Factors Associated with the Acquisition of Expertise in Upper Limb Hypertonicity Management

By Burgess, Tegan; Rassafiani, Mehdi et al. | British Journal of Occupational Therapy, August 2008 | Go to article overview

Factors Associated with the Acquisition of Expertise in Upper Limb Hypertonicity Management


Burgess, Tegan, Rassafiani, Mehdi, Copley, Jodie, British Journal of Occupational Therapy


Upper limb hypertonicity management is a complex domain, in which there is limited high level evidence to support treatment approaches. Therefore, it is important to identify clinical experts to assist practice development. This study aimed to investigate the relationship between the factors related to clinical experience and the development of expertise in this area.

Through correspondence, 29 therapists were asked to choose the most appropriate intervention for 60 case vignettes. The responses were examined using the Cochran-Weiss-Shanteau Index of Performance, and were analysed in regard to therapists' ability to prescribe differing interventions based on differences in the vignettes and on their consistency when vignettes were unknowingly repeated.

The number of professional development activities that the therapists had undertaken since attaining occupational therapy qualifications was the only factor significantly associated with increased levels of expertise. The factors not significantly associated with increased expertise included therapists' work setting, years of experience and current proportion of caseload comprising hypertonicity. The results indicated that expertise gained in the area of hypertonicity was not specific to clients' age or condition because, although all vignettes presented were those of children with cerebral palsy, there was no significant difference in the expertise found between paediatric and adult therapists. Further research is warranted to investigate the forms of professional development that best support the development of expertise in this area.

Key words: Upper limb hypertonicity, expertise, occupational therapy.

Introduction

In occupational therapy, attention is being directed towards the creation of an evidence base to guide clinical decision making. At present, there are many clinical areas within occupational therapy where the research has not yet provided 'definite answers' to clinical questions. This is particularly relevant to the management of upper limb hypertonicity, where much debate prevails regarding best practice.

Issues in the management of upper limb hypertonicity

Hypertonicity can be defined as increased resistance of the limbs to passive movement, which is often associated with neurological conditions such as stroke and cerebral palsy. It results from spasticity (hyperactivity of the stretch reflex) and/or changes in the characteristics of the muscular and connective tissues (Gordon 1990, Levin and Hui-Chan 1993, Umphred 2001). Other performance component impairments of the hand and arm resulting from these conditions may include sensory impairments, reduced muscle length, weakness or paralysis, changes in patterns of muscle recruitment, and disuse (Denislic and Meh 1995, Corry et al 1997, Boyd et al 2001, Fehlings et al 2001, Zackowski et al 2004). Combinations of these impairments contribute to difficulties in reaching, grasping, releasing and manipulating objects (Boyd et al 2001).

The literature in this area continues to reflect ongoing debate regarding the underlying mechanisms of upper limb dysfunction in the presence of hypertonicity, with treatment approaches guided by contrasting theories (Copley and Kuipers 1999, Mortenson and Eng 2003). Interventions aim to decrease tone, increase passive range and/or increase function. Both traditional neurophysiological approaches, such as neurodevelopmental therapy, and more contemporary movement science approaches, such as the motor relearning programme, have contributed to the literature in this area (Carr and Shephard 1987, Bobath 1990). Research has focused on the efficacy of these approaches, as well as on associated treatment modalities such as splinting, casting, constraint-induced movement therapy (CIMT), pharmacotherapy and soft tissue surgery. A review of the literature reveals that limited high level evidence exists to support the superiority of any one approach or modality (Copley and Kuipers 1999, Boyd et al 2001, Lannin and Herbert 2003, Mortenson and Eng 2003, Wasiak 2004). …

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