Improve implementation of a novel paediatric therapy programme : taking theories of human behaviour into account

Background: ‘COPing with and CAring for Infants with special Needs’ (COPCA) is a novel family-centred early intervention programme in paediatric physiotherapy. COPCA differs from well-known approaches, e.g. the therapist takes on the role of a coach and uses hands-off approaches. This implies, that to become a COPCA-coach, the therapist needs to change behaviour. Thus, it may be assumed that for successful implementation of new approaches, theories of human behaviour have to be taken into account. Purpose: The study aims to measure behaviour changes in therapists following a COPCA course in order to identify the challenges that interfere with the implementation of the COPCA program in daily practice. Methods: Data were collected during a three-part COPCA course over 6 months (with two months intervals between parts) in which 15 therapists learned to become a COPCA-coach. To document behaviour changes four treatment sessions (one prior to part I T0), one in each interval (T1, T2), and one after part III (T3) of each participant (n=60) were video-recorded and analysed quantitatively with the Groningen Observation Protocol version 2 (GOP 2.0). The videos were randomized and masked to the chronology of recording moment. GOP 2.0 is a quantitative tool to assess therapeutic behaviour in different categories, e.g. “educational actions toward caregivers” or “neuromotor actions”. It allows for a quantification of the relative duration of therapeutic actions (percentage of total treatment time) during a session. Interrater reliability of the GOP 2.0 was evaluated. The first author analysed changes in therapeutic behaviour over time with the Wilcox-sign rank test. Median changes and corresponding non-parametric confidence intervals were computed using the Hodges-Lehmann estimator (HL). Results: Interrater reliability of the GOP 2.0 (ICC2) was 0.48-1.00 (median 0.92). Course participation was associated especially with changes in “educational actions toward caregivers” and “ neuromotor actions”. Time spent on ‘caregiver coaching’ increased: between T0 and T1 by 77.9% (99% confidence interval (CI) 48.7-99.1) and between T0 and T3 by 96.1% (99%CI 51.7-100). Also time spent on hands-off techniques increased, 37.9% (99%CI 18.8-59.5) between T0 and T1 and 40.3% (99%CI 17.8-57.7) between T0 and T3. The implementation of hands-off approaches developed at a slower rate and somewhat less sustainable than that of coaching. Conclusions: Behaviours with a slower and less sustainable rate of change represented strong habits. The neural substrate of strong habits is located subcortically, making them relatively resistant to cognitive input. To overcome this challenge, future COPCA courses need to be adapted, by including (1) more modelling of desired behaviour and (2) more repetition and practice for the behaviours in the neuromotor domain. Implication: Quantitative analysis of therapeutic behaviour is a useful method to monitor changes in behaviour of therapists and – by doing so – may assist the implementation of new approaches. To implement new approaches successfully, theories of human behaviour have to be taken into account. The Behaviour Change Wheel of Michie et al., a method to characterise and design behaviour change in interventions, is a helpful framework to understand the nature of behaviour and to overcome behaviour change barriers

Prescription of the first prosthesis and later use in children with congenital unilateral upper limb deficiency: A systematic review

Background: The prosthetic rejection rates in children with an upper limb transversal reduction deficiency are considerable. It is unclear whether the timing of the first prescription of the prosthesis contributes to the rejection rates. Objective: To reveal whether scientific evidence is available in literature to confirm the hypothesis that the first prosthesis of children with an upper limb deficiency should be prescribed before two years of age. We expect lower rejection rates and better functional outcomes in children fitted at young age. Methods: A computerized search was performed in several databases (Medline, Embase, Cinahl, Amed, Psycinfo, PiCarta and the Cochrane database). A combination of the following keywords and their synonyms was used: "prostheses, upper limb, upper extremity, arm and congenital''. Furthermore, references of conference reports, references of most relevant studies, citations of most relevant studies and related articles were checked for relevancy. Results: The search yielded 285 publications, of which four studies met the selection criteria. The methodological quality of the studies was low. All studies showed a trend of lower rejection rates in children who were provided with their first prosthesis at less than two years of age. The pooled odds ratio of two studies showed a higher rejection rate in children who were fitted over two years of age ( pooled OR 3.6, 95% CI 1.6-8.0). No scientific evidence was found concerning the relation between the age at which a prosthesis was prescribed for the first time and functional outcomes. Conclusion: In literature only little evidence was found for a relationship between the fitting of a first prosthesis in children with a congenital upper limb deficiency and rejection rates or functional outcomes. As such, clinical practice of the introduction of a prosthesis is guided by clinical experience rather than by evidence-based medicine

Postural adjustments and reaching in 4-and 6-month-old infants:an EMG and kinematical study

Adequate postural control is a prerequisite for daily activities such as reaching for an object. However, knowledge on the relationship between postural adjustments and the quality of reaching movements during human ontogeny is scarce. Therefore we evaluated the development of the relationship between the kinematic features of reaching movements and the accompanying postural adjustments in young infants. Twelve typically developing (TD) infants were assessed twice, i.e. at 4 and 6 months of age, in supine and supported sitting position. Reaching was elicited by presenting toys in the midline at an arm-length distance while simultaneously surface EMG-activity was recorded from multiple arm-, neck-, trunk- and leg muscles. Concurrently kinematics of reaching were recorded with an ELITE system; kinematic analysis was restricted to the behaviour of so-called movement units, which are sub movements of reaching determined with the help of peaks in the velocity profile of the hand, maximum movement velocity and movement duration. A computer-algorithm determined significant phasic muscle activity. Activity in neck and trunk muscles (postural activity) was related to the onset of the prime mover, which was the arm muscle being activated first. The results indicated that about 50% of reaching movements in lying and sitting infants aged 4 and 6 months were accompanied by direction-specific postural adjustments. At 4 months variation dominated, but at 6 months a preference to recruit muscles in a top-down order (during sitting) and in the configuration of the complete pattern, i.e. the pattern in which all dorsal neck- and trunk muscles are activated in concert, (both conditions) emerged. Interestingly, the postural characteristics such as the presence of direction-specificity, recruitment of the complete pattern and top-down recruitment, were related to how successful the reaching was and the kinematics of reaching. It was concluded that the presence of direction-specific activity is not a prerequisite for the emergence of reaching movements. Nevertheless, already from 4 months onwards a better postural control is associated with a larger success and a better quality of reaching

Establishment of electric crematorium in Nepal: continuity, changes and challenges

Traditionally cremations in Nepal are performed with open pyres. These cremations are fluid public events organised and managed by relatives, local communities and ritual specialists. Traditional cremation practices are full of cosmological, eschatological and soteriological significance. The main purpose of the cremation practice is to purify and free the soul from the body of the deceased in order to secure a rebirth in another realm, render the soul a safe journey to heaven, and to turn the soul into a benign ancestor instead of a haunting ghost. On the 24th of January 2016, Pashupati Area Development Trust inaugurated the first functioning modern electric crematorium in Nepal at the traditional cremation site near the Pashupatinath temple, at the holy river Bagmati, 5 km northeast of Kathmandu. The main incentive for Pashupati Area Development Trust to establish an electric crematorium was to diminish river pollution, carbon dioxide emission and to curb deforestation. How do Hindus in Nepal continue, compromise and adapt their traditional cremation practice in the modern indoor electric crematorium? The aim of this article is to explore the continuity, changes and challenges to traditional Hindu cremation practice in the electric crematorium at Pashupati area.Establishment of electric crematorium in Nepal: continuity, changes and challengesacceptedVersionThis is an [Accepted Manuscript] of an article published by Taylor & Francis, available at https://doi.org/10.1080/13576275.2016.127429

Early Brain Damage and the Development of Motor Behavior in Children: Clues for Therapeutic Intervention?

The Neuronal Group Selection Theory (NGST) could offer new insights into the mechanisms directing motor disorders, such as cerebral palsy and developmental coordination disorder. According to NGST, normal motor development is characterized by two phases of variability. Variation is not at random but determined by criteria set by genetic information. Development starts with the phase of primary variability,during which variation in motor behavior is not geared to external conditions. At function-specific ages secondary variability starts, during which motor performance can be adapted to specific situations. In both forms, of variability, selection on the basis of afferent information plays a significant role. From the NGST point of view, children with pre- or perinatally acquired brain damage, such as children with cerebral palsy and part of the children with developmental coordination disorder, suffer from stereotyped motor behavior, produced by a limited repertoire or primary (sub)cortical neuronal networks. These children also have roblems in selecting the most efficient neuronal activity, due to deficits in the processing of sensory information. Therefore, NGST suggests that intervention in these children at early age should aim at an enlargement of the primary neuronal networks. With increasing age, the emphasis of intervention could shift to the provision of ample opportunities for active practice, which might form a compensation for the impaired selection

Emerging signs of autism spectrum disorder in infancy:Putative neural substrate

Autism spectrum disorder (ASD) is characterized by altered development of the social brain with prominent atypical features in the fronto-temporo-parietal cortex and cerebellum. Early signs of ASD emerge between 6 and 12 months: reduced social communication, slightly less advanced motor development, and repetitive behaviour. The fronto-temporo-parietal cortex and cerebellum play a prominent role in the development of social communication, whereas fronto-parietal-cerebellar networks are involved in the planning of movements, that is, movement selection. Atypical sensory responsivity, a core feature of ASD, may result in impaired development of social communication and motor skills and/or selection of atypical repetitive behaviour. In the first postnatal year, the brain areas involved are characterized by gradual dissolution of temporary structures: the fronto-temporo-parietal cortical subplate and cerebellar external granular layer. It is hypothesized that altered dissolution of the transient structures opens the window for the expression of early signs of ASD arising in the impaired developing permanent networks