support the use of DBS, with prospective sham-controlled studies performed in the setting of primary dystonia. A systematic review led by a joint working group of the European Federation of Neurological Societies and the Movement Disorder Society concluded in 2006 that the use of bilateral pallidotomy in the treatment of dystonia should be discouraged because of the absence of greater then class IV studies and concerns about the risk of dysarthria.6 Greater evidence to support the efficacy of DBS should not be considered as evidence of greater efficacy of DBS when compared to pallidotomy. Recent pragmatic expert opinion
has suggested that pallidotomy should still be considered over DBS when the risk of complications of DBS insertion might be particularly high, or when patients/carers decline the insertion of an implanted device.7 Pallidotomy will continue to play a role in resource-poor settings, given the associated costs of DBS implantation and ongoing programming and management. With the existing uncertainty over the place of pallidotomy in the management of dystonia, reports of outcomes following this procedure will continue to be of interest and help inform the ongoing debate.
REFERENCES 1. Guridi J, Lozano AM. A brief history of pallidotomy. Neurosurgery 1997; 41: 1169–80; discussion 1180–3. 2. Gross RE. What happened to posteroventral pallidotomy for Parkinson’s disease and dystonia? Neurotherapeutics 2008; 5: 281–93. 3. Laitinen LV, Bergenheim AT, Hariz MI. Ventroposterolateral pallidotomy can abolish all parkinsonian symptoms. Stereotact Funct Neurosurg 1992; 58: 14–21.
4. Efisio MC, Rizzi M, Cantonetti L, et al. Pallidotomy
(idiopathic) dystonia and dystonia plus syndromes:
for medically refractory status dystonicus in childhood.
report of an EFNS/MDS-ES Task Force. Eur J Neurol
Dev Med Child Neurol. 2014; 56: 649–56. 5. Fasano A, Ricciardi L, Bentivoglio AR, et al. Status dystonicus: predictors of outcome and progression patterns of
2006; 13: 433–44. 7. Moro E, Gross RE, Krauss JK. What’s new in surgical treatment for dystonia? Mov Disord 2013; 28: 1013–20.
underlying disease. Mov Disord 2012; 27: 783–8. 6. Albanese A, Barnes MP, Bhatia KP, et al. A systematic review on the diagnosis and treatment of primary
Clinical and research considerations in using the Melbourne Assessment 2 MARGARET WALLEN Cerebral Palsy Alliance – Research Institute, Allambie Heights, NSW, Australia. doi: 10.1111/dmcn.12428 This commentary is on the original article by Randall et al. on pages 665–672 of this issue.
The Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment) measures quality of movement for children with congenital or acquired neurological conditions. It predominantly contains items at the level of body function and structure according to the International Classification of Functioning, Disability and Health1 and measures capacity or best ability, rather than actual performance. Randall et al.2 developed the original Melbourne Assessment following rigorous test development processes based on classical test development principles, as was the norm at the time of publication. Further development of this measure extended the age group to include children aged 2 years 6 months to 15 years and provided valuable information about psychometric properties. The principal value of the Melbourne Assessment has been as an outcome measure and it has attracted the interest of researchers who have added to our knowledge on reliability and validity.3 The work presented in the current 608 Developmental Medicine & Child Neurology 2014, 56: 605–611
publication2 used Rasch modelling to evaluate and revise the Melbourne Assessment. Rasch analysis of total scores indicated that the Melbourne Assessment was not unidimensional. Further Rasch analysis of the four subscales, which were compiled as part of the original test development, resulted in deletion of misfitting or redundant items and rescaling of disordered rating scales. Differential item function (DIF) was absent for age and sex, as expected, thus providing evidence for construct validity. DIF did exist between raters, adding to evidence suggesting interrater reliability may be a relative weakness.3 Randall et al. have responded by providing access to online training and reliability resources for the revised Melbourne Assessment 2. Revision of the Melbourne Assessment is akin to a doubleedged sword. On the downside, the Melbourne Assessment 2 now needs to be evaluated with data collected using the revisions to items and rating scales in order to validate the new version. We also await knowledge regarding sensitivity to change and the amount of change following intervention which would be considered a minimally clinically important. Furthermore, we will need to consider carefully how, and if, we pool data collected with the Melbourne Assessment and Melbourne Assessment 2 in meta-analyses of the effects of interventions. The positive edge is that we have a clear understanding of important features of construct
validity of the Melbourne Assessment 2 such as dimensionality and rating scale structure. We know it is inappropriate to use the total score for interpretation and scores derived from individual subscales are more robust. Understanding that the subscales are relatively discrete may assist in planning intervention. The solid basis for the Melbourne Assessment 2 is a launching platform for more research, which will aid our confidence in its use as a discriminative tool and outcome measure. Decisions as to whether to use the Melbourne Assessment 2 for clinical and research purposes depend on balancing the requirements of the assessment, knowledge of psychometric properties, and clinical utility. The Melbourne Assessment is clearly feasible to use, considering frequency of use in intervention research, despite the need to videotape the assessment and time taken for scoring. The Melbourne Assessment 2 has a solid foundation to its psychometric properties based on Rasch modelling and extrapolating evidence from the existing Melbourne Assessment. The Melbourne Assessment 2 is more useful in out-
come evaluation than treatment planning, although understanding that the four subscales are discrete highlights relative areas of strength and weakness to exploit during treatment planning. It is probably the assessment of choice when a measure of unilateral, as opposed to bimanual, upper limb capacity is required. The Melbourne Assessment 2 may be used to assess both upper limbs, but the assessment is then undertaken and scored for each upper limb separately. Evaluation of bimanual performance in naturalistic environments would complement information obtained from the Melbourne Assessment 2. One option is observation of spontaneous use of the affected hand in bimanual activities using the Assisting Hand Assessments (AHA)4 for children with unilateral disability. The AHA is suitable for children aged 18 months to 12 years. Another option is the parent-rated ABILHAND-Kids5 for older children aged 6–15 years and which is validated for use with unilateral or bilateral cerebral palsy.
REFERENCES 1. Hoare B, Imms C, Randall M, Carey L. Linking cere-
3. Spirtos M, O’Mahony P, Malone J. Interrater reliability
bral palsy upper limb measures to the International
of the Melbourne Assessment of Unilateral Upper Limb
Classification of Functioning, Disability and Health. J
Function for children with hemiplegic cerebral palsy.
Rehabil Med 2011; 43: 987–96.
Am J Occup Ther 2011; 65: 378–83.
2. Randall M, Imms C, Carey L, Pallant J. Rasch analysis
4. Krumlinde-Sundholm L, Holmefur M, Kottorp A,
of the Melbourne Assessment of Unilateral Upper Limb
Eliasson AC. The Assisting Hand Assessment: current
evidence of validity, reliability and responsiveness to change. Dev Med Child Neurol 2007; 49: 259–64. 5. Arnould C, Penta M, Renders A, Thonnard JL. ABILHAND-Kids: a measure of manual ability in children with cerebral palsy. Neurology 2004; 63: 1045–52.
Function. Dev Med Child Neurol 2014; 56: 665–72.
Sedentary behaviour in adolescents and young adults with cerebral palsy NICHOLAS F TAYLOR 1,2 1 Department of Physiotherapy, La Trobe University, Bundoora, Vic.; 2 Allied Health Clinical Research Office, Eastern Health, Box Hill, Vic., Australia. doi: 10.1111/dmcn.12424 This commentary is on the original article by Shkedy Rabani et al. on pages 673–680 of this issue.
Much focus in public health recommendations has been on achieving a sufficient amount of physical activity (of at least moderate intensity) for good health. For example, it is recommended that adolescents up to age 17 years should accumulate at least 60 min of moderate to vigorous activity daily, and that when possible adolescents with disabilities should meet these guidelines. However, it is now emerging in large population studies that the amount of sedentary behaviour, and not just the total amount of physical activ-
ity, is an important predictor of cardiovascular and metabolic risk.1 Sedentary behaviour can be defined as sitting and lying postures characterized by low energy expenditure. Increased sedentary time, especially the time spent in sedentary behaviour without a break, can have a negative effect on the metabolic and cardiovascular systems, independent of the amount of time spent exercising at moderate to vigorous intensity.1 Therefore, it is possible for a person who is sufficiently physically active according to guidelines, to be to be at risk of developing heart disease and diabetes if they spend prolonged periods sitting and lying. It is also well recognized that people with cerebral palsy (CP) are a group that is particularly vulnerable to the negative health consequences of low levels of physical activity and increased amounts of sedentary behaviour. The physical impairments that characterize CP can result in a cycle of Commentaries
609
has suggested that pallidotomy should still be considered over DBS when the risk of complications of DBS insertion might be particularly high, or when patients/carers decline the insertion of an implanted device.7 Pallidotomy will continue to play a role in resource-poor settings, given the associated costs of DBS implantation and ongoing programming and management. With the existing uncertainty over the place of pallidotomy in the management of dystonia, reports of outcomes following this procedure will continue to be of interest and help inform the ongoing debate.
REFERENCES 1. Guridi J, Lozano AM. A brief history of pallidotomy. Neurosurgery 1997; 41: 1169–80; discussion 1180–3. 2. Gross RE. What happened to posteroventral pallidotomy for Parkinson’s disease and dystonia? Neurotherapeutics 2008; 5: 281–93. 3. Laitinen LV, Bergenheim AT, Hariz MI. Ventroposterolateral pallidotomy can abolish all parkinsonian symptoms. Stereotact Funct Neurosurg 1992; 58: 14–21.
4. Efisio MC, Rizzi M, Cantonetti L, et al. Pallidotomy
(idiopathic) dystonia and dystonia plus syndromes:
for medically refractory status dystonicus in childhood.
report of an EFNS/MDS-ES Task Force. Eur J Neurol
Dev Med Child Neurol. 2014; 56: 649–56. 5. Fasano A, Ricciardi L, Bentivoglio AR, et al. Status dystonicus: predictors of outcome and progression patterns of
2006; 13: 433–44. 7. Moro E, Gross RE, Krauss JK. What’s new in surgical treatment for dystonia? Mov Disord 2013; 28: 1013–20.
underlying disease. Mov Disord 2012; 27: 783–8. 6. Albanese A, Barnes MP, Bhatia KP, et al. A systematic review on the diagnosis and treatment of primary
Clinical and research considerations in using the Melbourne Assessment 2 MARGARET WALLEN Cerebral Palsy Alliance – Research Institute, Allambie Heights, NSW, Australia. doi: 10.1111/dmcn.12428 This commentary is on the original article by Randall et al. on pages 665–672 of this issue.
The Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment) measures quality of movement for children with congenital or acquired neurological conditions. It predominantly contains items at the level of body function and structure according to the International Classification of Functioning, Disability and Health1 and measures capacity or best ability, rather than actual performance. Randall et al.2 developed the original Melbourne Assessment following rigorous test development processes based on classical test development principles, as was the norm at the time of publication. Further development of this measure extended the age group to include children aged 2 years 6 months to 15 years and provided valuable information about psychometric properties. The principal value of the Melbourne Assessment has been as an outcome measure and it has attracted the interest of researchers who have added to our knowledge on reliability and validity.3 The work presented in the current 608 Developmental Medicine & Child Neurology 2014, 56: 605–611
publication2 used Rasch modelling to evaluate and revise the Melbourne Assessment. Rasch analysis of total scores indicated that the Melbourne Assessment was not unidimensional. Further Rasch analysis of the four subscales, which were compiled as part of the original test development, resulted in deletion of misfitting or redundant items and rescaling of disordered rating scales. Differential item function (DIF) was absent for age and sex, as expected, thus providing evidence for construct validity. DIF did exist between raters, adding to evidence suggesting interrater reliability may be a relative weakness.3 Randall et al. have responded by providing access to online training and reliability resources for the revised Melbourne Assessment 2. Revision of the Melbourne Assessment is akin to a doubleedged sword. On the downside, the Melbourne Assessment 2 now needs to be evaluated with data collected using the revisions to items and rating scales in order to validate the new version. We also await knowledge regarding sensitivity to change and the amount of change following intervention which would be considered a minimally clinically important. Furthermore, we will need to consider carefully how, and if, we pool data collected with the Melbourne Assessment and Melbourne Assessment 2 in meta-analyses of the effects of interventions. The positive edge is that we have a clear understanding of important features of construct
validity of the Melbourne Assessment 2 such as dimensionality and rating scale structure. We know it is inappropriate to use the total score for interpretation and scores derived from individual subscales are more robust. Understanding that the subscales are relatively discrete may assist in planning intervention. The solid basis for the Melbourne Assessment 2 is a launching platform for more research, which will aid our confidence in its use as a discriminative tool and outcome measure. Decisions as to whether to use the Melbourne Assessment 2 for clinical and research purposes depend on balancing the requirements of the assessment, knowledge of psychometric properties, and clinical utility. The Melbourne Assessment is clearly feasible to use, considering frequency of use in intervention research, despite the need to videotape the assessment and time taken for scoring. The Melbourne Assessment 2 has a solid foundation to its psychometric properties based on Rasch modelling and extrapolating evidence from the existing Melbourne Assessment. The Melbourne Assessment 2 is more useful in out-
come evaluation than treatment planning, although understanding that the four subscales are discrete highlights relative areas of strength and weakness to exploit during treatment planning. It is probably the assessment of choice when a measure of unilateral, as opposed to bimanual, upper limb capacity is required. The Melbourne Assessment 2 may be used to assess both upper limbs, but the assessment is then undertaken and scored for each upper limb separately. Evaluation of bimanual performance in naturalistic environments would complement information obtained from the Melbourne Assessment 2. One option is observation of spontaneous use of the affected hand in bimanual activities using the Assisting Hand Assessments (AHA)4 for children with unilateral disability. The AHA is suitable for children aged 18 months to 12 years. Another option is the parent-rated ABILHAND-Kids5 for older children aged 6–15 years and which is validated for use with unilateral or bilateral cerebral palsy.
REFERENCES 1. Hoare B, Imms C, Randall M, Carey L. Linking cere-
3. Spirtos M, O’Mahony P, Malone J. Interrater reliability
bral palsy upper limb measures to the International
of the Melbourne Assessment of Unilateral Upper Limb
Classification of Functioning, Disability and Health. J
Function for children with hemiplegic cerebral palsy.
Rehabil Med 2011; 43: 987–96.
Am J Occup Ther 2011; 65: 378–83.
2. Randall M, Imms C, Carey L, Pallant J. Rasch analysis
4. Krumlinde-Sundholm L, Holmefur M, Kottorp A,
of the Melbourne Assessment of Unilateral Upper Limb
Eliasson AC. The Assisting Hand Assessment: current
evidence of validity, reliability and responsiveness to change. Dev Med Child Neurol 2007; 49: 259–64. 5. Arnould C, Penta M, Renders A, Thonnard JL. ABILHAND-Kids: a measure of manual ability in children with cerebral palsy. Neurology 2004; 63: 1045–52.
Function. Dev Med Child Neurol 2014; 56: 665–72.
Sedentary behaviour in adolescents and young adults with cerebral palsy NICHOLAS F TAYLOR 1,2 1 Department of Physiotherapy, La Trobe University, Bundoora, Vic.; 2 Allied Health Clinical Research Office, Eastern Health, Box Hill, Vic., Australia. doi: 10.1111/dmcn.12424 This commentary is on the original article by Shkedy Rabani et al. on pages 673–680 of this issue.
Much focus in public health recommendations has been on achieving a sufficient amount of physical activity (of at least moderate intensity) for good health. For example, it is recommended that adolescents up to age 17 years should accumulate at least 60 min of moderate to vigorous activity daily, and that when possible adolescents with disabilities should meet these guidelines. However, it is now emerging in large population studies that the amount of sedentary behaviour, and not just the total amount of physical activ-
ity, is an important predictor of cardiovascular and metabolic risk.1 Sedentary behaviour can be defined as sitting and lying postures characterized by low energy expenditure. Increased sedentary time, especially the time spent in sedentary behaviour without a break, can have a negative effect on the metabolic and cardiovascular systems, independent of the amount of time spent exercising at moderate to vigorous intensity.1 Therefore, it is possible for a person who is sufficiently physically active according to guidelines, to be to be at risk of developing heart disease and diabetes if they spend prolonged periods sitting and lying. It is also well recognized that people with cerebral palsy (CP) are a group that is particularly vulnerable to the negative health consequences of low levels of physical activity and increased amounts of sedentary behaviour. The physical impairments that characterize CP can result in a cycle of Commentaries
609
