL) in children with hemiparesis. Patients and Methods A total of 20 children with hemiparesis (age, 6–12 years; 11 congenital, 9 acquired during childhood) were studied. Motor competence was assessed with the Assisting Hand Assessment, cognitive abilities with the German version of the Wechsler Intelligence Scale for Children IV, and the quality of ADL performance with the Assessment of Motor and Process Skills (AMPS). Results The motor skills scale of the AMPS correlated with motor competence, and the process skills scale of the AMPS correlated with cognitive abilities. Conclusion The quality of ADL performance is influenced not only by motor competence but also by the cognitive abilities of a hemiparetic child. This suggests that, in addition to motor-oriented training programs, an optimal therapy for hemiparetic children should also consider cognitive approaches.
Introduction Unilateral spastic cerebral palsy (USCP), formerly termed “congenital hemiparesis,” is a common cause of disability in childhood, with an incidence of 0.6 to 1 per 1,000 live births.1 Children with this disorder show various functional disabilities in the sensorimotor domain, such as muscle weakness, spasticity, reduction of range of motion, reduced amount of movements and precision of the movements, motor planning, and tactile dysfunction.2,3 Not surprisingly, most children with USCP have difficulties in the performance of activities of daily living (ADL),4,5 and it has been shown that singular “body functions” as defined in the international classification
received March 19, 2014 accepted April 22, 2014 published online July 15, 2014
of functioning, disability and health child and youth6 such as reduced speed, grip force, tone, and weakness of distal muscles, as well as tactile dysfunction influence the ADL performance and their quality.7–10 This phenomenon is, of course, not specific for USCP: Similar problems are also encountered in children with hemiparesis caused by brain lesions acquired after the neonatal period, for example, traumatic brain injuries or stroke.11 Sensorimotor deficits are, however, not the only problem in hemiparetic children: Impaired cognitive functions have been described in children with USCP12–14 and even more so in hemiparetic children with lesions acquired later in childhood.15,16 But despite the high prevalence of these problems
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1382824. ISSN 0174-304X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Caroline Adler1
Activities of Daily Living in Children with Hemiparesis
Adler et al.
Table 1 Diagnosis, age, and MACS level of the participants Participants
Age (y)
Sex
Side
MACS
Onset of hemiparesis (years ago)
Diagnosis
1
10.3
M
Right
1
3.11
Hemiparesis after traumatic brain injury
2
9.9
F
Left
3
6.2
Hemiparesis after ischemia during resection of dysembryoplastic neuroepithelial tumor (DNET) right temporal lobe
3
11.6
M
Left
2
2.1
Hemiparesis and aphasia after traumatic brain injury.
4
9.6
M
Left
3
1.4
Hemiparesis after resection of a pilocytic astrocytoma middle brain stem to right hemisphere
5
11.3
F
Left
2
Congenital
USCP
6
7.5
M
Right
3
Congenital
USCP
7
11.3
F
Left
3
4.2
Ischemic MCA infarction
8
7.6
M
Right
2
Congenital
USCP
9
11.7
M
Right
2
Congenital
USCP
10
10.8
F
Right
2
Congenital
USCP, hemispherotomy
11
7.7
F
Right
1
5.2
Hemiparesis after viral encephalitis (herpes simplex)
12
12.3
F
Right
1
Congenital
USCP
13
10.8
F
Right
2
Congenital
USCP
14
10.8
F
Left
3
7.2
Ischemic MCA infarction
15
8.0
F
Left
2
Congenital
USCP
16
12.2
F
Right
1
Congenital
USCP
17
8.8
F
Left
2
Congenital
USCP
18
12.5
M
Left
2
Congenital
USCP
19
10.6
M
Left
2
0.6
Hemiparesis after partial resection of pilocytic astrocytoma right thalamic
20
11
M
Right
3
2.7
Ischemic MCA infarction after clipping a giant aneurysm
Abbreviations: MACS, manual ability classification system; MCA, middle cerebral artery; USCP, unilateral spastic cerebral palsy.
in hemiparetic children, little is known in how far these factors can also influence the performance of ADLs—in addition to the well-described impact of sensorimotor dysfunctions. This was the scope of our study.
Approval from the ethic committee of the LudwigMaximilians-University of Munich and informed written consent from all participants and their caregivers were obtained.
Assessments
Patients and Methods Participants In total, 32 consecutive patients with hemiparesis were identified from our inpatient and day clinic service. Inclusion criteria were age between 6 and 12 years, USCP or acquired hemiparesis for at least 6 months, and eligibility for all assessments of the study. Of these 32 patients, 3 did not wish to participate, and 9 could not complete the whole assessment. Therefore, 20 children (average age, 10.3 years; standard deviation, 1.6) could be included in this study, 11 with USCP, and 9 with hemiparesis following lesions acquired later in childhood as seen in ►Table 1. Neuropediatrics
Vol. 45
No. 6/2014
Motor competence was measured using the Assisting Hand Assessment (AHA). The AHA is a sensitive, reliable, and valid tool to assess bimanual performance and use of the affected hand during play in hemiparetic children. After videotaping a play situation of 15 to 20 minutes duration, 22 items are scored on a 4-point ordinal scale. These raw scores are then converted by Rasch analysis into interval scaled from 0 to 100 AHA units (1 AHA unit ¼ 0.19 Rasch measurement logits).17–20 Quality of performance of ADL, which includes the physical effort, efficiency, safety, and independence of a person while performing the ADLs, was measured using the Assessment of Motor and Process Skills (AMPS). The AMPS is a cultureindependent, sensitive, reliable, and valid tool to assess the
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
342
Activities of Daily Living in Children with Hemiparesis
Statistical Analysis Correlations between AHA, WISC, and the two scores of the AMPS (motor skills and process skills) were calculated using Pearson product moment correlation. In addition, a multivariate model analysis was applied. All statistical tests were performed one tailed, with a significance level of p < 0.05.
Results The motor scale of the AMPS correlated strongly with motor competence (r ¼ 0.600; p ¼ 0.003), but not with cognitive abilities (r ¼ 0.111; p ¼ 0.321 not significant [n.s.])). For the process scale of the AMPS, we found a reciprocal correlation. A significant correlation was found with the cognitive abilities of the children (r ¼ 0.518; p ¼ 0.010) but not with their motor competence (r ¼ 0.320; p ¼ 0.085 n.s.). This finding can be seen in ►Fig. 1.
343
This finding was confirmed in the multifactorial analysis. The two variables AHA and WISC together explained 36.9% (corrected r square) of the variance of the AMPS motor scale and 22.4% (corrected r square) of the AMPS process scale. The AHA had an effect on the AMPS motor scale (sum square, 0.91; p ¼ 0.002), but it had no significant effect on the AMPS process scale (sum square, 0.13; p ¼ 0.353). The WISC showed a significant effect on the AMPS process scale (sum square, 0.72; p ¼ 0.039) but no significant effect on the AMPS motor scale (sum square, 0.16; p ¼ 0.151).
Discussion This study shows that, in hemiparetic children, the quality of ADL performance is not only influenced by their motor competence but also by their cognitive abilities. The influence of motor competence on quality of ADL performance has, to our knowledge, not yet been demonstrated formally for hemiparetic children. This correlation is, on the contrary, not unexpected, because impaired body functions such as increased tone or weakness of the paretic arm have been reported to influence not only motor competence but also the functioning in ADL and quality of ADL performance.5,14,23 In the treatment of children with hemiparesis motor-focused interventions are very common, for example, modified constrained-induced–movement therapy (mCIMT). mCIMT and hand-arm bimanual intensive therapy, for example, are well-established therapeutic interventions
Fig. 1 Correlation between motor competence and the Assessment of Motor and Process Skills (AMPS) scales and cognitive abilities and the AMPS scales.
Neuropediatrics
Vol. 45
No. 6/2014
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
quality of ADL performance in persons of 2 years of age and older. For this assessment, two standardized ADLs are chosen in a patient interview, which are then performed in a familiar context and observed by the therapist. The AMPS consists of two separate scales: the motor skill scale with 16 items, and the process skills scale with 20 items. A 4-point ordinal scale is used to score each item, and a multifaceted Rasch analysis is used to transform the raw scores into interval-scaled logits.21 Cognitive abilities were measured using the German version of the Wechsler Intelligence Scale for Children (WISC) IV.22
Adler et al.
Activities of Daily Living in Children with Hemiparesis
Adler et al.
to overcome the nonuse and improve children’s hand functioning. Therefore, such motor-based interventions are useful because they can improve not only body functions but also the ADL performance.24–26 A correlation between cognitive abilities and ADL performance has not yet been reported for hemiparetic children either. These findings are in line with Naygard et al,27 who found that cognitive abilities define 25% of variance of quality of ADL performance in patients with Alzheimer disease. Similarly, Lindén et al28 detected a parallel improvement of AMPS process skills and results of neuropsychological tests during the rehabilitation of adult patients with acquired brain injuries. An association between cognitive abilities and motor skills to neuropsychological assessments in patients after stroke was also described.29 Our results have important implications for therapeutic approaches in hemiparetic children. As we could show that quality of ADL performance correlates not only with motor competence but also with cognitive abilities, we propose that not only motor-focused but also cognitive-based interventions such as the “Cognitive orientation to daily occupational performance (CO-OP)”30 should be applied for improvement in the quality of ADL performance in these children. This aspect seems especially important when hemiparetic children present with a relatively good motor competence but impaired cognitive functions. These children often do not use their motor abilities efficiently, and a training of motor competence alone will not lead to a better quality of ADL performance. In such patients, cognitive-oriented interventions during therapy might make a very important contribution to improve the use of the paretic hand in ADL. The effectiveness and combination of motor approaches with cognitive approaches to improve ADL performance is not described yet.
Acknowledgments We thank all the children and their parents who made their contribution to this research. Also, many thanks to the team of psychologists, who administered the WISC assessments, and to the occupational therapists of the Schoen Klinik Vogtareuth, for doing all the AHA and AMPS assessments. Finally, we thank Hemihelp Deutschland e.V. and the Schoen Klinik Vogtareuth for financial support. The authors report no further declaration of interest.
4 Rice J, Russo R, Halbert J, Van Essen P, Haan E. Motor function in 5-
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