School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT)
Focused Question:
In infants and young children under age 6 years with or at risk for developmental delays,
does occupational therapy, physical therapy, and/or physiotherapy help improve motor
skills?
Prepared By:
Edith Feld and Michelle Versten
School of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89074

Date Review Completed:

September 21, 2015
Clinical Scenario:
Children with developmental delay have difficulty meeting developmental milestones
in one or more of the physical, cognitive, psychosocial, and lingual dimensions. The
disabilities they experience may create barriers that limit their ability to participate in
functional and community activities (Chen, Hwang, Lin, & Lin, 2014). The impairments
that preschoolers with developmental delays may experience limit their abilities to learn
and behave appropriately for their age. Developmental delays can include delayed motor,
cognitive, psychosocial, emotional, and speech language skill acquisition (Murata & Tan,
2009). Of these, delayed motor skill acquisition is most heavily focused on with children
of preschool age because movement is a major avenue through which such young
children learn. Further, a lack of or delay in the development of motor skills sufficient to
engage in daily activities may impair a young childs social skills and self-concept
(Murata & Tan, 2009). Preschool-age children with developmental delays often
experience difficulties with spatial awareness and the use of appropriate motor patterns,

ultimately impacting their ability to participate in age-appropriate occupations, such as

play, and functional daily activities (Murata & Tan, 2009). Therefore, young children
with developmental delays may benefit from motor programs in the context of
occupational therapy, physical therapy, or physiotherapy treatment to facilitate the
development of appropriate motor skills and movement patterns.
Summary of Key Findings:
Summary of Levels I, II and III:
Level I:
Research indicated that occupational therapy, physical therapy, and/or
physiotherapy including motor interventions may be effective at improving
motor skill development in young children with or at risk for developmental
delays. Different types of motor interventions can be utilized within the contexts
of these therapies to produce a wide variety of positive effects. A pediatric
physical therapy intervention program, Coping With and Caring for Infants With
Special Needs (COPCA), which involved at-home physical therapy treatment
with family involvement and caregiver education for 1 hour, twice per week for 3
months, was found to be no more effective in facilitating motor development of
infants at high risk for developmental disorders than traditional infant physical
therapy (TIP), though both interventions showed positive effects (BlauwHospers, Dirks, Hulshof, Bos, & Hadders-Algra, 2011, Level I). A constraintinduced movement therapy (CIMT) program, which involved clinical
occupational therapy treatment once per week for 8 weeks as well as a home
program for 2 hours per day, 6 days per week for 8 weeks, was found to produce
greater improvements in motor function for young children with unilateral
cerebral palsy than a neurodevelopmental treatment (NDT) program, which
involved clinical physiotherapy treatment for 1-2 hours per week for 8 weeks
(Al-Oraibi & Eliasson, 2011, Level I). A movement training program, which
involved caregivers, trained by physical therapists, engaging their infants in
physical interaction with toys during specific activities for 15-20 minutes per
day, 5 days per week for 8 weeks, showed greater increases in the emergence of
reaching in preterm infants than a social training program, which involved
similar caregiver interactions but without the physical interactions with toys
(Heathcock, Lobo, & Galloway, 2008, Level I). Additionally, a perceptualmotor program, which involved 50-minute clinical physical therapy sessions
twice per week for 8 weeks, showed greater increases in sitting postural control
of infants with cerebral palsy than a home program, which involved suggestions
from physical therapists, during 50-minute home visits once per week for 8
weeks, for caregivers to implement handling and positioning techniques with

their infants in daily activities, though both interventions facilitated improved

sitting postural control (Harbourne, Willett, Kyvelidou, Deffeyes, & Stergiou,
2010, Level I).
Level II:
Children who received occupational therapy or physically therapy between the
ages of 9 months and 2 years were able to sit independently and crawl 1 month
later, on average, than the untreated children. In regard to preschool motor skills,
around 70% were likely to perform certain, but not all, motor skills, but the
results for this study were not statistically significant. Providing occupational
therapy or physical therapy during early childhood may improve certain
preschool motor skills in infants born at a very low birth weight (Watkins et al.,
2013, Level II).
Level III:
Implementing adapted video games in occupational therapy treatment for 30
minutes, three times a week for five weeks was effective in improving visualmotor coordination and motor skills development in children with developmental
disabilities (Hsieh, Lin, Chiu, Meng, & Liu, 2015, Level III). Another study
found that preschool children receiving occupational therapy in their education
program during one school year showed improvements in fine motor skills. This
effective program, which occurred weekly for 30 to 45 minutes, focused on inhand manipulation, use of tools, grip strength, and eye-hand coordination. All
outcome areas showed statistically significant improvements except for grip
strength (Case-Smith, 1996, Level III). Children with spastic diplegic cerebral
palsy receiving physical therapy to improve hip abduction range of motion
showed to be effective at the end of treatment. All participants maintained or
increased hip abduction range of motion during the standing program utilized
within the study (Macias-Merlo, Baguar-Calafat, Girabent-Farres, & Stuberg,
2015, Level III).
Summary of Level IV and V:
Level IV:
Implementing combined sensory enhancements and manual assistance once a
week for three weeks in a treadmill training program during physical therapy
treatment proved to be effective for infants with spina bifida and other spinal
conditions. It showed to increase both total steps and alternating steps in the
friction plus load enhanced condition. Manual assistance at the slower speed was
also effective at increasing infant stepping (Moerchen & Hoefakker, 2013, Level

IV). The use of the ZeroG Aretech LLC dynamic system for mobility training
demonstrated the potential to change the course of motor development in infants
and toddlers with cerebral palsy. The results were effective short term following
intervention protocol, but in need of more for the long term (Prosser, Ohlrich,
Curatalo, Alter, & Damiano, 2012, Level IV).
No Level V studies were appraised.
Contributions of Qualitative Studies:
No qualitative studies were appraised.

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT: Use of occupational therapy, physical
therapy, and/or physiotherapy interventions, such as adapted videogames, constraintinduced movement therapy, home positioning and handling programs, treadmill stepping
programs, mobility training programs, and motor programs integrated into the preschool
classroom, may facilitate improved motor skills and the development of appropriate
movement patterns among young children with or at risk for developmental delays.
Program development: Physical therapy, occupational therapy, and/or physiotherapy may
have the capability to improve motor skills of children with developmental delays.
However, more research needs to be conducted in order to determine what type of therapy
interventions would be most effective in the long term and for specific populations. The
reviewed articles examined various forms of therapy interventions. However, the small
sample sizes used in each study, as well as the short-term nature of the studies, make it
difficult to generalize findings to larger populations and confidently implement the most
appropriate interventions into practice. Therefore, with further research to support the
reviewed studies findings, such interventions may potentially be used in the development
of pediatric therapy programs.
Societal Needs: Children with developmental delays may experience limited abilities to
learn and behave appropriately for their age. Developmental delays often negatively
impact a variety of different skills necessary for children to grow, learn, and acquire skills
for daily life. Determining appropriate therapy interventions may positively affect the
young childs development. However, these interventions must also be affordable and
effective in the long term. Based off the reviewed studies, interventions led by caregivers
and/or therapists in a more natural environment, such as in the home or classroom, could

save families money by reducing the need for numerous clinical visits. This could also
promote more compliance long term, which may produce more long-term positive effects
in childrens development.
Healthcare delivery and policy: Because of the small sample size of the reviewed studies,
further research to support their findings is necessary before funding for such programs
can be reasonably requested. However, these preliminary findings may be used to inform
policymakers of the potential benefits of different therapeutic interventions on the motor
skill development of young children with or at risk for developmental delays, as well as
how such interventions can be implemented into occupational therapy, physical therapy,
and/or physiotherapy practice.
Education and training of OT students: Before implementing any type of therapy
interventions, occupational therapy students should be knowledgeable about common
childhood diagnoses and their specific impacts on childrens motor development. In
regards to the interventions, students should be thoroughly educated on the types and
effects of therapy interventions that research has shown to be beneficial for the motor
development of children with varying diagnoses in both the short and long term.
Refinement, revision, and advancement of factual knowledge or theory: The reviewed
studies add to the current knowledge by providing additional support for various
therapeutic interventions in facilitating the development of motor skills and appropriate
movement patterns among young children with or at risk for developmental delays.

Review Process:

Focus question was compiled and approved by professor of OCCT 643.

Numerous databases were searched and seventeen articles were found.
Three articles were found hand searched.
Ten articles were selected for appraisal.
The ten articles matching criteria and relevance of focus question were assessed
on Evidence Table.

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:

Articles written in English

Articles written between years 1996-2015
Articles were levels I-IV
Articles published in a peer-reviewed journal

Articles with available full text

Participants were children ages 0-6 years
Participants had, or were at risk for, developmental disability or delay
Participants received occupational therapy, physical therapy, and/or physiotherapy
Participants motor skills evaluated post-treatment

Exclusion Criteria:

Articles not written in English

Articles written before year 1996
Level V articles
Articles not published in a peer-reviewed journal
Articles without available full text
Participants were over age 6 years
Participants were typically developing children
Participants did not receive any occupational therapy, physical therapy, or
physiotherapy
Participants motor skills were not evaluated post-treatment
Search Strategies:
Categories

Key Search Terms

Patient/Client Population

Preschool*, Preschoolers*, Child*, Children*, Infants,

Infancy, Early Childhood, Developmental Disabilities,
Developmental Delays

Intervention

Therapy, Occupational Therapy

Outcomes

Motor, Motor Skills

Databases and Sites Searched

Hand search, CINAHL, MEDLINE, ERIC, SPORTDiscus, EBSCO
Quality Control/Peer Review Process:
Instructor reviewed PICO question and weekly submissions
Methodological quality was assessed with McMaster forms
Peer-reviewed by checking each others work

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence

Study Design/Methodology of Selected Articles

Number of
Articles Selected

Systematic reviews, meta-analysis, randomized

controlled trials

II

Two groups, nonrandomized studies (e.g., cohort,

case-control)

III

One group, nonrandomized (e.g., before and after,

pretest, and posttest)

IV

Descriptive studies that include analysis of

outcomes (single subject design, case series)

Case reports and expert opinion, which include

narrative literature reviews and consensus
statements

Other

Qualitative Studies

TOTAL:

10

Limitations of the Studies Appraised:

Levels I, II, and III
Level I:
Differences in training intensity between groups, difference in
intervention intensity between treatment groups was apparent, and a small
sample size was used (Al-Oraibi & Eliasson, 2011, Level I)
Limited sample size and differences in frequency and duration between
groups during intervention (Blauw-Hospers et al., 2011, Level I)
Outcome measure used may not be sensitive to small changes within a
participant's skill, small sample size was utilized, study did not control for
practice time or other motor interventions, and differences in skill and
experience among families was apparent (Harbourne et al., 2010, Level
I).

 Infants in the study represented a heterogeneous group and were

characteristically diverse, outcome measures only looked at short-term
effects, and volunteer bias may have been present during recruiting of
subjects (Heathcock et al., 2008, Level I).
Level II:
Intensity and duration of treatments not always determined, participants
environments and participation in other movement programs unknown,
and unbalanced treatment and non-treatment groups (Watkins et al., 2013,
Level II)
Level III:
Purposive sampling was used and no control group nor participant
randomization (Hsieh et al., 2015, Level III)
No control group and the study design prevented ability to identify
specific variables leading to motor skill improvements (Case-Smith,
1996, Level III)
Lack of established reliability of measurements, lack of a control group,
and a small size sample was utilized (Macias-Merlo et al., 2015, Level
III).

Levels IV and V
Level IV:
Small sample size, participants diagnoses and impairments varied in
regards to their spinal condition, and week-to-week variability in infant
behavior was not controllable by averaging data due to the withinsubjects design of the study (Moerchen & Hoefakker, 2013, Level IV).
Small sample size and no control group was utilized (Prosser et al., 2012,
Level IV).
No Level V studies appraised

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Articles Selected for Appraisal:

Al-Oraibi, S., & Eliasson, A. C. (2011). Implementation of constraint-induced movement
therapy for young children with unilateral cerebral palsy in Jordan: A home-based
model. Disability and Rehabilitation, 33(21-22), 2006-2012.
doi:10.3109/09638288.2011.555594
Blauw-Hospers, C. H., Dirks, T., Hulshof, L. J., Bos, A. F., & Hadders-Algra, M. (2011).
Pediatric physical therapy in infancy: From nightmare to dream? A two-arm
randomized trial. Physical Therapy, 91(9), 1323-1338. doi:10.2522/ptj.20100205
Case-Smith, J. (1996). Fine motor outcomes in preschool children who receive
occupational therapy services. The American Journal of Occupational Therapy,
50(1), 52-61. doi:10.5014/ajot.50.1.52
Harbourne, R. T., Willett, S., Kyvelidou, A., Deffeyes, J., & Stergiou, N. (2010). A
comparison of interventions for children with cerebral palsy to improve sitting
postural control: A clinical trial. Physical Therapy, 90(12), 1881-1898.
doi:10.2522/ptj.2010132
Heathcock, J. C., Lobo, M., & Galloway, J. C. (2008). Movement training advances the
emergence of reaching in infants born at less than 33 weeks of gestational age: A
randomized clinical trial. Physical Therapy, 88(3), 310-322.
doi:10.2522/ptj.20070145
Hsieh, H.-C., Lin, H.-Y., Chiu, W.-H., Meng, L. F., & Liu, C. K. (2015). Upper-limb
rehabilitation with adaptive video games for preschool children with
developmental disabilities. American Journal of Occupational Therapy, 69,
6904290020. http://dx.doi.org/10.5014/ajot.2015.014480
Macias-Merlo, L., Bagur-Calafat, C., Girabent-Farrs, M., & Stuberg, W. A. (2015).
Standing programs to promote hip flexibility in children with spastic diplegic
cerebral palsy. Pediatric Physical Therapy, 27(3), 243-249.
doi:10.1097/PEP.0000000000000150
Moerchen, V. A., & Hoefakker, H. L. (2013). Infants with spina bifida: Immediate
responses to contextual and manual sensory augmentation during treadmill
stepping. Pediatric Physical Therapy, 25(1), 36-45.
doi:10.1097/PEP.0b013e31827a7533
Prosser, L. A., Ohlrich, L. B., Curatalo, L. A., Alter, K. E., & Damiano, D. L. (2012).
Feasibility and preliminary effectiveness of a novel mobility training intervention in
infants and toddlers with cerebral palsy. Developmental Neurorehabilitation, 15(4),
259-266. doi:10.3109/17518423.2012.687782
Watkins, S., Jonsson-Funk, M., Brookhart, M. A., Rosenberg, S. A., OShea, T. M., &
Daniels, J. (2013). Preschool motor skills following physical and occupational

therapy services among non-disabled very low birth weight children. Maternal and
Child Health Journal, 18(4), 821-828. doi:10.1007/s10995-013-1306-x

Other References:
Chen, C.-N., Hwang, A.-W., Lin, S.-Y., & Lin, Y.-C. (2014). Initiation of movement and energy
expenditure in children with developmental delay: A case-control study. Physical
Therapy, 94(10), 1434-1442. doi:10.2522/ptj.20130443
Murata, N. M., & Tan, C. A. (2009). Collaborative teaching of motor skills for preschoolers
with developmental delays. Early Childhood Education Journal, 36(6), 483-489.
doi:10.1007/s10643-007-0212-5

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05