Perspectives of children and adolescents with cerebral palsy about involvement as research partners: a qualitative study

PURPOSE

Children and adolescents with cerebral palsy have diverse needs and often engage with healthcare services, including paediatric rehabilitation. Partnering with these children and adolescents on research projects to inform practice has the potential to ensure services continue to remain relevant and appropriate. This study aimed to identify what children and adolescents with cerebral palsy suggest are effective ways for researchers to involve them as partners in research.

MATERIALS AND METHODS

This qualitative study was guided by interpretive description. Children and adolescents with cerebral palsy between 8 and 18 years participated in semi-structured, activity-based focus groups or interviews. Verbatim transcripts were coded and analysed using thematic analysis. One member of the research team was a young woman with cerebral palsy.

RESULTS

Seventeen children and adolescents with cerebral palsy from NSW and Victoria (Australia) were involved. Participants were between 8 and 18 years (mean = 12 years), male (n = 11) and female (n = 6). Analysis identified four nested themes: "insider knowledge", "reasons for involvement", "roles in research" and "facilitating partnership".

CONCLUSION

This study identified perspectives of children and adolescents on their involvement as research partners, and considerations for researchers to facilitate involvement of children and adolescents with cerebral palsy as partners in research.IMPLICATIONS FOR REHABILITATIONThe commitment in healthcare to client-centred practice requires that consumers, including children and young people with cerebral palsy, have opportunities to influence the direction of research which impacts them.Children and young people with cerebral palsy are interested in research partnerships and motivated to be involved in various areas of research.Effective research partnerships with younger populations can be facilitated by researchers acknowledging a child or young person's expertise, and employing strategies relating to open communication, flexibility and support.

A magic-themed upper limb intervention for children with unilateral cerebral palsy: The perspectives of parents

AIM

To explore parent's perspective of their child's participation in a magic-themed intervention called Amazing Magic Club (AMC), and to further our understanding of motivated engagement and the impact of themed group-based interventions for children with unilateral cerebral palsy (CP).

METHODS

Twenty-nine parents of children with unilateral CP completed semi-structured interviews. The child participants (n = 28) attended one of three AMCs; average age of the children was 10y 6mo (SD 2y 2mo). The parent interviews were analysed using thematic analysis.

RESULTS

The three themes are: "It's okay to be me", the magic effect and "I can do it". Parents observed their children to belong and learn about their abilities. The importance of the magicians and the performance is described. Parents observed their children to have increased self-belief and a new willingness to attempt difficult tasks.

DISCUSSION

AMC appears to capture intrinsic motivation for children with unilateral CP to complete challenging tasks.

Upper Limb Function of Children with Unilateral Cerebral Palsy After a Magic-Themed HABIT: A Pre-Post-Study with 3- and 6-Month Follow-Up

Aims: To examine changes in upper limb function, and performance in everyday tasks, for children with unilateral cerebral palsy who participated in a magic-themed hand-arm bimanual intensive therapy (HABIT). Methods: Twenty-eight children participated; mean age 10 y 6 mo (SD 2 y 2 mo), n = 15 male and n = 13 female. Using a single group, pre-and post-test design, the magic-themed HABIT was delivered for 60 hours over 10 days. Bimanual and unimanual hand function were measured using the Assisting Hand Assessment (AHA) and Box and Blocks Test (BBT). Occupational performance was rated using the Canadian Occupational Performance Measure (COPM). Two parent questionnaires explored change in bimanual hand use in everyday activities; ABILHAND-Kids and Children's Hand-use Experience Questionnaire (CHEQ). Assessments were completed pre-, immediately post, 3 months and 6 months after the intervention. Results: Friedman's ANOVA revealed a significant improvement for COPM and CHEQ grasp subscale. Repeated measures ANOVA revealed a significant improvement in BBT, and ABILHAND-Kids, and no significant change for AHA. Conclusions: Children who participated in the magic-themed HABIT experienced improved occupational performance, unimanual skills, and parent ratings of performance in challenging everyday tasks.

Developing research competencies through a project-based tissue-engineering module in the biomedical engineering undergraduate curriculum

In addressing the task of developing an undergraduate module in the field of tissue engineering, the greatest challenge lies in managing to capture what is a growing and rapidly changing field. Acknowledging the call for the development of greater critical thinking and interpersonal skills among the next generation of engineers as well as encouraging students to engage actively with the dynamic nature of research in the field, the module was developed to include both project-based and cooperative-learning experiences. These learning activities include developing hypotheses for the application of newly introduced laboratory procedures, a collaborative mock grant submission, and debates on ethical issues in which students are assigned roles as various stakeholders. Feedback from module evaluations has indicated that, while students find the expectations challenging, they are able to gain an advanced insight into a dynamic field. More importantly, students develop research competencies by engaging in activities that require them to link current research directions with their own development of hypotheses for future tissue-engineering applications.

Intra-articular steroids and splints/rest for children with juvenile idiopathic arthritis and adults with rheumatoid arthritis

BACKGROUND

Resting or immobilizing a joint to enhance outcomes following intra-articular (IA) steroid injection is generally advocated. This systematic review aimed to determine the efficacy of IA steroid injections and the influence of post-injection rest.

OBJECTIVES

1. Compare IA steroid injections versus no treatment or placebo. 2. Determine the effects of rest following IA steroid injection in rheumatoid or juvenile idiopathic arthritis.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL- Issue 4, 2003), Cochrane Database of Systematic Reviews (CDSR - Issue 4, 2003), Database of Abstracts of Reviews of Effectiveness (DARE - searched 8.1.04), MEDLINE (1966 to August Week 2 2004), EMBASE (1980 to August Week 2 2004) , CINAHL (1982 to December Week 2 2003), Clinical Trials site of the National Institute of Health, (USA - searched 8.1.04), OTseeker (Occupational Therapy Systematic Evaluation of Evidence - searched 8.1.04) and PEDro (Physiotherapy Evidence Database - searched 8.1.04) were searched. Journals and reference lists were hand searched.

SELECTION CRITERIA

Eligible were randomised controlled trials of IA steroid injections or of rest following IA steroid injections in rheumatoid or juvenile idiopathic arthritis.

DATA COLLECTION AND ANALYSIS

Potentially relevant references were evaluated and all data extracted by two independent reviewers.

MAIN RESULTS

Five trials (n=346) examining IA steroid injection in the knee joint were included. It was not possible to pool data as outcome measures, timing of follow up and the methods of data reporting differed between trials. There was inconclusive conflicting evidence from two trials that walking time was reduced. There was evidence from one moderate quality trial that pain was reduced at 1-day post-injection (0-100 VAS from 28.33 to 13.46; McGill Pain Scale from 8.89 to 3.96) but not at 1 week or 7-12 weeks post-injection. There is some evidence that IA injections improved knee flexion (by 14 degrees) and reduced knee extension lag (by 20 degrees), knee circumference (median reduction = 0.3 cm) and morning stiffness (reduced from 60 mins to 7.6 mins). One trial (n=91) examined the effects of rest following injection in the knee. The rested group achieved significant improvement in pain, stiffness, knee circumference, and walking time when compared with the non-rested group (no point estimates provided). One trial evaluated rest following injection of the wrist (n=117). Relapse rate was higher in the rested group (rest relapse rate = 24/58, no-rest group = 14/59); but there were no differences between the rested and non-rested groups on pain, joint circumference, wrist function, grip strength or ROM.

AUTHORS' CONCLUSIONS

There is some evidence to support the use of IA steroid injections and resting a knee following injections but that wrists should not be rested following injections. The included studies involved adult participants so any conclusions can only cautiously applied to children. Further research is required to examine the use and type of rest and the differential responses of different joints following injections.

Optimal timing for intravenous administration set replacement

BACKGROUND

Administration of intravenous therapy is a common occurrence within the hospital setting. Routine replacement of administration sets has been advocated to reduce intravenous infusion contamination. If decreasing the frequency of changing intravenous administration sets does not increase infection rates, a change in practice could result in considerable cost savings.

OBJECTIVES

The objective of this review was to identify the optimal interval for the routine replacement of intravenous administration sets when infusate or parenteral nutrition (lipid and non-lipid) solutions are administered to people in hospital via central or peripheral venous catheters.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, EMBASE: all from inception to February 2004; reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. We did not have a language restriction.

SELECTION CRITERIA

We included all randomized or quasi-randomized controlled trials addressing the frequency of replacing intravenous administration sets when parenteral nutrition (lipid and non-lipid containing solutions) or infusions (excluding blood) were administered to people in hospital via a central or peripheral catheter.

DATA COLLECTION AND ANALYSIS

Two authors assessed all potentially relevant studies. We resolved disagreements between the two authors by discussion with a third author. We collected data for the outcomes; infusate contamination; infusate-related bloodstream infection; catheter contamination; catheter-related bloodstream infection; all-cause bloodstream infection and all-cause mortality.

MAIN RESULTS

We identified 23 references for review. We excluded eight of these studies; five because they did not fit the inclusion criteria and three because of inadequate data. We extracted data from the remaining 15 references (13 studies) with 4783 participants. We conclude that there is no evidence that changing intravenous administration sets more often than every 96 hours reduces the incidence of bloodstream infection. We do not know whether changing administration sets less often than every 96 hours affects the incidence of infection. In addition, we found that there were no differences between participants with central versus peripheral catheters; nor between participants who did and did not receive parenteral nutrition, or between children and adults.

AUTHORS' CONCLUSIONS

It appears that administration sets that do not contain lipids, blood or blood products may be left in place for intervals of up to 96 hours without increasing the incidence of infection. There was no evidence to suggest that administration sets which contain lipids should not be changed every 24 hours as currently recommended.

Mediastinal chest drain clearance for cardiac surgery

BACKGROUND

Cardiac tamponade may occur following cardiac surgery as a result of blood or fluid collecting in the pericardial space compressing the heart and reducing cardiac output. Mediastinal chest drains (including pericardial drains) are inserted as standard post-operative practice following cardiac surgery to assist the clearance of blood from the pericardial space and to prevent cardiac tamponade. To prevent chest tubes from blocking and so causing tamponade nurses manipulate them to prevent or remove clots. Manipulation methods including milking, stripping, fanfolding and tapping may be applied to the tubes to keep them from blocking. Evidence is required as to the safest and most effective means of preventing chest tube blockage and preventing cardiac tamponade.

OBJECTIVES

To compare different methods of chest drain clearance (i.e. varying levels of suction or suction in combination with milking, stripping, fanfolding and tapping of chest drains) in preventing cardiac tamponade in patients following cardiac surgery.

SEARCH STRATEGY

Over both the initial review and the 2004 revision, we searched the Cochrane Heart Group trials register, the Cochrane Controlled Trials Register (CCTR) (Issue 4, 2003) The Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effectiveness (DARE), Issue 4, 2003, MEDLINE (1966 to Nov Week 2, 2003), EMBASE (1980 to 2003 Week 47), CINAHL (1982 to Nov 2003), the Clinical Trials site of the NIH, (USA) (24.11.03) and reference lists of articles.

SELECTION CRITERIA

Randomised, quasi-randomised or systematically allocated clinical trials of chest tube manipulation methods in adults and children with mediastinal chest drains following cardiac surgery were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information where required. Adverse effects information was collected from the trials.

MAIN RESULTS

Three studies with a total of 471 participants were included. There was no data, however, which could be included in a meta-analysis. This was due to inadequate data provision by two of the studies. Where adequate data were provided there were no common interventions or outcomes to pool. On the basis of single studies there was no evidence of a difference between groups on incidence of chest tube blockage, heart rate, cardiac tamponade or incidence of surgical re-entry.

REVIEWERS' CONCLUSIONS

There are insufficient studies which compare differing methods of chest drain clearance to support or refute the relative efficacy of the various methods in preventing cardiac tamponade. Nor can the need to manipulate chest drains be supported or refuted by results from RCT's.

Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a central nervous system deficit resulting from a non-progressive lesion in the developing brain. Although the brain lesions are static, the movement disorders that arise are not unchanging and are characterised by atypical muscle tone, posture and movement (Rang 1990). The spastic motor type is the most common form of CP and its conventional therapeutic management may include splinting/casting, passive stretching, facilitation of posture and movement, spasticity-reducing medication and surgery. More recently, health care professionals have begun to use botulinum toxin A (BtA) as an adjunct to interventions in an attempt to reduce muscle tone and spasticity to improve function

OBJECTIVES

To assess the effectiveness of intramuscular BtA injections as an adjunct to managing the upper limb in children with spastic CP.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1966 to March Week 3 2004), EMBASE (1980 to 2003 Week 16) and CINAHL (1982 to Week 3 March 2004).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing intramuscular BtA injections into any muscle group of the upper limb with placebo, no treatment or other interventions.

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion. Data was extracted and entered into RevMan 4.2.3.

MAIN RESULTS

Two trials met the inclusion criteria, each having short-term follow up, a small number of subjects and using a single set of injections. The study by Corry 1997 compared BtA with an injection of normal saline and found promising results in elbow extension, elbow and wrist muscle tone. At three months, encouraging results for wrist muscle tone and grasp and release were noted. The trial reported median change, range of changes and the difference in these measures between groups. The study by Fehlings 2000 compared BtA with no intervention. When data were analysed no treatment effect was found for quality of upper limb function, passive range of motion, muscle tone, grip strength or self-care ability.

REVIEWERS' CONCLUSIONS

This systematic review has not found sufficient evidence to support or refute the use of intramuscular injections of BtA as an adjunct to managing the upper limb in children with spastic cerebral palsy. Only one of the two identified RCTs reported some promising results in support of reduced muscle tone following BtA injections. Further research incorporating larger sample sizes, rigorous methodology, measurement of upper limb function and functional outcomes is essential.

Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a central nervous system deficit resulting from a non-progressive lesion in the developing brain. Although the brain lesions are static, the movement disorders that arise are not unchanging and are characterised by atypical muscle tone, posture and movement (Rang 1990). The spastic motor type is the most common form of CP and its conventional therapeutic management may include splinting/casting, passive stretching, facilitation of posture and movement, spasticity-reducing medication and surgery. More recently, health care professionals have begun to use botulinum toxin A (BtA) as an adjunct to interventions in an attempt to reduce muscle tone and spasticity to improve function

OBJECTIVES

To assess the effectiveness of intramuscular BtA injections as an adjunct to managing the upper limb in children with spastic CP.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003), MEDLINE (1966 to March Week 3 2004), EMBASE (1980 to 2003 Week 16) and CINAHL (1982 to Week 3 March 2004).

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing intramuscular BtA injections into any muscle group of the upper limb with placebo, no treatment or other interventions.

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion. Data was extracted and entered into RevMan 4.2.3.

MAIN RESULTS

Two trials met the inclusion criteria, each having short-term follow up, a small number of subjects and using a single set of injections. The study by Corry 1997 compared BtA with an injection of normal saline and found promising results in elbow extension, elbow and wrist muscle tone. At three months, encouraging results for wrist muscle tone and grasp and release were noted. The trial reported median change, range of changes and the difference in these measures between groups. The study by Fehlings 2000 compared BtA with no intervention. When data were analysed no treatment effect was found for quality of upper limb function, passive range of motion, muscle tone, grip strength or self-care ability.

REVIEWERS' CONCLUSIONS

This systematic review has not found sufficient evidence to support or refute the use of intramuscular injections of BtA as an adjunct to managing the upper limb in children with spastic cerebral palsy. Only one of the two identified RCTs reported some promising results in support of reduced muscle tone following BtA injections. Further research incorporating larger sample sizes, rigorous methodology, measurement of upper limb function and functional outcomes is essential.

Mediastinal chest drain clearance for cardiac surgery

BACKGROUND

Cardiac tamponade may occur following cardiac surgery as a result of blood or fluid collecting in the pericardial space compressing the heart and reducing cardiac output. Mediastinal chest drains (including pericardial drains) are inserted as standard post-operative practice following cardiac surgery to assist the clearance of blood from the pericardial space and to prevent cardiac tamponade. Manipulation techniques including milking, stripping, fanfolding and tapping may be applied to the tubes to keep them from blocking. Evidence is required as to the safest and most effective means of preventing chest tube blockage and preventing cardiac tamponade.

OBJECTIVES

To compare different methods of chest drain clearance (i.e. varying levels of suction or suction in combination with milking, stripping, fanfolding and tapping of chest drains) in preventing cardiac tamponade in patients following cardiac surgery.

SEARCH STRATEGY

We searched the Cochrane Heart Group specialised register, the Cochrane Controlled Trials Register (CCTR) (Issue 1, 2001) The Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of Reviews of Effectiveness (DARE), Issue 1, 2001, MEDLINE (1966 to May Week 1, 2001), EMBASE (1980 to 2001 Week 35), CINAHL (1982 to March 2001), the Clinical Trials site of the NIH, (USA) (10.09.01) and reference lists of articles.

SELECTION CRITERIA

Randomised, quasi-randomised or systematically allocated clinical trials of chest tube manipulation techniques in adults and children with mediastinal chest drains following cardiac surgery were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information where required. Adverse effects information was collected from the trials.

MAIN RESULTS

Three studies with a total of 471 participants were included. There was no data, however, which could be included in a meta-analysis. This was due to inadequate data provision by two of the studies and where adequate data were provided there were no common interventions or outcomes to pool. On the basis of single studies there was no difference between groups on incidence of chest tube blockage, heart rate, cardiac tamponade or incidence of surgical re-entry.

REVIEWER'S CONCLUSIONS

There are insufficient studies which compare differing methods of chest drain clearance to support or refute the relative efficacy of the various techniques in preventing cardiac tamponade. Nor can the need to manipulate chest drains be supported or refuted by results from RCT's.

Improving lipid evaluation and management in medicare patients hospitalized for acute myocardial infarction

BACKGROUND

The control of low-density lipoprotein cholesterol (LDL-C) levels in patients with known coronary artery disease, particularly in those with acute myocardial infarction, has been shown to reduce the rates of disease progression, recurrent events, and mortality.

OBJECTIVES

To evaluate and improve hospital-based processes for measuring and treating, when necessary, LDL-C levels above 3.36 mmol/L (>130 mg/dL) in patients with an acute myocardial infarction.

DESIGN

A nonrandomized retrospective baseline study followed by a collaborative educational intervention with participating hospitals and a second nonrandomized postintervention study.

PATIENTS

Four hundred six preintervention patients discharged from the hospital alive after a confirmed acute myocardial infarction in 1996, and 498 postintervention patients discharged from the hospital in 1999.

INTERVENTIONS

Performance of lipid profiles on admission to the hospital and during hospitalization and drug and dietary interventions.

RESULTS

The measurement of LDL-C level on admission to the hospital increased from 8% preintervention in 1996 to 32% postintervention in 1999. The measurement during hospitalization increased from 14% preintervention to 48% postintervention. Hospitals that initiated programs to ensure early lipid evaluations through preprinted orders and policy changes achieved an average patient LDL-C measurement rate of 70% in 1999. Hospitals lacking standard policies averaged only 23% at the same time. Of the patients with a measured LDL-C level greater than 3.36 mmol/L (>130 mg/dL) who were not undergoing drug therapy on admission to the hospital, 46% were given lipid-lowering agents by discharge from the hospital during the postintervention period. During this same period, only 11% of the patients were prescribed this therapy if they had either a lower measured level or no LDL-C measurement at all.

CONCLUSION

Active hospital-based programs to ensure routine LDL-C measurements in patients admitted for acute myocardial infarction increased the use of appropriate lipid-lowering therapy in these high-risk individuals and could contribute to reducing the incidence of recurrent coronary artery disease.

The use of quality indicators for assessing radical prostatectomy specimens

The information contained in pathology reports of radical prostatectomy specimens is critically important to treating physicians for selecting adjuvant therapy, evaluating therapy, estimating prognosis, and analyzing outcomes. This information is also of importance to patients and their families. In recent years, the Cancer Committee of the College of American Pathologists and the Association of Directors of Anatomic and Surgical Pathology developed suggested protocols for reporting the findings on radical prostatectomy specimens. The objectives of this study were to assess radical prostatectomy-specimen reports by using quality indicators derived from existing suggested protocols and to thereby assist pathologists in improving the quality of their reports on such specimens. A retrospective chart review of 554 cases for the second 6-month period of 1996 focused on 10 quality indicators: submission of a frozen section; location of the adenocarcinoma; proportion of the specimen involved by adenocarcinoma; perineural involvement; vascular involvement; seminal vesicle involvement; periprostatic fat status; number of nodes submitted; status of nodes; and prostate intraepithelial neoplasia (PIN). The findings of this study were shared with the pathology departments in all hospitals in New York State. In addition, the 113 hospitals from which the 554 cases were drawn were given their institution-specific data. Teleconferences were held with the 37 hospitals that accounted for 72.4% of all cases. These conferences included directors of pathology and laboratories and focused on the aggregate statewide findings. The presence of quality indicators in reports varied from a mean of 14.8% (periprostatic fat) to a mean of 85.9% (seminal vesicle involvement). For all hospitals, 4 indicators (proportion of the specimen involved by adenocarcinoma, vascular involvement, periprostatic fat status, and PIN) were included in fewer than 50% of cases. These 4 quality indicators and an additional 3 others (submission of a frozen section, perineural involvement, and the number of nodes submitted) were included in fewer than 70% of cases. Only 3 indicators (location of the adenocarcinoma, seminal vesicle involvement, and the status of nodes) were found in more than 70% of cases. Although the mean level of quality indicator inclusion ranged from 14.8% to 85.9% for all cases examined, the absolute range for any individual indicator was 0% to 100%. Thus, some hospitals included a given indicator 100% of the time; others never included it. This pattern held true for all 10 indicators. High-volume hospitals (10 or more cases) performed significantly better than low-volume hospitals (1-4 cases) on 5 indicators (P < .05), and better, but not significantly so, for an additional 2 indicators. Overall, the mean inclusion levels for all 10 indicators were 10% higher for high-volume hospitals compared with low-volume and medium-volume hospitals (5-9 cases). This study demonstrated wide variations in the inclusion of quality indicators by pathologists in their radical prostatectomy-pathology reports. Whereas some hospitals always include given indicators, others never mentioned them. These marked disparities point to the need for standardized reporting for radical prostatectomy specimens.

Comparison of the characteristics and features of pressure garments used in the management of burn scars

Two companies provide custom-made pressure garments to clients with burn scars at Westmead Hospital. This prospective study was completed in order to make objective decisions about which garments were most appropriate and cost effective to provide to clients. Issues such as cost, durability, fit and client preferences were investigated. Data were collected from 43 clients; at the time of initial fitting, at a follow-up appointment 4-6 weeks later, and at the time one of the garments required replacement. One Second Skin and one Jobst garment were provided to each client and the garments were compared using therapists' evaluation and clients' perspectives on a number of variables. Second Skin garments had significantly more favourable results on the variables of time for delivery, fit at follow-up, garment design, quality of fabric and seams, overall satisfaction and garment preference for ongoing wear. On all other variables there was no significant difference between the garments. Second Skin provided the most optimal and appropriate option for pressure garments in the management of burn scars for our clients.