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Cognitive Orientation to (Daily) Occupational Performance intervention leads

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Developmental Coordination...

Article  in  Disability and Rehabilitation · July 2015

DOI: 10.3109/09638288.2015.1070298

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ISSN 0963-8288 print/ISSN 1464-5165 online

Disabil Rehabil, Early Online: 1–8

! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2015.1070298

RESEARCH PAPER

Cognitive Orientation to (Daily) Occupational Performance intervention

leads to improvements in impairments, activity and participation in
children with Developmental Coordination Disorder
Ashleigh Thornton1, Melissa Licari1, Siobhan Reid1, Jodie Armstrong2, Rachael Fallows2, and Catherine Elliott3
1
School of Sport Science, Exercise and Health, The University of Western Australia, Perth, Australia, 2Child and Adolescent Health Services, Princess
Margaret Hospital for Children, Perth, Australia, and 3Faculty of Health Sciences, Curtin University, Perth, Australia
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Abstract Keywords
Introduction: Children diagnosed with Developmental Coordination Disorder (DCD) present Goal based, group, motor impairment,
with a variety of impairments in fine and gross motor function, which impact on their activity therapy
and participation in a variety of settings. This research aimed to determine if a 10-week group-
based Cognitive Orientation to Daily Occupational Performance (CO-OP) intervention improved History
outcome measures across the impairment, activity and participation levels of the International
Classification of Functioning, Disability and Health (ICF) framework. Methods: In this quasi- Received 5 November 2014
experimental, pre–post-test, 20 male children aged 8–10 years (x9y1m ± 9 m) with a confirmed Revised 23 June 2015
For personal use only.

diagnosis of DCD participated in either the 10 week group intervention based on the CO-OP Accepted 4 July 2015
framework (n ¼ 10) or in a control period of regular activity for 10 weeks (n ¼ 10). Outcome Published online 27 July 2015
measures relating to impairment (MABC-2, motor overflow assessment), activity (Handwriting
Speed Test) and participation [Canadian Occupational Performance Measure, (COPM) and Goal
Attainment Scale) were measured at weeks 0 and 10 in the intervention group. Results: Children
who participated in the CO-OP intervention displayed improvements in outcome measures for
impairment, activity and participation, particularly a reduction in severity of motor overflow.
Parent and child performance and satisfaction ratings on the COPM improved from baseline to
week 10 and all goals were achieved at or above the expected outcome. No significant changes
were reported for the control group in impairment and activity (participation was not measured
for this group). Conclusion: The strategies implemented by children in the CO-OP treatment
group, targeted towards individualised goal attainment, show that CO-OP, when run in a group
environment, can lead to improvements across all levels of the ICF.

ä Implications for Rehabilitation

 Development Coordination Disorder is a condition which has significant physical, academic
and social impacts on a child and can lead to activity limitations and participation restrictions.
 Cognitive Orientation to Daily Occupational Performance is an approach which uses
cognitive-based strategies to improve performance of specific tasks based on child chosen
goals.
 The intervention program had a positive effect on self-perceived levels of performance which
may lead to changes in quality of life.
 Parents felt the intervention enhanced socialisation, peer modelling and encouragement and
felt that this increased confidence and independence.

Introduction activities of daily living [1]. They also experience activity

limitations including mobility, domestic life and self-care and
Developmental Coordination Disorder (DCD) is a movement
consequentially experience participation restrictions [1]. These
disorder characterised by impaired motor function. Children
difficulties are not just present during childhood, many individ-
diagnosed with this disorder have a marked impairment in motor
uals diagnosed with DCD continue to show symptoms throughout
coordination that interferes with academic achievement and
adolescence and into adulthood [2].
Current evidence supports the use of task specific and
cognitive interventions to improve impairments in functional
Address for correspondence: Dr. Ashleigh Thornton, School of Sport
Science, Exercise and Health, University of Western Australia, M408 35 performance of children with DCD [3,4], with a focus on the
Stirling Highway, Crawley, Western Australia 6009, Australia. Tel: +61 cognitive elements involved in task performance proven to be
864882661. E-mail: ashleigh.thornton@uwa.edu.au effective in this population [5]. The Cognitive Orientation to daily
 2 A. Thornton et al. Disabil Rehabil, Early Online: 1–8

Occupational Performance (CO-OP) is one such approach the term used throughout this paper and the type of motor
developed for children with DCD, which uses cognitive-based overflow that will be the central focus of this work is contralateral
strategies to improve performance of specific tasks based on child motor overflow, which refers to movements on one side of the
chosen goals. From a motor learning and control perspective, the body while the opposite performs a voluntary movement [24].
theoretical framework for CO-OP is based upon the proposition Considering children with DCD display more pronounced motor
that motor learning is a process of solving movement problems, overflow than children of the same age [25], it is possible that
originally proposed by Bernstein [6]. Further developed by motor overflow could consequently be one of the contributing
Thelen [7], and now known as the dynamic systems theory, it factors toward delayed motor development and reduced fine and
suggests that musculoskeletal, neurological and cognitive systems gross motor proficiency in children with DCD.
all interact with the performance of a task. To facilitate motor While traditionally, intervention methods have focused on the
learning, factors relating to each system must adapt to the task impairment level of the ICF in children with DCD [18], there has
required. CO-OP intervention requires the child to generate been no research investigating whether interventions such as CO-
several alternative ways of ‘‘solving’’ the movement problems to OP, can successfully integrate dynamic neurological, musculo-
overcome these barriers to motor learning and, through guided skeletal and cognitive systems to facilitate improvements in
discovery, determine the most effective solutions to their move- impairments such as motor overflow, and fine and gross motor
ment problems [8]. coordination. In addition, if CO-OP intervention results in
Several studies have found CO-OP to be a successful approach improvements in these impairments, this may benefit outcomes
to learn, maintain and transfer strategies related to the perform- at the activity and participation levels of the ICF. Therefore, this
ance of fine motor skills such as handwriting and cutting, as well research aims to establish if a 10-week group-based intervention
as gross motor skill such as running and basketball shooting, in program, using the CO-OP framework, aids in the improvement of
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children with DCD aged 7–12 years [9–12]. To date this outcomes associated with impairment, activity and participation
intervention has been shown to be effective in improving motor levels in children with DCD. It was hypothesised that improve-
performance in individuals and also in a group environment. ment would be seen across outcomes associated with fine and
Given that children with DCD present with fine and gross motor gross motor impairment, motor overflow, performance of
impairments, activity limitations and participation restrictions, activities and participation following the intervention period.
focusing on improving performance through interventions such as
CO-OP, is a vital progression in understanding this disorder. Methods
Using the World Health Organisation’s International
Classification of Functioning, Disability and Health (ICF) [13] Participants
framework allows for a holistic approach to evaluating treatment
For personal use only.

Power calculations were completed a priori. With an expected

outcomes, across the levels of impairment, activity and partici- effect of 0.8 [19] it was determined that a sample of 10 children
pation in children with DCD. The framework offers a conceptual per group would achieve a power of 0.97, and detect a meaningful
support for intervention and suggests that impairment, activity difference between intervention and control group. A total of 20
and participation are all interconnected and, through various male right handed children aged 8–10 years (x9y1m ± 9 m) were
contextual factors, can influence a person’s daily life [14]. recruited for participation in this quasi-experimental, pre–post-
Research has demonstrated that DCD is a heterogeneous test study. Each participant was block randomised into either the
disorder [15], thus the impairments and activity limitations, as CO-OP group or the control group, with children in both groups
classified by the ICF, that children with DCD experience are individually matched for age (within six months). As reported by
varied. Impairment such as poor motor coordination may manifest parents all children met the diagnostic criteria from the
itself as poor balance, dropping or bumping into things or Diagnostic and Statistical Manual IV (DSM-IV) [1], that being:
persistent delay in the acquisition of basic motor skills such as (A) performance in daily activities that require motor coordination
catching, running and jumping [15]. Challenges in terms of is substantially below that expected, given the person’s chrono-
activity, such as dressing, cutting, colouring and handwriting [14] logical age and measured intelligence, (B) the disturbance in
are also reported in this population. Criterion A significantly interferes with academic achievement or
Impairments in fine motor proficiency have been shown to activities of daily living, (C) the disturbance is not due to a
affect the education and academic achievement of children with general medical condition (e.g. cerebral palsy, hemiplegia, or
DCD [16]. Specifically, laborious handwriting techniques and muscular dystrophy) and does not meet criteria for a Pervasive
difficulties in copying from the board [17] hamper children with Developmental Disorder, (D) if mental retardation is present, the
DCD’s ability to participate in a structured classroom setting. motor difficulties are in excess of those usually associated with it.
These participation restrictions are not limited to the classroom, Criterion A was established using the Movement Assessment
children with DCD are found to be restricted in their ability to Battery for Children-2 (MABC-2), and Criteria B, C and D
participate in most typical childhood activities [18]. Additionally, established through parental report. Males were selected to
evidence shows that as a result of low gross motor proficiency, control for potential gender differences that might exist in the
children with DCD display much lower levels of physical activity, presentation of impairment. Written informed consent from
and extremely low levels of participation in team sports [19]. parents and assent from children were obtained prior to data
There are a number of factors thought to contribute to poor collection. The Code of Ethics of the World Medical Association
skill execution in children with DCD, including issues with (Declaration of Helsinki) was followed and human research ethics
muscle tone, postural control and spatial awareness [20]. Another approval was obtained from the University of Western Australia
characteristic of the disorder is the presence of neurological soft Ethics Committee; RA/4/1/4351.
signs, such as the presence of extraneous movements during the
performance of voluntary movement [21,22]. These movements
Procedures
may decrease the biomechanical efficiency and increase the
energy cost of their actions [21], leading to a decrement in The intervention program was conducted over 10 weeks, with
movement quality. A number of different terms have been used to children allocated into groups of 3–4, based on common
describe the presence of these mirror movements, including motor occupational performance problems, identified by the children
overflow and associated movements [23]. Motor overflow will be and their parents through the use of the Perceived Efficacy and
 DOI: 10.3109/09638288.2015.1070298 CO-OP to improve children with DCD 3
Table 1. Goals developed through use of the PEGS by children in the CO-OP group.

Group 1 Group 2 Group 3

Child 1 Using a knife Writing neater Handwriting speed
Tying shoelaces Writing faster Handwriting legibility
Writing speed Doing up buttons Cutting with scissors
Child 2 Handwriting speed Tying shoelaces Cutting with scissors
Handwriting legibility Doing up buttons Doing up shoelaces
Kicking a football Handwriting legibility Writing legibility
Child 3 Cutting with a knife Handwriting legibility Handwriting speed
Catching a ball Doing up buttons Handwriting legibility
Handwriting legibility Cutting food Hitting a tennis ball
Child 4 Handwriting legibility
Handwriting speed
Kicking a football

Table 2. Outcome measures used at week 0 and 10 across the ICF domains of impairment, activity and participation.

ICF domain Assessment Area of measurement

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Impairment 3D UL motion analysis Motor overflow

Flex-sensor glove Motor overflow
Movement Assessment Battery for Children–2 Movement proficiency
Activity Handwriting Speed Test Handwriting speed and legibility
Participation GAS Goal attainment
COPM Occupational performance

Goal Setting system (PEGS) [20] (Table 1). Each group session All 20 participants completed impairment and activity out-
For personal use only.

was conducted once a week for approximately 1 h in duration, come measures, with the CO-OP group also completing additional
along with 15 min/day of home activities, and run by two measures of participation, prior to and at the conclusion of the 10-
Occupational Therapists trained and experienced in the use of week intervention. All outcome measures were completed with an
the CO-OP intervention. Both therapists were blinded to the independent therapist blinded to intervention status. Each out-
specific outcome measures of the study but were aware of the come measure and its domain within the ICF framework is
children’s goals. All children involved in the intervention outlined in Table 2. Parents of children allocated to the CO-OP
program were required to have a minimum of two fine motor group also completed a satisfaction survey at the completion of
related goals for inclusion in this study. All children identified the 10-week intervention period.
fine motor goals of handwriting speed and legibility, other fine
motor goals included using scissors and cutlery appropriately.
Impairment
Sessions were focused on the global problem solving strategy,
described as the Goal-Plan-Do-Check method [26], to create Contralateral motor overflow was quantified in the inactive non-
strategies to improve the child’s functional performance and goal dominant hand while the dominant hand executed three upper
achievement. The group program was developed to address at limb movement assessment tasks; finger sequencing, clip
least 2–3 goals for each child and was themed as a Police pinching and the pegboard task, before and after the intervention
Detective Club. The therapists used a Police Detective puppet to period. All tasks were selected due to their use in previous
introduce the ‘‘Goal-Plan-Do-Check’’ strategy to help solve research into motor overflow [21,22,27]. Movements pertaining to
(performance) problems. Goal is the task that the child wishes to motor overflow, quantified as range of motion about the inactive
perform (e.g. handwriting). Plan refers to how the child will limb, were collected via three-dimensional motion analysis
tackle the goal (involving specific strategies). Do refers to the using a twelve camera Vicon MX system (Oxford Metrics,
performance of the task, requiring the child to practice. Check is Oxford, UK) capturing at 250 Hz. Thirty-eight, 15 mm diameter,
the child’s evaluation of the strategies employed and whether retro-reflective markers were affixed to the body, in accordance to
they were successful [26]. During each session, children were the UWA Upper Limb Assessment Protocol [28].
encouraged to develop and modify individual plans to achieve Contralateral motor overflow was also measured using gloves
their identified goals and then perform the do and check tasks as equipped with flex sensors, to detect movement of the non-
a group to decide which strategies were successful and which dominant inactive hand, during the finger sequencing task. This
were not. While children worked on common goals throughout movement was measured as mean amplitude of displacement of
the sessions, the level of difficulty was graded to meet the needs each finger of the inactive hand. To standardise the timing of
of the individual child. Children allocated to the control group finger sequencing between participants, a metronome was set at
received no intervention, and were encouraged to participate in 50 bpm, with participants instructed to tap their thumb to each
activities as they normally would for the duration of the 10-week finger in time with the metronome and complete five sequences of
period. Due to time and funding restrictions, it was not possible the task at this speed. Data were collected at 100 Hz during the
for children within the control group to be offered the CO-OP finger sequencing task, using LabView Signal Express for DAQ
intervention at the conclusion of the 10 weeks and instead, they software (LabView, National Instruments, Austin, TX) and
were offered access to a remedial movement program run by the processed using customised MATLAB script (MATLAB, The
coordinating institution. MathWorks Inc., Natick, MA).
 4 A. Thornton et al. Disabil Rehabil, Early Online: 1–8

The MABC-2 [29] was administered by a trained movement finger sequencing task, significant differences were seen
specialist blinded to the individual’s group allocation and used to between groups for range of motion about the shoulder during
determine movement proficiency prior to and at the conclusion of abduction/adduction (Z ¼ 3.78, p ¼ 0.001), at the elbow in
the CO-OP intervention. Test–retest reliability for this assessment flexion/extension (Z ¼ 3.55, p ¼ 0.001) and pronation/
is reported to be 0.80 [29]. supination (Z ¼ 3.38, p ¼ 0.001) and wrist abduction/adduction
(Z ¼ 3.59, p ¼ 0.001), with the intervention group displaying
Activity and participation lower range of motion than the control group in all instances.
For the clip pinching task, range of motion was significantly
The PEGS [20], a tool used to set and prioritise goals, was
lower in the intervention group at week 10 than the control
administered by an occupational therapist independent to the
group at the shoulder in flexion/extension (Z ¼ 2.86, p ¼ 0.004)
study, as a process that would provide participants with the
and internal/external rotation (Z ¼ 3.02, p ¼ 0.003) and at
opportunity to reflect on their strengths and abilities for daily
the elbow for flexion/extension (Z ¼ 3.02, p ¼ 0.003) and
tasks in the school, home and community settings and to establish
pronation/supination (Z ¼ 3.10, p ¼ 0.002). No differences
goals for the intervention period. The top four tasks each child
were noted between groups at week 10 for the pegboard task.
chose as a result of the PEGS were used as prompts for both the
Within group comparisons of motor overflow in the inactive
child and parent to identify occupational performance problems
non-dominant limb (Table 3), demonstrated no significant
on the Canadian Occupational Performance Measure (COPM)
differences in range of motion at any joint across all tasks over
[30]. As all children identified handwriting as a primary goal, the
the control period. During the finger sequencing task, range of
Handwriting Speed Test (HST) was used as an outcome measure
motion decreased at week 10 in the intervention group for wrist
of activity with the outcome of handwriting speed and legibility
abduction/adduction (Z ¼ 2.80, p ¼ 0.005), with thorax lateral
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measured [31]. The writing sample was then scored by two

flexion (Z ¼ 2.60, p ¼ 0.009) and shoulder abduction
independent examiners blinded to group’s allocations for speed;
(Z ¼ 2.70, p ¼ 0.007) range of motion approaching significance.
by recording letters per minute and letter and word legibility; with
At the elbow, flexion/extension (Z ¼ 2.67, p ¼ 0.008) and
scoring criteria from the Evaluation Tool of Children’s
pronation/supination (Z ¼ 2.67, p ¼ 0.008) also approached
Handwriting – Manuscript version (ETCH-M) [32], a method
significance. For the clip pinching task, significant decreases in
used successfully in previous research [33].
range of motion occurred within the intervention group at the
The occupational performance issues as rated most important
thorax for rotation (Z ¼ 2.80, p ¼ 0.005) and in shoulder
by the child and parent on the COPM were used as the basis for
adduction/abduction (Z ¼ 2.80, p ¼ 0.005). There were also
the development of goals for the Goal Attainment Scale (GAS)
significant decreases in range of motion in elbow flexion/
[34]. Both were administered by an independent occupational
extension (Z ¼ 2.80, p ¼ 0.005). For the pegboard task, signifi-
For personal use only.

therapist. The most common occupational performance area that

cant decreases in range of motion were found across two planes of
was identified as a problem, by the child and parent was
motion at the thorax; flexion extension (Z ¼ 2.80, p ¼ 0.005)
productivity – school (handwriting speed and legibility, drawing
and lateral flexion (Z ¼ 2.80, p ¼ 0.005) with rotation approach-
and other fine motor manipulation skills such as cutting) and self-
ing significance (Z ¼ 2.70, p ¼ 0.007 effect size 0.83). No
care (using cutlery, managing buttons and shoelaces). The control
significant changes were found at the shoulder, elbow or wrist
group did not complete the COPM or GAS, but in an initial
on this task.
interview, parents of children in the control group did identify
The flex-sensor glove was used to assess movement of fingers
handwriting speed and legibility, along with participation in age-
on the inactive hand during the finger sequencing task. Finger
appropriate physical activity as common performance problems.
movement of the inactive hand, displayed as mean amplitude, is
shown in Table 4. Movements of the fingers on the inactive hand
Data analysis
increased significantly in both groups from week 0 to week 10,
As the data did not meet assumptions for normality and with no significant differences between groups pre- and post-
homogeneity, non-parametric statistics were used. Mann– intervention.
Whitney U tests were employed to compare differences between Movement proficiency was assessed using the MABC-2 over
the groups prior to and following the completion of the the course of the intervention. No significant differences were
intervention. Kruskall–Wallis tests were also used to compare found between the control and CO-OP groups at baseline or after
within group differences pre- and post-intervention or control intervention for the MABC-2 raw score (F(1) ¼ 2.13, p ¼ 0.73) or
period. Due to the number of comparisons made within the range manual dexterity scores (F(1) ¼ 0.22, p ¼ 0.65). No significant
of motion data, a Bonferroni correction was applied to the Mann– differences were found between MABC-2 percentile rank over
Whitney U and Kruskall–Wallis comparisons, resulting in an time (F(1) ¼ 1.96, p ¼ 0.178).
alpha level of p ¼ 0.005 denoting statistical significance. Figure 1 shows the mean scores for components of the activity
MABC-2 and HST scores complied with the assumptions of measure, the HST. The HST raw score (letters per minute) was
normality and homogeneity, as such, were compared using significantly higher in the intervention group when compared to
parametric statistics, using a repeated measures ANOVA. For the control group at week 10 (F(19) ¼ 14.16, p ¼ 0.018), as was
the CO-OP group, COPM scores were analysed using paired word legibility (F(19) ¼ 4.45, p ¼ 0.030). Letter legibility did not
samples t-tests and baseline and achieved GAS scores were differ between groups over time (F(19) ¼ 0.01, p ¼ 0.94).
converted to aggregate T-scores [33], then analysed using paired
samples t-tests.
Activity and participation
Results Figure 2 illustrates parent and child performance and satisfaction
ratings for the CO-OP group, based on the COPM. Parents
Impairment
reported significant improvements in performance (t(9) ¼ 5.78,
At baseline, there were no significant differences between the p50.01) and satisfaction (t(9) ¼ 3.81, p50.01) following the
control and intervention groups in motor overflow. At the intervention. Children also rated performance (t(9) ¼ 3.64,
conclusion of the intervention period differences were observed p50.01) and satisfaction (t(9) ¼ 6.08, p50.01) significantly
between the two groups (Table 2). During performance of the higher post-intervention, with 100% of individuals reporting
 DOI: 10.3109/09638288.2015.1070298 CO-OP to improve children with DCD 5
Table 3. Mean (SD) degrees of range of motion about the non-dominant, inactive limb in the control and intervention groups at week 0 and week 10 –
within groups comparison.

Control CO-OP
Segment Movement Week 0 Week 10 Z p CO-OP Week 0 CO-OP Week 10 Z p
Finger sequence
Thorax Flex/Ext 5.63 (4.86) 6.17 (2.70) 1.274 0.203 6.11 (5.30) 4.25 (4.63) 0.255 0.799
Lat Flex 3.46 (1.67) 4.15 (1.76) 0.764 0.445 3.82 (1.53) 1.42 (3.25) 2.599 0.009
Rot 5.64 (6.29) 6.40 (6.50) 0.459 0.646 3.50 (.87) 0.81 (2.40) 2.803 0.005*
Shoulder Flex/Ext 30.58 (27.95) 28.95 (17.14) 0.357 0.721 25.88 (20.02) 16.78 (5.42) 1.478 0.139
Abd/Add 27.47 (8.68) 54.27 (13.10) 0.051 0.959 22.32 (6.60) 15.30# (10.92) 2.701 0.007
Int/Ext Rot 30.02 (25.02) 28.05 (16.09) 0.153 0.878 29.31 (21.03) 24.82 (5.08) 1.886 0.059
Elbow Flex/Ext 10.91 (2.42) 15.57 (10.98) 1.183 0.237 11.02 (9.96) 8.31# (8.41) 2.666 0.008
Pro/Sup 14.14 (9.74) 16.81 (7.63) 0.000 1.00 14.33 (6.89) 8.57# (3.46) 2.666 0.008
Wrist Flex/Ext 20.90 (10.48) 18.81 (10.14) 0.420 0.674 25.13 (16.14) 14.86 (7.67) 1.274 0.203
Abd/Add 11.78 (11.37) 13.03 (6.47) 0.140 0.889 15.19 (11.20) 6.22# (10.91) 2.803 0.005*
Clip pinch
Thorax Flex/Ext 8.39 (4.73) 9.11 (4.35) 0.357 0.721 9.86 (5.23) 2.97 (8.07) 2.701 0.007
Lat Flex 6.01 (2.49) 5.88 (1.63) 0.459 0.646 5.63 (1.53) 2.08 (1.63) 2.395 0.017
Rot 9.43 (5.97) 9.94 (6.44) 0.153 0.878 10.31 (6.51) 1.75 (8.06) 2.395 0.017
Shoulder Flex/Ext 11.50 (6.32) 12.56 (8.38) .059 0.953 11.11 (5.82) 6.25# (3.42) 2.547 0.011
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Abd/Add 11.50 (5.99) 13.63 (8.96) 0.178 0.859 13.44 (7.98) 8.67 (5.90) 1.955 0.051
Int/Ext Rot 19.82 (18.66) 19.15 (14.31) 0.533 0.594 22.25 (18.89) 4.10# (14.12) 2.310 0.021
Elbow Flex/Ext 22.22 (31.04) 16.95 (14.11) 0.415 0.678 23.77 (32.26) 6.86# (3.80) 2.310 0.021
Pro/Sup 33.68 (39.44) 26.51 (9.01) 0.770 0.441 36.41 (43.01) 21.57# (19.34) 2.599 0.011
Wrist Flex/Ext 19.55 (14.55) 15.54 (12.57) 1.070 0.285 17.91 (13.72) 3.55 (13.33) 1.886 0.059
Abd/Add 13.16 (10.50) 10.50 (10.92) 0.968 0.333 12.17 (9.84) 1.28 (10.47) 1.784 0.074
Pegboard
Thorax Flex/Ext 7.57 (2.17) 11.53 (9.57) 0.051 0.959 6.88 (4.93) 4.07 (10.07) 2.803 0.005*
Lat Flex 9.18 (2.70) 6.19 (5.36) 1.274 0.203 6.38 (2.82) 4.19 (5.41) 2.803 0.005*
Rot 10.86 (1.91) 9.25 (6.12) 0.153 0.878 8.13 (2.94) 4.62 (3.13) 2.701 0.007
Shoulder Flex/Ext 7.17 (3.86) 7.49 (8.33) 1.836 0.066 14.22 (13.45) 7.64 (8.16) 2.380 0.017
Abd/Add 10.70 (5.17) 19.37 (16.80) 1.362 0.173 13.67 (8.21) 25.98 (16.32) 1.120 0.263
For personal use only.

Int/Ext Rot 13.44 (6.28) 17.38 (5.29) 0.77 0.441 18.71 (12.16) 11.07 (9.12) 2.380 0.017
Elbow Flex/Ext 13.69 (9.00) 15.63 (9.54) 1.836 0.066 20.34 (18.39) 10.13 (6.50) 2.100 0.036
Pro/Sup 17.57 (8.24) 10.51 (13.39) 1.007 0.314 19.56 (7.19) 9.11 (7.09) 2.521 0.012
Wrist Flex/Ext 14.77 (7.26) 7.26 (3.21) 0.357 0.721 15.93 (3.21) 7.48 (4.03) .561 0.575
Abd/Add 7.59 (3.71) 4.71 (9.15) 1.682 0.093 12.63 (10.92) 2.87 (10.85) 2.803 0.005*

Flex/Ext, flexion/extension angle, Lat Flex, lateral flexion angle, Rot, rotation angle, Abd/Add, abduction/adduction angle, Int/Ext Rot, internal/
external rotation angle, Pro/Sup, pronation/supination angle.
*p50.005.
#p50.05.

Table 4. Mean (SD) amplitude of the inactive fingers at 0 and 10 weeks in the control and CO-OP groups.

Control CO-OP
Week 0 Week 10 Z p Week 0 Week 10 Z p
Finger 1 3.41 (1.29) 3.95 (0.54) 1.59 0.112 3.59 (0.21) 3.87 (0.21) 2.52 0.012
Finger 2 3.65 (0.51) 3.88 (0.51) 2.32 0.020 3.57 (0.27) 3.84 (0.27) 2.52 0.012
Finger 3 3.77 (0.61) 4.01 (0.63) 2.32 0.020 3.68 (0.32) 3.95 (0.32) 2.52 0.012
Finger 4 3.73 (0.67) 3.97 (0.66) 2.32 0.020 3.66 (0.37) 3.94 (0.32) 2.52 0.012

clinically significant changes of two points or greater in both participated in the CO-OP intervention, with no change demon-
areas. All children in the CO-OP group showed improvement in strated by the control group. These results suggest that CO-OP
GAS scores from week 0 to week 10, with mean achieved scores intervention has aided the suppression of motor overflow in the
(x64.30, ± 9.66) at week 10 significantly higher than baseline more proximal segments of the body. This is a promising finding,
scores (x40.80, ± 13.71) at week 0 (t(9) ¼ 5.27, p ¼ 0.001). given that previous research into the suppression of motor
overflow in children with DCD found no improvement over an 8-
week training period [35]. This previous intervention program
Discussion
focused on the specific task of running, with an emphasis on
This research aimed to determine if CO-OP intervention approach correcting inefficient movement patterns to decrease impairment.
facilitated improvements across levels of the ICF framework in This is different to the CO-OP approach, where the focus is
children with DCD. Consistent with our hypothesis, children who on utilising a global problem solving method to improve
undertook the 10 week intervention program experienced task performance, rather than concentrating directly on the
improvements in impairment, activity and participation. impairments that limit task performance. Evidence suggests
In terms of impairment, levels of motor overflow (measured by intervention protocols that make use of global problem solving
range of motion of the inactive limb) decreased in children who training strategies are an effective way of remediating
 6 A. Thornton et al. Disabil Rehabil, Early Online: 1–8

improvement at the wrist. Herzog and Durwen surmised that the

more distal muscles are involved in task performance, the greater
the levels of motor overflow produced [36]. It is possible that
while the strategies children in the CO-OP group developed were
successful in suppressing proximal motor overflow, they were not
able to overcome the greater neurological demand placed on
activities that recruited distal muscles, in the time period of the
current intervention. This has potential implications for interven-
tions targeting motor overflow in the future which, based on the
results of this research, should potentially look to longer periods
of intervention in order to address this problem, or generate
strategies around targeting distal segments specifically.
The nature of the cognitive strategies employed by the children
alludes to the underlying issues of DCD and provides insight into
why there were improvements in skills that had been addressed in
the past with little success. Traditional bottom-up approaches,
which target the underlying motor components of performance,
have been documented to be the most effective means of
facilitating functional improvement [4]. Yet if this were the
case, it is likely that the children with DCD would have adopted
Disabil Rehabil Downloaded from informahealthcare.com by 180.216.58.124 on 07/27/15

more strategies based around their body position or feeling the

Figure 1. HST component averages at week 0 and 10 for the control movement. In fact, strategies that enhanced children’s awareness
group and intervention (CO-OP) group. *Significant difference within of the task requirements were used most extensively, which is
group p50.05. consistent with other studies into the effectiveness of CO-OP as
an intervention [37,38]. This suggests that the children’s
difficulties with their chosen skills originated from a lack of
understanding of what steps constituted the task and how to
proceed with these steps. The dominance of the task specification
and modification strategies supports the notion that DCD may in
fact be a motor-based learning problem [19].
For personal use only.

MABC-2 scores did not differ between intervention and

control groups over time. However, when it is taken into account
that the MABC-2 incorporates aspects of movement that were not
in the scope of the intervention, such as balance and aiming and
catching, this may provide some reasoning behind the lack of
improvement. When assessing the individual components of the
MABC-2, there were no differences in manual dexterity scores
between groups over time. This was in contrast to expectations, as
fine motor tasks were the focus during the intervention period.
However, all children chose fine motor goals which involved
improving handwriting speed and legibility. As the tasks
comprising the manual dexterity component of the MABC-2 do
not include a measure of handwriting, it is difficult to draw
comparisons between the two. The MABC-2 tasks have greater
time and performance constraints than other tests of handwriting
proficiency [39] which more accurately emulate how the task is
performed on a daily basis. Handwriting speed and legibility were
Figure 2. Performance and satisfaction ratings of parents and children both found to improve significantly over the intervention period in
in the CO-OP group, based on the COPM at week 0 and week 10. the treatment group, further demonstrating that in this instance,
*p Value50.05. manual dexterity scores in the MABC-2 are not indicative of
handwriting proficiency.
In terms of activity and participation, children in the CO-OP
impairments at an executive level, as they allow a greater intervention group displayed significant changes in performance
understanding of the task requirement. By directing cognitive and satisfaction ratings on the COPM for the goals worked on
attention to the task and asking the individual to identify the key during the intervention period post-treatment, with all individuals
features of their performance, rather than trying to correct reporting changes of two or greater in both areas, the critical unit
technique, transfer of the strategies developed to other tasks [7] is for suggesting a clinically significant change [34]. These changes
more likely to take place. were also seen in parent scores of perceived performance and
Despite improvements in motor overflow presentation in their satisfaction with the outcomes. This provides valuable
proximal segments, there were no improvements made in motor information in terms of child and parent perception of their
overflow presentation in the fingers of the inactive limb, with improvement over the intervention period. While the outcome
movements of the inactive digits increasing marginally. The lack measures employed by this study have provided an objective
of improvement in motor overflow in the fingers suggest an issue measure of this improvement, higher levels of perceived capabil-
with distal inhibition as opposed to proximal, particularly when it ity displayed in the participants of this study have been shown to
is considered that reduced range of motion of the inactive limb provide feelings of empowerment which lead to increased goal
was found predominantly at the shoulder and elbow, with some commitment and confidence to set new goals [40]. Higher
 DOI: 10.3109/09638288.2015.1070298 CO-OP to improve children with DCD 7
perceived levels of capability may also mediate outcomes in a References
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