Implementation of COPCA
Akhbari-Ziegler, Schirin
DOI:
10.33612/diss.132156787
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Publication date: 2020
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Akhbari-Ziegler, S. (2020). Implementation of COPCA: A family-centred early intervention programme in infant physiotherapy. University of Groningen. https://doi.org/10.33612/diss.132156787
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2
Psychometric properties of a
standardized observation protocol
to quantify pediatric physical
therapy actions
Patrizia Sonderer Schirin Akhbari Ziegler Barbara Gressbach Oertle André Meichtry Mijna Hadders-Algra
30
ABSTRACT
Purpose: Pediatric physical therapy (PPT) is characterized by heterogeneity. This blurs the evaluation of effective components of PPT. The Groningen Observation Protocol (GOP) was developed to quantify the contents of PPT. The study assesses the reliability and completeness of GOP.
Methods: Sixty infant PPT sessions were video-taped. Two random samples of 10 videos were used to determine interrater and intrarater reliability using interclass correlation coefficients (ICC) with 95% confidence intervals. Completeness of GOP 2.0 was based on 60 videos.
Results: Interrater reliability of quantifying PPT actions was excellent (ICC 0.75-1.0) in 71% and sufficient to good (ICC 0.4-0.74) in 24% of PPT actions. Intrarater reliability was excellent in 94% and sufficient to good in 6% of PPT actions. Completeness was good for grater than 90% of PPT actions.
Conclusions: GOP 2.0 has a good reliability and completeness. After appropriate training, it is a useful tool to quantify PPT for children with developmental disorders. Key words: Groningen Observation Protocol, infants, pediatric physical therapy, quantify contents, reliability
Schirin_Thesis.indd 30
INTRODUCTION AND PURPOSE
Multiple early pediatric physical therapy (PPT) intervention strategies are used to treat infants with or at risk for neuromotor disorders or developmental delay.1 The
interventions, such as neurodevelopmental treatment, Vojta, general developmental programs using infant stimulation, and conductive education,2-4 aim to support motor
development and functional abilities and to reduce neuromotor dysfunction.5,6 The
interventions, however, use different physical therapy actions. Evidence suggests that especially the infant stimulation programs are associated with improved developmental outcome,7 an effect that is present despite the large heterogeneity within these
programs.2 This suggests that our understanding of the effective elements of PPT is
limited. New intervention strategies have been developed, such as constraint-induced movement therapy (CIMT)8 and specific motor training programs, for example,
action-observation training.9
Pediatric physical therapists (PTs) choose from a repertoire of actions.3,10,11 They
implement those techniques with which they have had good results and positive experience in the past.12,13 This means that PPT in infants is characterized by large
variations in practice,3 which makes it extremely difficult to evaluate the effect of PPT
intervention.
Infant physical therapy varies with the specific PT and within regional area and countries because of differences in the education, health policies, family culture, and the context where therapy is provided. Therapy can be provided in a clinical setting or at home.3
To promote the development of evidence-based practice in PPT, we need to know how PPT is practiced and what actions the PT uses during a PPT session. Knowledge of the specific contents of PPT is a prerequisite in understanding the effect or the effects of PPT. The Groningen Observation Protocol (GOP) was developed to quantitatively assess the contents of PPT sessions. This standardized protocol is based on information the literature and from clinical practice.12,14 GOP is a video-based method that classifies
physical therapy actions observed during a PPT session into main categories, such as “neuromotor actions” and “communication”. Some main categories are divided in subcategories. For example, subcategories of neuromotor actions are “facilitation techniques” and “sensory experience”.
Blauw-Hospers et al.14 reported that the GOP was a reliable instrument to assess
PT actions in Dutch infant PPT sessions. And, in the Dutch context, the GOP has also been shown to be an appropriate and thorough assessment tool, as it classified greater than 97% of the PT actions into protocol categories and the categories were to a large extent mutually exclusive.14 Moreover, the GOP was able to document theoretically
expected differences between 2 PPT approaches3 and revealed that specific PPT actions
32
were related to infant developmental outcome.12,15 This indicates that the GOP has an
appropriate construct validity. Recently, the GOP was updated to the GOP 2.0 (Appendix I + II) to (a) include new developments in PPT, such as constraint-induced movement therapy (Baby-CIMT)8, (b) expand the PT items of the GOP for applicati on in other
countries, for example by adding specifi c acti ons of pediatric Vojta therapy, and (c) allow for a reorganizati on of categories, especially by grouping neuromotor acti ons into the main category of “neuromotor acti ons”. The latt er reorganizati on resulted in 5 instead of 8 main categories.
The aim of this study is to assess the psychometric properti es of the GOP 2.0 by testi ng (1) the inter- and intrarater reliability of GOP 2.0 in PTT sessions, using interclass correlati on coeffi cients (ICC) with 95% confi dence interval and (2) the completeness of GOP 2.0 defi ned as its ability to classify the majority (>90%) of the PT acti ons.
Design
This study is part of a larger study on the quanti fi cati on of the contents of PPT in diff erent countries. For that study, 60 PPT sessions were video recorded in Switzerland, 30 videos of PTT sessions of infants aged 4.3 to 8.0 months, and 30 videos of PTT sessions of infants 8.3 to 14.0 month corrected age. The current study addresses GOP 2.0’s completeness on the sample of 60 videos and GOP 2.0’s reliability on 2 random samples of 10 videos (Figure 1). To determine intrarater reliability, 1 assessor (masked) assessed the 10 videos with an interval of 3 weeks. To assess interrater reliability, 2 assessors (masked) rated 10 videos independently.
The study design was approved by the ethical committ ee of the cantons St. Gallen (EKSG) and Zürich (KEZ). Signed consent was received from all therapists and the parents of the infants.
Fig. 1. Flow diagram of video selecti on
Schirin_Thesis.indd 32
Ta bl e 1 Ch ar ac te ris tic s o f i nf an ts All In ter ra ter rel ia bi lit y In tr ar at er rel ia bi lit y YI OI all YI OI all YI OI all Nu m be r o f v id eo s 30 30 60 6 4 10 5 5 10 In fa nt a ge i n m on th s C A, m ed ian (r an ge ) 6.1 (4 .3 –8 .0 ) 11 .3 (8 .3 –1 4. 0) 8.1 (4 .3 –1 4. 0) 7. 3 (5 .5 –7 .8 ) 11 .3 (1 0.8 –1 1. 5) 7. 5 (5 .5 –1 1.5 ) 7. 3 (5 .8 –8 .0 ) 11 .5 (1 1. 3–1 4. 0) 9. 6 (5 .8 –4 .0 ) Se x: M / F 15 /1 5 22 /8 37/ 23 3/ 3 3/1 6/4 1/4 4/1 5/ 5 Ge st ati on al a ge a t b irt h in w ee ks m ed ian (r an ge ) 37 ( 25 –4 2) 38 (27– 42 ) 37 ( 25 –4 2) 39 ( 37 –4 0) 39 ( 30 –4 0) 39 ( 30 –4 1) 40 ( 26 –4 1) 35 ( 27 –4 0) 40 ( 26 –4 1) Bi rt h w ei gh t i n g ra m s m ed ian (r an ge ) 27 20 (5 45 –4 000 ) 27 70 (6 90 –4 28 0) 27 20 (54 5– 42 80 ) 33 80 (2 46 0– 4000 ) 26 52 (1 20 0– 35 00 ) 307 3 (1 200 –4 000 ) 37 20 (10 30 -4 00 0) 16 70 (6 90 –3 00 5) 23 00 (6 90 –4 000 ) M at er na l e du ca tio n (n , H / M / L) a m iss in g d at a ( n) 10/ 20/ 18 .3 1 16 .7 /1 8. 3/1 5 0 26 .7/ 38 .3/ 33 .3 1 3. 3/ 5/ 1. 7 0 3. 3/ 0/ 3. 3 0 6. 7/5 /5 0 1. 7/ 1. 7/ 3. 3 1 3. 3/ 3. 3/ 1. 7 0 5/ 5/ 5 1 a Le ve l o f ed uc ati on : L = lo w ( co m pu lso ry s ch oo lin g) , M = m ed iu m ( hi gh s ch oo l), H = h ig h ( un iv er sit y) CA = c or re ct ed a ge , F = fe m al e, M = m al e, O I = o ld er i nf an ts , Y I = y ou ng er i nf an ts
2
34
Participants
Infants
All infants received PPT between June 2013 and August 2014 on the basis of referral of a pediatrician. Inclusion criteria were the presence of neurological dysfunction or/ and developmental delay as diagnosed by the pediatrician. Infants diagnosed with plagiocephaly or/and torticollis only, or with congenital hip dysplasia, congenital heart diseases or cystic fibrosis were excluded from the study, as the interest of the study was especially PPT actions in infants at high risk for neurodevelopmental disorders. The clinical and social characteristics of the infants are summarized in Table 1.
The pediatric PTs
To be included in the study, pediatric PTs had to be working with infants between June 2013 and August 2014. The study did not have exclusion criteria for pediatric PTs. Forty PTs were involved in the study. The participating PTs had between 1 and 34 years (median 14 years) of experience in PPT. Table 2 summarizes the characteristics of the PT`s.
Table 2
Characteristics of pediatric physical therapists In Interrater Reliability Videos (n=10) In Intrarater Reliability Videos (n=10) In 60 videos
Number of therapists involved* 9 8 40
Years of experience as PT
Median (range) 23 (9-33) 24 (9-36) 18 (3-40)
Years of experience as pediatric PT
Median (range) 21 (3-30) 19 (3-34) 14 (1-34) Sex (M / F) 0 / 9 0 / 8 4 / 37 Additional education NDT, Bobath (n) 36 NDT- Baby (n) 10 Vojta (n) 6 Sensory integration (n) 15
Abbreviations: NDT, neurodevelopmental treatment; PT, physical therapist. * Some PTs treated more than one infant, i.e., a younger and an older infant
Schirin_Thesis.indd 34
METHODS
Video recording of the PPT session
The treatment session was recorded in the child’s usual therapy setting and at its regular treatment time. The cameraperson (a physical therapist) influenced the treatment as little as possible while recording the session. The camera was positioned as far away as possible from the infant and therapist. Care was taken to have the infant and therapist in full view of the video, so that all therapeutic an infant actions could be clearly observed. The children’s and therapist’s data were coded and treated as confidential information.
GOP 2.0
The GOP 2.0 manual describes PT actions in 5 main categories: neuromotor actions, educational actions, communication, position, and situation (Appendix I + II). Each category contains various subcategories, (‘behaviors’). For instance, examples of subcategories of the main category “neuromotor actions” are “facilitation techniques,” “self-produced motor behavior,” and “passive motor behavior,” and examples of subcategories of the main category “communication” are “information exchange” and “instruct”. The PT actions of the subcategories (“behaviors”), may be further specified by modifiers; for example, the subcategory “facilitation techniques” was further subdivided into the modifiers “handing,” “pressure techniques,” and “tapping techniques”.
The training of the assessors (n = 2) included a 2-day training in Groningen by one of the developers of the GOP and GOP 2.0. The training consisted of intensive personal tutoring and practicing assessment of videos of PPT sessions with GOP 2.0 and the Observer XT program.16 After the 2 days of training, the assessors scored 5 videos of
PPT sessions (Appendix II). Supervision by staff in Groningen was provided via Skype and e-mail. Finally, another day of “live” tutoring and practicing was performed. Training was considered completed when interassessor agreement with a trained Groningen assessor on the last 3 videos assessed reached a median ICC of more than 0.80.
The PT actions, as defined by GOP 2.0, were scored quantitatively with The Observer XT (Version 11.5; Noldus, Wagingen, the Netherlands) (Appendix III).14 The
Observer XT allows for assessing different actions taking place simultaneously during a PTT session with an accuracy of 0.01 second (Appendix IV). Actions were measured by full seconds and were calculated from The Observer XT in percentage of the duration of the PPT session.
36
Statistical analysis
Three sequences of 5 minutes were selected from each video starting at 100 to 200 seconds, 500 to 800 seconds and 1000 to 1300 seconds from the onset. Reliability was quantified with ICCs’ 95% confidence intervals (CIs). For the interrater reliability, we used ICC2 (t2-way random model) for the intrarater reliability we used ICC1 (1-way random model). According to Shrout and Fleiss,17 values more than 0.75 reflect excellent
agreement, values between 0.4 and 0.75 sufficient to good agreement, and all values less than 0.4 insufficient agreement. PPT actions observed less than 2% of time were excluded from the reliability analyses. Completeness was defined when at least 90% of PT actions could be scored with GOP 2.0. All analyses were performed using The R statistical software R version 2.14.118 was used for analyses.
RESULTS
The interrater and intrarater ICCs and their associated 95%-CIs are summarized in Table 3. Interrater reliability was calculated for 17 behaviors. In 16 of the 17 behaviors, the ICCs indicated an excellent agreement. In the remaining behavior “transition”, the ICC indicated sufficient to good agreement (ICC, 0.70; 95% CI, 0.45-0.84). Interrater agreement was calculated for 26 modifiers. The ICCs indicated an excellent agreement in 15 modifiers (58%), a sufficient to good agreement in 9 modifiers (35%) and an insufficient agreement in 2 modifiers (8%). The latter occurred in the modifier “little variation” of the behavior “challenged to self-produced motor behavior” and in the modifier “minimal postural support” of the position “prone”.
Intrarater-reliability and 95%-CIs could be calculated for 23 behaviors. All but one had an excellent intrarater agreement; this was “instruct” in the domain of communication for which agreement was sufficiently to good. Intrarater agreement and 95% CIs were calculated for 40 modifiers. Thirty-seven had an excellent agreement (93%) and 3 had sufficient to good agreement. These were the modifier “strict instruction” of the behavior “instruct”, the modifier “with imposed pelvis lift” of the position “supine” and the modifier “minimal postural support” of the position “prone”.
To evaluate completeness of GOP 2.0, we analyzed the prevalence of the behavior “not specified neuromotor action”. This behavior was observed in 50 of the 60 videos and occurred with a median value of 3% (standard deviation: 2%) and a maximum of 6.7% of time. The most prevalent action during the PPT sessions was motor activity occurring in 90.4% of time (median value; range 59.3–100%). Within the main category of “neuromotor actions” the various behaviors occurred in the following relative median frequencies: “facilitation” 20.6% (range 0%-77.4%), “sensory experience” 9.6% (range 0%-44.7%), “passive motor experience” 0.3% (range 0%-22.5%), “self-produced motor behavior” 19.1% (range 3.0%-53.53%), “challenged to self-produced motor behavior
Schirin_Thesis.indd 36
(CSPMB), allowed to continue activity by himself” 9.6% (range 0%-77.0%), and “CSPMB flows into facilitation, sensory or passive experience’” 24.8% (range 0%-61.8%). The time educational actions, was spent in either on “caregiver training” (median value 21.3% of time, range 0%-100%) or “not-specific educational actions” 78.7% of time (median value, range 0%-100%). In about 90% of time communication occurred (median 89.9%; range 53.7%-100%); major part (60.5%; range 25,7%-98.1%) of the communication consisted of “not specified communication”, other types of communication consisted of 1.2% (range 0%-24.7%) “information exchange”, 5.1% (range 0%-38.0%) “instruct,” and 13.2% (range 0.2%-51.3%) “provide feedback”.
Table 3
Interrater and intrarater agreement on PPT actions and situations determined with GOP 2.0
Intervention Interrater agreement ICC (95% CI) Intrarater agreement ICC (95% CI) Neuromotor actions Facilitation techniques 0.79 (0.61-0.89)a 0.99 (0.99-1) Handling 0.75 (0.55-0.87) 1 (0.99-1)
Pressure technique n.o. 0.99 (0.99-1)
Sensory experience, state event 0.89 (0.79-0.95) 1 (0.99-1)
With the aim of body awareness 0.83 (0.55-0.88) n.o.
Passive motor experience 0.76 (0.56-0.88) 1 (0.99-1)
SPMB 0.87 (0.67-0.94) 0.98 (0.97-0.99)
CSPMB to SPMB 0.86 (0.72-0.93) 0.99 (0.97-0.99)
Large variation 0.86 (0.73-0.93) 0.97 (0.94-0.99)
Little variation 0.39 (0.06-0.65) 0.89 (0.79-0.95)
Just at the verge of the infants ability 0.82 (0.61-0.91) 0.99 (0.97-0.99)
CSPM, activity flows into facilitation, sensory or
passive experience 0.88 (0.75-0.94) 0.98 (0.96-0.99)
Large variation 0.46 (0.13-0.70) 1 (0.99-1)
Little variation 0.47 (0.15-0.70) 0.98 (0.95-0.99)
Handling techniques 0.80 (0.58-0.90) n.o
Sensory experience 0.67 (0.41-0.83) 0.94 (0.88-0.97)
Just at the verge of the infants abilities 0.88 (0.76-0.94) 0.96 (0.91-0.98)
Without challenge 0.86 (0.73-0.93) n.o.
Not specified neuromotor action n.o. 0.96 (0.91-0.98)
Educational actions towards caregiver
Caregiver training 0.80 (0.62-0.90) 1 (1-1)
Not specified education 0.80 (0.62-0.90) 1 (1-1)
Communication
Information exchange 0.93 (0.86-0.97) 1 (1-1)
38
Interrater and intrarater agreement on PPT actions and situations determined with GOP 2.0
Intervention Interrater agreement ICC (95% CI) Intrarater agreement ICC (95% CI) Instruct n.o. 0.66 (0.40-0.82)
Strict instruction n.o. 0.66 (0.40 – 0.82)
Provide feedback 0.83 (0.68 - 0.92) 1 (0.99-1)
Share information 0.89 (0.96-0.99)
Evaluating the procedure 0.62 (0.32-0.80) 0.98 (0.95-0.99)
Not specified communication 0.82 (0.66-0.91) 0.99 (0.97-0.99)
No communication 0.89 (0.78-0.95) 0.98 (0.95-0.99)
Positions
Supine 0.99 (0.99-1) 1 (1-1)
On flat surface 1 (0.99-1) 1 (1-1)
On lap PT/CG 1 (1-1) n.o.
Other surface n.o. 1 (1-1)
Pelvis not lifted 0.92 (0.83-0.96) 0.80 (0.62-20.90)
With imposed pelvis lift 0.95 (0.90-0.98) 0.72 (0.50-0.86)
Adaptive equipment 0.94 (0.89-0.97) 1 (1-1)
Not adaptive equipment 1 (1-1) 1 (1-1)
Prone 0.99 (0.98-0.99) 1 (1-1)
Across leg/arm of PT/CG 0.98 (0.95-0.99) 1 (1-1)
On flat surface 0.92 (0.84-0.96) 1 (1-1)
Other surface n.o. 1 (1-1)
Clear postural support n.o. 1 (1-1)
Minimal postural support 0.09 (-0.23-0.41) 0.69 (0.45-0.84)
No postural support 0.76 (0.56-0.88) 0.77 (0.58-0.88)
Adaptive equipment 0.58 (0.29-0.77) 0.99 (0.98-1)
No adaptive equipment 0.69 (0.44-0.84) 1 (1-1)
Side 0.99 (0.98-1)
On flat surface n.o. 0.99 (0.99-1)
Minimal postural support n.o. 0.99 (0.98-1)
No adaptive equipment n.o. 0.99 (0.99-1)
Sitting n.o. 1 (1-1)
On flat surface On lap PT/CG
Clear postural support Minimal postural support No postural support No adaptive equipment n.o. 0.93 (0.86-0.97) n.o. 1 (1-1) n.o. 0.85 (0.72-0.93) n.o. 0.81 (0.63-0.90) n.o. 0.99 (0.97-0.99) n.o. 1 (0.99-1) Standing n.o. 1 (0.99-1) Schirin_Thesis.indd 38 Schirin_Thesis.indd 38 07/07/2020 21:28:0907/07/2020 21:28:09
Interrater and intrarater agreement on PPT actions and situations determined with GOP 2.0 Intervention Interrater agreement ICC (95% CI) Intrarater agreement ICC (95% CI) On flat surface
Minimal postural support No adaptive equipment
n.o. 0.99 (0.99-1)
n.o. 1 (0.99-1)
n.o. 1 (0.99-1)
Transition 0.70 (0.45-0.84) 0.95 (0.91-0.98)
With a handling technique
No adaptive equipment 0.72 (0.50-0.86) 0.94 (0.89-0.97)0.71 (0.35-0.87) 0.96 (0.91-0.98)
Situation of treatment
Motor activity/play 1 (0.99 – 1) 0.90 (0.80 – 0.95)
Dressing 0.99 (0.98 – 1) 1 (0.99 – 1)
Carrying n.o. 0.89 (0.78 – 0.95)
Abbreviations: CI, confidence interval; CSPMB, challenged to self-produced motor; GOP, Groningen Observation Protocol, ICC, interclass correlation; n.o., not observed action, PPT pediatric physical therapy; PT/CG, physicaltherapist/caregiver; SPMB, self-produced motor behavior.
a Values in italic denote the ICCs of the behaviors, leaving the values of the modifiers in
nonitalicized face.
DISCUSSION
The good to excellent results on reliability and completeness of the GOP 2.0 are consistent with the previous research of Blauw-Hospers et al.14 on basis of the first
version of the GOP. Blauw-Hospers et al.14 reported that the GOP is a good tool to
assess PPT actions in a standardized and reliable way. The present replication study, using a larger video sample than the Blauw-Hospers et al.14 study, confirmed the
appropriateness of GOP 2.0 for quantitative video analysis of PPT sessions.
Exceptions to the good to excellent reliability, interrater agreement for the modifier “little variation” of the behavior “challenged to self-produced motor behavior” and in the modifier “minimal postural support” of the position “prone” was insufficient. Both parameters require observation experience, as it is difficult to describe in words the exact criteria for “little variation” and “minimal postural support”.
The completeness of the GOP 2.0 for PPT was very good, as more than 90% of the content of the PPT sessions could be classified by the GOP 2.0. The percentage of neuromotor actions that could be classified was even higher than expected (97%). This high value of neuromotor behavior that could be classified matches the one of Blauw-Hospers et al.14 This means that GOP 2.0 is a good instrument to quantitatively
describe the contents of PPT in infants with neuromotor disorder or developmental delay in Switzerland. As the contents of PPT for high-risk infants is very heterogeneous,3
40
a quantitative analysis of the contents of PPT is required to understand the effects of PPT.12,15 GOP 2.0 also allows for the evaluation of the contents of PPT across countries.
This may facilitate an understanding what other PPT colleagues do during therapy and promote the development of increasingly effective early intervention strategies.
A major strength of the study was that it analyzed of PPT sessions of a heterogeneous group of high-risk infants treated by a heterogeneous group of pediatric physiotherapists who had a varied level of experience and education. The heterogeneity of the infants was larger than in Blauw-Hospers et al,14 who studied a selective group of
infants who had been hospitalized in the Neonatal Intensive Care Unit of the University Medical Center Groningen and had shown definitely abnormal General Movements,19,20
at 10 weeks’ corrected age. Our study indicates that the GOP 2.0 is applicable in a selective sample of high-risk infants, and also in the more heterogeneous population of infants treated in PPT.
It may be considered a limitation that participation in the study was the therapist’s choice. Thus, the findings of this study may not be generalized to all PPT, as the therapists who participated were characterized by an open mindedness to new knowledge and changes in therapy practice. Another limitation of the study is the artificial presence of a video camera during the PPT session. Even though it has been reported in literature that the presence of a video camera in general does not affect the behavior of people being filmed,21 some of the therapists told the researcher that they worked less “freely”
in the presence of a video camera and a colleague therapist holding that camera. In conclusion, GOP 2.0 is a reliable instrument to quantify the contents of PPT. GOP 2.0’s completeness indicates that it is a good instrument to classify virtually all PPT actions observed during PPT session in Switzerland. We recommend 2 types of future studies: studies that apply GOP 2.0 in other countries, such that we obtain information on similarities and differences in PPT across the world, and studies using GOP 2.0 to evaluate the effect of PPT on developmental outcome.
ACKNOWLEDGEMENTS
The authors thank all the infants and their parents who participated in the study as well as the participating therapists.
Schirin_Thesis.indd 40
REFERENCES
1. Spittle A, Orton J, Anderson PJ, Boyd R, Doyle LW. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database Syst Rev. 2015;11:CD005495. doi: 10.1002/14651858.CD005495.pub4.
2. Blauw-Hospers CH, Hadders-Algra M. A systematic review of the effects of early intervention on motor development. Dev Med Child Neurol. 2005;47:421-432.
3. Dirks T, Blauw-Hospers CH, Hulshof L, Hadders-Algra M. Differences between the family-centered „COPCA” program and traditional infant physical therapy based on neurodevelopmental treatment principles. Phys Ther. 2011;91:1303-1322.
4. Benzies KM, Magill-Evans JE, Hayden KA, Ballantyne M. Key components of early intervention programs for preterm infants and their parents: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2013;13 (suppl 1):S10.
5. Sweeney JK, Heriza CB, Blanchaard Y. Neonatal physical therapy. Part I: Clinical competencies and neonatal intensive care unit clinical training models. Pediatr Phys Ther. 2009;21:296-307.
6. Cameron EC, Maehle V, Reid J. The effects of an early physical therapy intervention for very preterm, very low birth weight infants: a randomized controlled clinical trial. Pediatr Phys Ther. 2005;172:107-119.
7. Blauw-Hospers CH, de Graaf-Peters, VB, Dirks T, Bos AF, Hadders-Algra M. Does early intervention in infants at high risk for a developmental motor disorder improve motor and cognitive development? Neurosi Biobehav Rev. 2007;31 1201-1212.
8. Eliasson A-Ch, Sjöstrand L, Ek L, Krumlinde-Sundholm L, Tedroff K. Efficacy of baby-CIMT: study protocol for a randomised controlled trial on infants below a 12 month, with clinical signs of unilateral CP. BMC Pediatr. 2014; 14:141. 9. Guzzetta A, Boyd RN, Perez M, et al. UP-BEAT (Upper limb baby early
actio-observation training): protocol of two parallel randomised controlled trials of action-observation training typically developing infants and infant with asymmetric brain lesion. BMJ open. 2013;3:e002512.
10. Mayston M. Bobath Concept: A view from the United Kingdom. Laguna Beach, CA: NDTA Networ;. 2005; 12(2).
11. Howle J. NDT in the United States. Laguna Beach, CA: NDTA Network; 2005; 12(2).
12. Blauw-Hospers CH, Dirks T, Hulshof L, Bos A, Hadders-Algra M. Pediatric physical therapy in infancy: from nightmare to dream? A two-arm randomized trial. Phys Ther. 2011;91:1323-1338.
13. Mayston M. Editorial: bobath concept: bobath@50: mid-life crisis – what of the future? Physiother Res Int. 2008;13:131-136.
42
14. Blauw-Hospers CH, Dirks T, Hulshof LJ, Hadders-Algra M. Development of a quantitative tool to assess the content of physical therapy for infants. Pediatr Phys Ther. 2010;22:189-197.
15. Hielkema T, Blauw-Hospers C, Dirks T, Drijver-Messelink M, Bos AF, Hadders-Algra M. Does physiotherapeutic intervention affect motor outcome in high-risk infants? An approach combining a randomized controlled trial and process evaluation. Dev Med Child Neurol. 2011;53:38-e15.
16. The Observer XT, version 11.5. Noldus Information Technology b.v. International Headquarters Wageningen, The Netherlands; www.noldus.com 17. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability.
Psychol Bull. 1979;86:420-428.
18. R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2015.
19. Prechtl HF, Einspieler C, Cioni G, Bos AF, Ferrari F, Sontheimer D. An early marker of neurological deficits after perinatal brain lesions. Lancet. 1997;349: 1361-1363.
20. Hadders-Algra M. General movements: a window for early identification of children at high risk for developmental disorders. J Pediatr. 2004;145:S12-18. 21. Albrecht TL, Ruckdeschel JC, Ray FL III, et al. Portable, unobtrusive device for
videorecording clinical interactions. Behav Res Methods. 2005;37:165–169.
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APPENDIX I
The Groningen Observer Protocol (GOP 2.0)
A standardized observation protocol for the classification of paediatric physical therapy actions
A. Dependent variables
A.1 Neuromotor actions 1.1 Behaviours
1.1.1 Facilitations techniques
All therapeutic hands-on actions of the physical therapist or caregiver aimed at guidance of movement or maintenance of the infant’s posture by gently placing the hands on specific parts of the infant’s body, thus providing the infant with sensorimotor experience and controlling movement output. Note that if the therapists also applies constraint of the best arm during facilitation, scoring of facilitation continues (i.e., it is not interrupted by ‘constraint’).
Modifier group: Type of facilitation 1.1.2 Reflex locomotion
According to Vojta holding and pressure point techniques aim to provoke reflex locomotion. These techniques may be observed in two major forms: a) ‘pure’ Vojta like, i.e., consisting of actions that aim to fixate the infant in a defined starting position (holding) which may be followed by application of pressure on defined points of the body (pressure points). b) Vojta pressure point techniques which are applied in combination with handling.
Examples of holding:
o Supine, side lying, prone
o Head turned with an arm and/or leg in a seemingly unnatural position Examples of pressure points:
o Points on the head, around the mouth, around the shoulder, elbow or wrist o Points on the thorax or pelvis
o Points around the hip, knee and ankle Modifier group: Type of reflex locomotion
1.1.3 & 1.1.4 Sensory experience; point & state event
All tactile and vestibular stimulation given to the infant during treatment – without the aim of facilitation, tapping, or passive motor experience. Sensory events are only scored when they are explicitly provided as a sensory stimulus. This implies that other activities involving sensory experience, such as spontaneous motility, being dressed or
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undressed, or being repositioned a few centimetres in order to obtain a better camera view, are not scored as sensory experience.
Examples of concrete PT/caregiver actions: o Touching skin with toy.
o Touching to comfort or praise the infant. Modifier group: Aim of sensory experience 1.1.5 Passive motor experience
All handling techniques induced by the PT or the caregiver in which no activity of the infant is required in the performance of the actions.
Examples of concrete PT/caregiver actions: o Passive movements of arms and/or legs
o Repetitive movements of the upper arm towards (frontal) support surface. 1.1.6 Self-produced motor behaviour (SPMB), no interference with PT/CG
All actions during which the infant is given ample opportunities to explore toys or other aspects of the environment or his body, without interference from PT or caregiver. Examples of concrete PT/caregiver actions:
o Placing an infant activity play centre over the infant and letting the infant explore the effect of movements of arms, hands, legs, and feet. Note that this implies that the infant plays by itself and that nobody interferes or joins in, e.g., by shaking one of the rattles of the activity centre. If the latter occurs CSPMB is scored. o Infant is given opportunity for spontaneous exploration with or without toy. o Postural challenges, infant spontaneously explores postural capacities 1.1.7 SPMB in combination with constraint of one upper limb
All actions during with the infant is given ample opportunities to explore toys or other aspects of the environment or his body while one upper limb, i.e., the best performing limb, is being restrained to participate by a caregiver, PT or by a device such as a sling, towel or mitten.
When SPMB in combination with a constraint (SPMB+) is combined with a facilitation-technique, SPMB+ will change into facilitation when the constraint lasts for more than 10 seconds.
Modifier-group: Type of constraint
1.1.8 Challenged to SPMB (CSPMB), infant is allowed to continue activity by him/herself All actions in which the infant is challenged by toys or the face of the PT or caregiver to experience a variety of motor activity that is continued by the infant her/himself. Note
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that the neuromotor action CSPMB changes into ‘Self-produced motor behaviour’ if PT/ CG has not renewed the challenge within an interval of 20 seconds. However, if in the latter case ‘SPMB’ lasts less than 10 seconds before it changes into challenging again, CSPMB is not interrupted by SPMB but continued.
Modifier-groups: 1. Variation
2. Extent of challenge
1.1.9 CSPMB in combination with constraint of upper limb, infant is allowed to continue by him/herself
All actions in which the infant is challenged by toys or the face of the caregiver to experience a variety of motor activity that is continued by the infant her/himself while one upper limb, i.e., the best performing limb, is being restrained to participate by a caregiver or by a device such as a sling, towel or mitten.
Modifier-groups: 1. Variation
2. Type of constraint upper limb 3. Extent of challenge
1.1.10 CSPMB, activity flows over into or is combined with facilitation, sensory or passive experience
All actions in which the infant is challenged by toys or the face of the PT or caregiver to experience a variety of motor activity that is followed by or combined with handling techniques, facilitation (with or without the help of support devices; pressure; tapping), sensory or passive experiences. The interval between the challenge and the handling techniques may be very short (starting virtually simultaneously) and may last maximally 20 seconds. If the time interval between challenging and therapeutic handling is longer than 20 seconds, ‘CSPMB; infant is allowed to continue activity by her/himself’ is scored. Note that the activity that is being challenged (for instance grasping behaviour) does not have to be directly related to the main aim of handling (for instance facilitation of rolling into prone). To indicate that a ‘facilitation technique’ starts while the challenge continues, in the category ‘Educational actions towards the infant’ an ‘interference by PT/CG during treatment session’ is scored as ‘PT/CG corrects when infant fails’. Modifier-groups: 1. Variation
2. Type of facilitation techniques, sensory, passive motor experience 3. Extent of challenge
1.1.11 Craniosacral therapy
Applying a gentle manual force to address somatic dysfunctions of the head and spinal cord, in particular aiming to mobilise the cranial structures. Craniosacral therapy is a
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hands on technique focussing on mobility in neck and spine. This aim is clear from the hand movements of the therapist.
1.1.12 Not specified neuromotor action
All therapeutic actions during the treatment session that cannot be classified into the ten defined categories.
Example:
o Changing the treatment situation. 1.2 Modifier groups
1.2.1 Type of facilitation
- Handling: Specific hands-on techniques to give the infant sensorimotor experience to improve the quality and repertoire of the infant’s movements. Examples of concrete PT/caregiver actions:
o In supine position or sitting: Shoulders function as key point: handling hands guide shoulders of the infant in protraction to control tone and to facilitate hand-hand contact and symmetry.
o In supine position: Proximal or distal leg functions as key point: the infant’s hip is passively brought in semi-flexion while adducting the leg across the midline to facilitate head righting and rolling.
o In supine position: Pelvis functions as key point: the infant’s pelvis is slightly lifted to elongate the extensor muscles of the trunk and to control tone; in this way hand-foot contact and symmetry are facilitated.
o In prone position: Shoulder functions as key point, the arms are placed in puppy position to facilitate head righting, midline orientation, and body-alignment. o Sitting: Shoulder functions as key point: the shoulders are moved alternately
forwards and backwards to dissociate and facilitate independent arm movements. - Pressure techniques: All handling techniques that produce intermittent
pressure to stimulate and gain control over muscle tone, posture, and movement. Pressure is scored when the observer is able to see that the hand which rests on the child exerts pressure. The presence of pressure should not be concluded on the basis of the behavioural reaction of the child.
Examples of concrete PT/caregiver actions:
o Sitting: intermittent downward pressure on shoulders in the direction of the pelvis to facilitate extension of the trunk.
o Sitting: slight intermittent pressure movements on abdominal region in direction of the sacrum to facilitate contraction of the ventral muscles.
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- Tapping techniques, intermittent and sweep tapping 1.2.2 Type of reflex locomotion
- Holding with pressure points - Pressure points with handling - Holding without pressure points
- Other
1.2.3 Aim of sensory experience - Affective sensory experience - Mixed affective and body awareness - With the aim of body awareness 1.2.4 Type of constraint
- Caregiver/ PT - Towel, mitten, etc. 1.2.5. Type of variation
During one activity variation is scored once; it represents the overall degree of variation during that activity. If the child during a specific activity is challenged to explore more than two strategies, the modifier of variation is scored as ‘large’ as long as ‘CSPMB’ continues. Little variation: All actions in which the infant is challenged by toys or the face of the PT or caregiver to explore one or two strategies to reach and grasp, to control posture, to roll, etc. This may also imply that the PT or caregiver presents objects in various directions, but does not provide the infant with ample opportunity to deal with the challenge. - Large variation: All actions in which the infant is challenged by toys or the
face of the PT or caregiver; the infant is challenged to explore more than two strategies to reach and grasp, to control posture, to roll, etc. This implies that the infant is offered ample time to deal with the various challenges, and that some challenges are offered multiple times.
1.2.6 Extent of challenge
- Minimal challenge (easy/too easy)
- Just at the verge of the infant’s abilities (has to put some effort)
A.2A Educational actions towards infant; Interference by PT/CG during treatment session 2A.1 Behaviours
2A.1.1 PT/CG interferes with activities of infant
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2A.1.2 Not specified educational actions towards infant 2A.2 Modifier-groups
2A.2.1 Type of interference
- PT/CG interrupts activities of infant after having given ample time
- PT/Caregiver interrupts activities of the infant, does not allow the infant time - PT/Caregiver provokes reflex activity
- PT/CG corrects when infant fails A.2B Educational action toward caregiver 2B.1 Behaviour
2B.1.1 Caregiver training
All actions during which the PT instructs caregivers on how to handle the infant or how to use specific Vojta techniques with the aim being that caregivers can continue treatment strategies during daily-life activities and/or in the home environment. The PT (teacher) provides parents with references about what the therapist is doing or what a parent could do while the therapist treats the infant (hands-on).
Examples of concrete actions:
o PT demonstrates therapeutic handling actions to caregiver. o PT demonstrates Vojta techniques to caregiver
o PT demonstrates action to caregiver, variable options provided.
o PT practices with caregivers teaching them how to continue some of the handling
o techniques in daily life at home.
o PT practices with caregivers; he/she teaches caregivers how to continue some of o the handling techniques in combination with some of the Vojta techniques in
daily life at home
o PT practices with caregivers; he/she teaches the caregivers how to perform reflex rolling and crawling in the home situation
2B.1.2 Caregiver coaching
All actions during which the PT coaches the caregiver. Coaching aims to empower caregivers so that they can make their own educational decisions during daily-care activities in the home environment. The coach listens, informs, and observes (hands-off), while the caregiver is involved in daily routines with the child, including play, thereby creating a situation in which caregivers feel free to explore and discuss alternative strategies.
Examples of concrete actions:
o PT patiently observes the parent and infant behaviour.
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o PT provides a suggestion how the caregiver may challenge motor performances just at the limit of the infant’s abilities.
o PT provides a suggestion how the caregiver may provide as little postural support as possible – in order to challenge postural behaviour of the infant. o PT observes while the caregiver tries to evoke pleasure in the infant. 2B.1.3 Not specified educational action toward caregiver
A.3 Communication 3.1 Behaviours
3.1.1 Information exchange
All communication between the PT and the caregiver that is related to the guidance of infant and family (includes imparting knowledge) and that is not directly related to the child’s development. Impart knowledge implies communication that provides the caregiver with knowledge about the therapeutic actions that are performed.
Examples of concrete actions:
o PT asks about the performance of an action. o PT explains the ins and outs of an action. o PT asks about understanding.
o PT asks about ability of caregiver to perform an action; PT listens to caregiver’s o comments on actions.
Modifier group: Type of exchange 3.1.2 Instruct
All communication in which the caregiver is given assignments, hints or strict directions regarding treatment strategies.
Examples of concrete actions:
o PT assigns, gives advice what to do.
o PT gives hints, provides a suggestion or clue in a very indirect way so that caregivers feel free to explore ample variable opportunities.
o PT gives strict directions what to do. Modifier group: Type of instructing
3.1.3 Provide Feedback
All communication in which the treatment or the performances of infant and caregiver are evaluated.
Examples of concrete actions:
o PT tells the caregiver what went right/wrong.
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o PT evaluates the procedure.
o PT asks and listens to the opinion of the caregiver.
o Caregiver and PT share information on infant development Modifier group: Type of feedback
3.1.4 Not specified communication, e.g. communication with infant 3.1.5 No communication
No communication is scored if there is a silence for more than 5 seconds. 3. Modifier-groups
3.2.1 Type of exchange
- Regarding family history, NICU experiences, current situation or daily business - Regarding principles of NDT: All communication that explains the background
of the treatment strategies, including developmental education and family related items (includes imparting knowledge).
Examples of concrete actions:
o Information on role of parents as member of the team, as co-therapist; PT informs the parent what they should or may do (extension of therapy) o PT explains handling in terms of typical movement patterns, typical
development, posture, muscle tone, asymmetry/symmetry, and hand placing. o PT discusses the application of intervention strategies to daily routines in terms
of handling.
- Regarding principles of VOJTA: All communication that explains the background of the treatment strategies, including developmental education and family related items (includes imparting knowledge).
Examples of concrete actions:
o Information on role of parents as therapist in treatment according to Vojta: therapist as teacher, the PT informs the parent what to do during daytime (frequency and duration). PT explains Vojta test and reflex locomotion in terms of holding the infant in a specific position, pressure on specific parts of the body, reflex rolling, reflex crawling
o PT discusses the frequency of application of Vojta techniques at home (e.g., number of times/day and duration)
- Regarding principles of COPCA: All communication that explains the background of the treatment strategies, including developmental education and family related items (includes imparting knowledge).
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Examples of concrete actions:
o Information on family function, individual lifestyle, family autonomy, raising children, coping with problems, role of siblings, and daily care
o Information on role of the coach: observing, listening, partners
o PT explains the need for variation, minimal support, exploration, trial and error, challenge, and patience.
o PT explains the infant’s need to explore.
o PT explains means to stimulate speech and language development [communication].
o PT discusses the application of the intervention to daily routines in terms of variation, exploration, motor challenge
3.2.2 Type of instructing
Different types of instruction or rather in the way ideas are communicated can be distinguished. The distinction is based on the space of freedom created by the PT allowing the CG to discover and/or formulate own ideas and actions. Note that the way the information is provided does not determine the type of instruction. For example strict instructions may be phrased as a polite question.
- PT gives strict instruction on the best way to perform: only a single, explicitly formulated option is provided, e.g. “While bathing, the child should be sitting” or “Could you, please, have the child in sitting position during bathing?”. - Instruction about multiple ways to achieve best performance: more than one
explicitly formulated option is provided, e.g. “While bathing, the child can either sit or lay in supine position”.
- PT gives hints, provides a suggestion/clue (indirect): no explicitly formulated options are provided, the subject to be discussed is presented in an open way, encouraging the CG to generate options and ideas, e.g. “Could you think of different positions while bathing your child?”
- Not specified 3.2.3 Type of feedback
- PT tells the caregiver what went right/wrong: only short comments without details, e.g. ‘well done’, ‘good job’.
- PT evaluates the procedure: includes all communication on therapeutic actions and caregiving strategies which have been addressed during PT-sessions. E.g. how well the child performs during treatment, how implementation in daily life works out or how the child reacts to different actions.
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- PT asks and listens to the opinion of the caregiver: scored when the PT is interested in the CG’s opinion, is interested to obtain more insight in the CG’s point of view.
- Caregiver and PT share information on infant development: all information exchange involving the child’s development that is not directly related to therapeutic actions or CG coaching.
A.4 Position
The position of the child is always scored except for situations in which the child is not visible. A new position (after a transition) starts when the child stays in the position for at least three seconds.
For exceptions and specific scorings of postures see Appendix I. 4.1 Behaviours
4.1.1. Supine
Modifier groups: 1. Surface
2. Lifting of the pelvis 3. Adaptations 4.1.2. Prone
4.1.3. Side Modifier groups: 1. Surface
4.1.4. Sitting 2. Postural support
4.1.5. Standing 3. Adaptations
4.1.6. Walking 4.1.7. Transition
Modifier group: With or without handling 4.1.8: Not specified position
4.2 Modifier-groups 4.2.1.Lifting of the pelvis: - With imposed pelvis lift - Pelvis not lifted
- Pelvis lift not observable 4.2.2. Surface - On flat surface - On lap PT /CG - On Bobath ball - On Bobath roll Schirin_Thesis.indd 52 Schirin_Thesis.indd 52 07/07/2020 21:28:1107/07/2020 21:28:11
- Across leg/arm of PT/CG - Saddle - Maxicosi/buggy - Baby chair - Baby walker - On dressing mattress
- Against upper part of CG/PT’s body - Other surface
4.2.3 Postural support:
Postural support can be offered by the CG/PT or the environment, e.g., a baby chair. Other examples of postural support by the environment are holding onto the table, leaning against the wall or leaning with one or two hand(s) on the ground.
- No postural support: PT or caregiver leaves it to the infant to adjust posture independently. “Hands-off.”
- Minimal postural support: PT or caregiver provides as little support as possible in order to challenge postural behaviour of the infant performance just at the verge of the infant’s abilities, The child has to “work” hard to maintain balance, which is for example visible in wobbling or swaying back and forth. The amount of support that is considered minimal is depending on the abilities of the child and varies between infants and situations. Note that if the infant is able to maintain the position itself, e.g., is able to sit independently on a flat surface, it is not possible to allude the score ‘minimal’ to the support provided. The latter support has to be classified as either clear or full support depending on the situation. - Clear postural support: PT or caregiver provides support to such that minimal
active involvement of the infant is required to adjust posture.
- Full postural support: PT or caregiver supports all parts of the body of the infant that play a role in postural adjustments. No active involvement of the infant is required.
4.2.4 Adaptive equipment, e.g., lying, seating, standing or walking devices - No adaptive equipment
- Adaptive equipment 4.2.5 With or without handling
- With a handling technique: when the PT/CG changes the position of the child by using a specific handling technique (‘Handling’ has to be scored at the same time for ‘Neuromotor action’)
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- Without a handling technique: when the PT/CG changes the position without using a specific technique (‘Not specified neuromotor action’ has to be scored at the same time for ‘Neuromotor action’.)
5.2 Situation of treatment session
The situation of the treatment is always scored except for situations in which the child is not visible.
5.1 Behaviours
5.1.1. Motor activity/ play 5.1.2. Feeding
5.1.3. Bathing
5.1.4. Dressing/ Undressing 5.1.5. Changing Diapers 5.1.6. Carrying
5.1.7. Not specified situation Additional categories a) Comforting
Comforting of the infant is scored when the therapeutic actions stop in order to comfort the child. When applicable the variables ‘Situation of the treatment session’, ‘Position’ and ‘Neuromotor action’ are scored / continue to be scored during comforting. When the child is held and cuddled to be comforted, the ‘Neuromotor action’ in general will be ‘Sensory state event – Affective’. When the ‘Neuromotor action’ is not clear, ‘not specified neuromotor action’ is scored.
a.1 Behaviours a.1.1 No comforting
a.1.2 Comforting of the infant when infant is upset/crying/tired. b) Interruption by operator b.1 Behaviours b.1.1 No interruption b.1.2 Interruption c) Locomotion c.1 Behaviours c.1.1. Crawling c.1.2. Creeping Schirin_Thesis.indd 54 Schirin_Thesis.indd 54 07/07/2020 21:28:1107/07/2020 21:28:11
c.1.3. Bottom shuffling c.1.4. Walking
c.1.5. Other
c.1.6. No locomotion
B. Independent variables
Independent variables: the value of this variable is supposed not to change during the course of an observation. It gives the observer the opportunity to summarize briefly the important characteristics of the observation. Independent variables are to be scored after finishing the Observer XT in a dropdown menu.
B.1 Type of session (clinical impression) Categories:
1. COPCA
2. TIP (based on NDT)
3. VOJTA
4. TIP (based on NDT) in combination with VOJTA 5. Cranio-sacral therapy
6. TIP (based on NDT) in combination with Cranio-sacral therapy 7. Constraint Induced Movement Therapy (CIMT)
8. COPCA in combination with CIMT B.2 Dressing
The way in which the infant is dressed during the treatment session. If the dressing situation changes during the session, score the predominant dressing situation. Categories:
1. Dressed
2. Infant is partially dressed, wears more clothes than underwear only. 3. Infant is wearing underwear only
4. Infant is undressed.
B.3. Family members involved in the treatment session
The description of the family members that have an active role in the treatment session are included in scoring. This also implies that e.g. the presence of an infant twin sister of brother who does not play an active role in the session, is not scored as ‘other family member present’.
Categories:
1. Mother present only
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2. Father present only
3. Other adult relatives only, e.g. grandparents, aunt. 4. Both caregivers but no other family members present 5. In addition to parent(s) also other family members present
6. Caregiver or caregivers present but no active role in the treatment session B.4 Role of the caregiver
The way in which the caregiver of family members are involved in the treatment session. Categories:
1. Physical therapist performs treatment by means of handling techniques 2. PT performs treatment by means of specific Vojta techniques (holding the
infant in specific ‘Vojta positions’ provoking reflex locomotion by pressure stimulation on specific defined points on the head, trunk or limbs).
3. PT performs treatment by means of handling in combination with Vojta techniques 4. Caregiver and physical therapist act together in handling techniques, physical
therapist performs the treatment (hands on) while the caregiver guides the attention of the infant
5. Caregiver performs handling techniques. The PT instructs the caregiver how to handle.
6. PT and caregiver act together; PT trains caregiver how to perform the Vojta techniques
7. Caregiver performs the treatment by means of specific Vojta techniques 8. Caregiver performs the treatment by means of handling in combination with
Vojta techniques
9. Caregiver and PT act together (hands off), caregiver is playing with the child and may provide the infant with minimal support but leaves the infant always with ample opportunities for exploration. PT observes the caregiver-infant relationship and may give hints.
10. Caregiver is playing with the infant (hands off) and leaves the infant with ample opportunities for exploration.
11. PT is playing with infant (hands off) and leaves the infant with ample opportunities for exploration – caregiver observes
12. PT is playing with infant (hands off) and leaves the infant with ample opportunities for exploration – no specific role of caregiver
B.5. Presence of twins Categories: 1. no = singleton infant 2. yes = twins Schirin_Thesis.indd 56 Schirin_Thesis.indd 56 07/07/2020 21:28:1207/07/2020 21:28:12
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Be ha vi or M od ifie r-gr ou ps Mod ifi er s A1 . N eu ro m ot or a cti on s 1. 1. Fa cil ita tio n t ec hn iq ue s Ty pe o f f ac ili ta tio n - H an dl in g - Pr es su re t ec hn iq ue s - T ap pi ng t ec hn iq ue s, i nt er m itt en t a nd s w ee p t ap pi ng 1. 2. Re fle x L oc om oti on Ty pe o f r efl ex l oc om oti on - H ol di ng w ith ou t p re ss ur e p oi nt s - H ol di ng w ith p re ss ur e p oi nt s - Pr es su re p oi nt s w ith h an dl in g - O th er 1. 3. S en so ry e xp er ie nc e; s ta te eve nt Ai m o f s en so ry e xp er ie nc e - A ffe cti ve s en so ry e xp er ie nc e - M ixe d a ffe cti ve a nd a im in g b od y a w ar en es s - W ith t he a im o f b od y a w ar en es s 1. 4. Se ns or y e xp er ie nc e; p oi nt eve nt Ai m o f s en so ry e xp er ie nc e 1. 5. Pa ss iv e m ot or e xp er ie nc e 1. 6. Se lf-pr od uc ed m ot or be ha vi or ( SM BP ), n o in te rf er en ce w ith P T/ CG 3 1. 7. Se lf-pr od uc ed m ot or be ha vi or ( SM PB ) i n co m bi na tio n w ith co ns tr ai nt o f o ne u pp er lim b, n o i nt er fe re nc e o f ca re gi ve r/ PT Ty pe o f c on st ra in t - C G/ PT - T ow el , m itt en , e tc2
58 Be ha vi or M od ifie r-gr ou ps Mod ifi er s 1. 8. C ha lle ng ed t o S PM B (C SP M B) , i nf an t i s a llo w ed to c on tin ue a cti vi ty b y hi m/ he rs el f a) Var ia tio n b) Ex te nt o f c ha lle ng e Var ia tio n: - L itt le v ar ia tio n - L ar ge v ar ia tio n Ty pe o f c on st ra in t u pp er l im b - C ar eg iv er / P T - T ow el , s lin g, m itt en , e tc . Ex te nt o f c ha lle ng e: - M in im al c ha lle ng e ( ea sy /t oo e as y) - J us t a t t he v er ge o f t he i nf an t’s a bi liti es Fa cil ita tio n t ec hn iq ue s, s en so ry , p as siv e m ot or e xp er ie nc e: - H an dl in g t ec hn iq ue s - Pr es su re - T ap pi ng - S en so ry - P as siv e 1. 9. CS PM B i n c om bi na tio n w ith c on st ra in t o f u pp er lim b, i nf an t i s a llo w ed t o co nti nu e a cti vi ty b y h im / he rs el f a) Var ia tio n b) Ty pe o f c on st ra in t u pp er l im b c) Ex te nt o f c ha lle ng e 1. 10 . C SP M B, a cti vi ty fl ow s o ve r in to f ac ili ta tio n, s en so ry or p as siv e e xp er ie nc e a) Var ia tio n b) Ty pe o f f ac ili ta tio n t ec hn iq ue s, se ns or y, p as siv e m ot or e xp er ie nc e c) Ex te nt o f c ha lle ng e 1. 11 . C ra ni os ac ra l t he ra py 1. 12. N ot s pe ci fie d Schirin_Thesis.indd 58 Schirin_Thesis.indd 58 07/07/2020 21:28:1207/07/2020 21:28:12
Be ha vi or M od ifie r-gr ou ps Mod ifi er s A2 . E du ca tio na l a cti on s 2A E du ca tio na l a cti on s t ow ar ds i nf an t; I nt er fe re nc e b y P T/ CG d ur in g t rea tm en t s es sio n a. PT /C G i nt er fe re s w ith ac tiv iti es o f i nf an t p oi nt eve nt Ty pe o f i nt er fe re nc e - P T/ CG i nt er ru pt s a cti vi tie s o f i nf an t a fte r h av in g g iv en a m pl e ti m e - P T/ CG i nt er ru pt s a cti vi tie s o f t he i nf an t, d oe s n ot a llo w t he i nf an t ti m e - P T/ CG p ro vo ke s r efl ex a cti vi ty - P T/ CG c or re ct s w he n i nf an t f ai ls b. No t s pe ci fie d 2B E du ca tio na l a cti on s t ow ar ds c ar eg iv er 2. 1. C ar eg iv er t ra in in g 2. 2. C ar eg iv er c oa ch in g 2. 3. N ot s pe ci fie d A3 . C om m un ica tio n 3. 1. Inf or ma tio n ex ch an ge Ty pe o f e xc ha ng e - F am ily h ist or y, N IC U e xp er ie nc es , c ur re nt s itu ati on o r d ai ly b us in es s - N DT p rin cip le s - V OJ TA p rin cip le s - C O PC A p rin cip le s 3. 2. In st ru ct Ty pe o f i ns tr uc tin g - P T g iv es s tr ic t i ns tr uc tio n o n t he b es t w ay t o p er fo rm - I ns tr uc tio n a bo ut m ul tip le w ay s t o a ch ie ve b es t p er fo rm an ce - P T g iv es h in ts , p ro vi de s a s ug ge sti on /c lu e ( in di re ct ) - N ot s pe ci fie d 3. 3. Pr ov id e f ee db ac k Ty pe o f f ee db ac k - P T t el ls t he c ar eg iv er w ha t w en t r ig ht /w ro ng . - P T e va lu at es t he p ro ce du re . - P T a sk s a nd l ist en s t o t he o pi ni on o f t he c ar eg iv er . - C G a nd P T s ha re i nf or m ati on o n i nf an t d ev el op m en t. 3. 4. No t s pe ci fie d, e .g . co m m un ic ati on w ith i nf an t 3. 5. No c om m un ic ati on
2
60 Be ha vi or M od ifie r-gr ou ps Mod ifi er s A4. P osi tion a. Su pi ne a) Su rf ac e b) Li fti ng o f t he p el vi s Li fti ng o f t he p el vi s: - W ith i m po se d p el vi s l ift - P el vi s n ot l ift ed - P el vi s l ift n ot o bs er va bl e Su rf ac e: - O n fl at s ur fa ce - O n l ap P TP T/ CG - O n B ob at h b al l - O n B ob at h r ol l - A cr os s l eg /a rm o f P T/ CG - S ad dl e - M axic os i/bu gg y - B ab y c ha ir - B ab y w al ke r - O n d re ss in g m att re ss - A ga in st u pp er p ar t o f C G/ PT ’s b od y - O th er s ur fa ce Po stu ral sup po rt : - N o p os tu ra l s up po rt - M in im al p os tu ra l s up po rt - C le ar p os tu ra l s up po rt - F ul l p os tu ra l s up po rt - N ot o bs er va bl e Ada pti ve e quip m en t: - N o a da pti ve e qu ip m en t - A da pti ve e qu ip m en t 4. 2. Pr on e 4. 3. S id e 4.4 . Si tti ng 4. 5. S tan di ng 4. 6. W al ki ng a) Su rf ac e b) Po stu ral sup po rt 4. 7. Tr an siti on W ith o r w ith ou t h an dl in g - W ith a h an dl in g t ec hn iq ue - W ith ou t a h an dl in g t ec hn iq ue 4. 8. N ot s pe ci fie d p os iti on Schirin_Thesis.indd 60 Schirin_Thesis.indd 60 07/07/2020 21:28:1207/07/2020 21:28:12
Be ha vi or M od ifie r-gr ou ps Mod ifi er s A5 . S itu ati on o f t re at m en t s es sio n 5. 1. M ot or a cti vi ty / p la y 5. 2. Fee di ng 5. 3. B athi ng 5.4 . Dr es sin g/ u ndr es sin g 5. 5. Ch an gi ng D ia pe rs 5. 6. Ca rr yi ng 5. 7. No t s pe ci fie d s itu ati on
2
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B. Independent Variables (note after session is completed) B.1 Type of session (clinical impression)
Categories:
1. COPCA
2. TIP (based on NDT)
3. VOJTA
4. TIP (based on NDT) in combination with VOJTA 5. Cranio-sacral therapy
6. TIP (based on NDT) in combination with Cranio-sacral therapy 7. Constraint Induced Movement Therapy (CIMT)
8. COPCA in combination with CIMT B.2 Dressing
1. Dressed
2. Infant is partially dressed, wears more clothes than underwear only. 3. Infant is wearing underwear only
4. Infant is undressed.
B.3. Family members involved in the treatment session 1. Mother present only
2. Father present only
3. Other adult relatives only, e.g. grandparents, aunt. 4. Both caregivers but no other family members present 5. In addition to parent(s) also other family members present
6. Caregiver or caregivers present but no active role in the treatment session B.4 Role of the caregiver
1. Physical therapist performs treatment by means of handling techniques 2. PT performs treatment by means of specific Vojta techniques (holding the
infant in specific ‘Vojta positions’ provoking reflex locomotion by pressure stimulation on specific defined points on the head, trunk or limbs).
3. PT performs treatment by means of handling in combination with Vojta techniques
4. Caregiver and physical therapist act together in handling techniques, physical therapist performs the treatment (hands on) while the caregiver guides the attention of the infant
5. Caregiver performs handling techniques. The PT instructs the caregiver how to handle.
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6. PT and caregiver act together; PT trains caregiver how to perform the Vojta techniques
7. Caregiver performs the treatment by means of specific Vojta techniques 8. Caregiver performs the treatment by means of handling in combination with
Vojta techniques
9. Caregiver and PT act together (hands off), caregiver is playing with the child and may provide the infant with minimal support but leaves the infant always with ample opportunities for exploration. PT observes the caregiver-infant relationship and may give hints.
10. Caregiver is playing with the infant (hands off) and leaves the infant with ample opportunities for exploration.
11. PT is playing with infant (hands off) and leaves the infant with ample opportunities for exploration – caregiver observes
12. PT is playing with infant (hands off) and leaves the infant with ample opportunities for exploration – no specific role of caregiver
B.5. Presence of twins 1. no = singleton infant 2. yes = twins
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