1 Running head: ARTICLE

Article Critique Kelly Garcia Touro University Nevada

2 ARTICLE Article Critique Introduction In the following pages, a study conducted about the effectiveness of two treatment interventions for children with cerebral palsy (CP) will be discussed. Cerebral palsy is a medical condition involving damage or an abnormal development of areas of the brain, resulting in a series of complications, such as motor disorders, cognitive delays, and speech delays (Crepeau, Cohn, & Schell, 2009). The two treatment interventions being examined in this study are context-focused and child-focused. As described by Law et al. (2010) in their article Focus on function: a cluster, randomized controlled trial comparing child-versus context-focused intervention for young children with cerebral palsy, a context-focused approach focuses on changing factors in the childs environment while child-focused approach focuses on changing factors with in the child. This study was conducted over a period of 9 months and included physical and occupational therapists. The results of the study, how it was carried out, and what the researchers concluded, will be discussed in further detail throughout the paper. Merit The research question presented in the article Focus on function: a cluster randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy is pressing because it is investigating an emerging treatment method that could potentially improve the development of children with cerebral palsy (Law et al., 2010, p.622). The emerging treatment that the researchers are referring to is the context-focused intervention. Although the results of this study may not be pressing for people who do not have children with CP, it is definitely pressing to the families and parents who have children with CP, because the results could give health care professionals more information about a better treatment

3 ARTICLE intervention. It is also pressing because depending on the results of the study and if a treatment intervention proved to be significantly more effective than the other treatment, then the principles of that treatment can be applied to other populations at risk. As mentioned previously, the research question is novel because it is looking at a relatively new treatment intervention: context-focused. This particular treatment intervention is based on the dynamic systems theory, which challenges traditional treatment perspectives in that it does not focus on the remediation of movement components (Law et al., 2010, p. 622). As explained by the researchers, there is limited research out there on context-focused related interventions (Law et al., 2010). In other words, this study is novel in the sense that it is exploring an area of research that is currently limited. The research question is feasible because the researchers are not seeking to study anything that is impossible to obtain. For example, the researchers need children who have been diagnosed with cerebral palsy and they need therapists who are willing to provide treatment to the children. This means that they can obtain their sample from various settings, such as pediatric and rehabilitation clinics, without many problems. The researchers can also obtain their results in a feasible time frame of nine months without the costs being excessive. Furthermore, the research question is ethical because the researchers are not putting participants in danger or depriving them of appropriate medical treatment. They are simply comparing a traditional treatment (child-focused) to an emerging treatment (context-focused) and determining which children showed a better improvement. In general, the research question is interesting because it is investigating a relatively novel intervention. The fact that there is not much information on the effectiveness of the treatment makes it exciting to learn about. Clarity

4 ARTICLE The research question of this study is clearly stated from the beginning of the article. The researchers want to find out how effective a child-focused intervention is versus a contextfocused intervention on improving performance of functional tasks and mobility in young children with cerebral palsy (Law et al., 2010, p. 621). The research question is clear in what it purports to measure, which is how the children in the study improve in the selected criteria chosen by the researchers (performance and mobility). It is also clear on what the treatment interventions are (child-focused and context-focused), and for who the treatment interventions are aimed to help (children with cerebral palsy). However, the research hypothesis is not clearly stated. In other words, whether the researchers expect for the child-focused or context-focused intervention to yield better results is implied. The reader must read beyond the abstract and read carefully into the introduction of the article to establish the directionality of the research hypothesis. Due to the fact that the researchers discuss the child-focused intervention as a traditional way of practitioners treating patients and the context-focused intervention as newer under-researched intervention, it can be concluded that the researchers expect the contextfocused intervention will yield better results than the child-focused intervention. Research Design A true experimental, randomized controlled trial cluster research design was utilized to answer the research question. The independent variable being studied is the treatment intervention, whether child- or context-focused, and the dependent variable is the level of improvement. The studys control group consisted of 79 participants being allocated to receive the child-focused intervention and the experimental group consisted of 67 participants being allocated to receive the context-focused intervention. The researchers in the study recruited participants by using a purposive, non-randomized cluster sampling method. They obtained their

5 ARTICLE sampling frame from 19 children rehabilitation clinics in Canada and then they mailed out recruitment packages. Before the recruitment packages were mailed, an assessment for eligibility was conducted. A total of 486 recruitment packages were mailed out to the families of children with cerebral palsy and 209 recruitment packages were mailed back. Of the 209 recruitment packages received, only 146 were enrolled. A total of 63 potential participants were excluded by the researchers, 26 refused to participate, and 26 did not participate due to other reasons. This sampling method was purposive because of the inclusion and exclusion criteria that the researchers used to create their sample. For example, if the children had planned surgical or medication changes during the 6-month study period that might have affected [their] motor function they were excluded (Law et al., 2010, p. 623). As for inclusion criteria, the children could be at any level of the Gross Motor Function Classification System (GMFCS) (Law et al., 2010). To determine which children were going to be placed in the experimental and the control group, random assignment was used. This was conducted by the research coordinator who first randomized all of the therapists participating in the study to a treatment group. Then the children followed their assigned therapist into the corresponding treatment group. Depending on which treatment group the therapists were assigned, they were provided with training on the appropriate protocols to follow. A true experimental design was the best research design that the researchers could have chosen to answer their research question. For starters, the fact that they used random assignment to assign participants to the treatment groups helped limit and weaken the threats to internal validity. Also, the way that they randomly assigned participants to a treatment group was appropriate because it prevented the therapists from having any type of ethical or moral conflicts. For example, the therapists were not faced with the concern of having to offer one participant a

6 ARTICLE certain type of treatment and another participant another type of treatment. Another research design, such as a quasi-experimental design, would not have worked because the child-focused and context-focused approaches are not typically found in any type of setting isolated; however this also presents a major limitation to this study. Although the researchers used a true experimental research design, the fact that the treatment interventions being studied are not typically found in other settings limits the generalizability of the study. This is a limitation of the study due in large part to the research question itself. Additionally, the choice of the studys research design is somewhat flawed because it lacks random sampling, which can significantly affect the studys internal validity. Perhaps if they had used a randomized cluster sampling method instead, the threats to internal validity could have been further minimized. Execution of Research Design The researchers executed this research design over a time frame of 9 months. The first 6 months consisted of the participants receiving the treatment intervention and the remaining three months consisted of the participants returning to their regular treatment sessions. Throughout these 6 months only 63 participants received the context-focused intervention and 73 received the child-focused intervention. The difference in numbers between the participants who were initially allocated to receive the intervention and those who actually received the intervention, were due to factors, such as family choice, child health issue, lost contact, and not feasible (Law et al., 2010, p. 623). During the follow up assessment conducted by researchers at 9 months, only 57 participants were analyzed in the context-focused group and 71 in the childfocused group. This was caused by the interval validity threats of attrition and mortality. Unfortunately, a couple of participants died throughout the length of the study, three participants did not continue due to the choice of the family, two participants withdrew due to health issues,

7 ARTICLE and one lost contact with the researchers. Due to the attrition and mortality factors the study faced, the researchers could have limited the follow up assessment of 9 months closer to the 6 month intervention period. Another component of the execution of the research design was how the researchers prepared the therapists to provide context-focused or child-focused interventions to their participants. According to the researchers, the therapists received one and a half days of training and were subject to continuing expert consultation throughout the study (Law et al., 2010, p. 624). Although the therapists were trained one and half days, the researchers could have expanded their training or stuck with one profession, either physical therapy or occupational therapy, to eliminate any biases from the therapists or differences in outcomes due to the professions. Data Collection Procedures and Implementation In order to determine the degree to which participants improved performance on functional tasks and mobility, the researchers conducted pre- and post-test measures of participants using the Pediatric Evaluation of Disability Inventory (PEDI) and the Gross Motor Function Measure (GMFM-66). They conducted these assessments before the children received the intervention, at the 6 month period when they stopped receiving the intervention, and at the 9 month follow up when they returned to their regular treatment. It is important to mention that these outcome assessments were conducted by seven trained evaluators, who were not told the treatment allocation of the participants they were assessing. Furthermore, the evaluators also assessed participants hip abduction range of motion (ROM), popliteal angle, and ankle dorsiflexion at a 3 month interval to make sure that the children in the context-focused treatment were not at risk for decreased range of motion (Law et al., 2010, p. 624).

8 ARTICLE The researchers used appropriate data collection techniques to measure the participants performance on functional tasks and mobility. They made sure that their study was ethical by conducting an additional assessment of participants at the 3 month interval to ensure that the children receiving the context-focused intervention were not at a disadvantage. Their allotted time frames for the measurement assessments were also appropriate considering the length of the study. Using trained evaluators, independent from the study, eliminates any possible threats to external validity, such as experimenter biases. Keeping the evaluators from knowing the treatment intervention that the children are receiving also prevents any biases from the evaluators themselves. Statistical Analysis The researchers used two types of statistical analysis to analyze their findings: descriptive and inferential statistics. Descriptive statistics were utilized to describe the study sample and to organize the demographic information. The demographics included, gender, the participants level on the GMFCS (I, II, III, IV, or V), age, parental education, and therapy sessions received during the study. Measurements of central tendency, such as the mean, and measurements of variability, such as percentages and standard deviations, were calculated for the demographic variables. The study does not clearly state what specific inferential statistical test was used to analyze the data; however, due to the categorical variables of time and treatment being discussed, the researchers indicate that a non-parametrical Chi-Square statistical test was utilized to interpret the findings. The researchers also evaluated the difference between means for the context-based intervention and the client focused-intervention to determine the effect of the

9 ARTICLE intervention on the participants (Law, et al., 2010, p. 624). A Pearsons x2 test with Yates continuity correction was used to determine the p-value of certain variables, such as gender. These particular approaches were used for analyzing the data because the researchers wanted to determine if there was a difference in the change scores obtained from the experimental and control group. In order for this to happen, the researchers had to first organize the study sample (descriptive statistics). Then they had to use inferential statistics to determine if they can draw conclusions about the population of interest based on the studys sample. A ChiSquare statistical test was used because the researchers wanted to determine the relationship between the categorical variables being studied. Interpretation of Findings The results of the descriptive statistics stated the demographic information of the studys sample. For example, there were 50 males and 21 females in the child-focused treatment group and there were 29 males and 28 females in the context-focused treatment group. According to the researchers, the differences between participants in regards to their level of GFMFCS, their parents education, or their parents income were not significant. The results from the descriptive statistics also gave information about the number therapy sessions each treatment group received. The child-focused intervention received an average of 18.7 therapy sessions and the context-focused group received an average of 17.7 therapy sessions (Law et al., 2010). As for the inferential statistics, the researchers concluded that both treatment interventions, the child-focused and context-focused, significantly helped the participants improve in the areas measured. However, the results of the statistical analysis demonstrated that there were no significant differences between the child-focused and context-focused groups on the various assessment measurements utilized by the researchers (e.g. PEDI and GMFCS). In

10 ARTICLE other words, the participants in both treatment groups showed improvement, but it cannot be concluded that one group showed more improvement than the other due to the type of treatment intervention that they were receiving. The researchers did notice a small, but significant difference between the scores of the child-focused and context-focused treatment group on the PEDI Caregiver Mobility Scale. This difference was only prevalent when analyzing and comparing the scores at the 6 month and the 9 month assessment. The researchers noticed that the scores for the participants in the child-focused group increased, while they decreased for the participants in the context-focused group. The researchers further explain that the change in scores could be due to the fact that during the 6 and 9 month assessment period the participants went back to their regular treatment regimens, in which they received less therapy sessions than when they were in the study. It is clear that throughout the article the researchers were honest and remained objective in their findings. They accepted their null hypothesis of the context-focused group not producing better results than the child-focused group. They also discussed the small significant finding that their results produced and explained how further research needs to be done to investigate their findings. However, they only mentioned one limitation to their study which was that their results cannot be generalized to the population of interest. As previously mentioned in this paper, both the context-focused and child-focused interventions are not typically found isolated in rehabilitation settings like they were in this study. There are other weaknesses to their study, such as the fact that several participants dropped out of the study and the therapists providing treatment only received one and half days of training. The therapists were also a mixture of physical and occupational therapists, which could have affected the results of the study. Conclusion

11 ARTICLE Focus on function: a cluster randomized controlled trial comparing child-versus contextfocused intervention for young children with cerebral palsy is an article that discusses the effectiveness of a child-focused and a context-focused intervention for children with cerebral palsy. Although the results of the study concluded that both treatment interventions are equally effective, it provides insightful information about what can make therapy successful. For example, it teaches healthcare professionals that a combination of both child-focused and context-focused treatments can helps patients during therapy. It also creates an opportunity for new research to be done about the benefits of the amount of therapy sessions patients receive. In general, the article was informative and interesting. As a future health care practitioner I can use what I have learned in this article and apply it to my future practice by creating treatments that are client-centered and take into account the clients environment.

12 ARTICLE References Crepeau, E.B., Cohn, E.S., & Boyt Schell, B.A. (2009). Willard & Spackmans Occupational Therapy (11th ed). Philadelphia: Lippincott Williams & Wilkins. Law, M. C., Darrah, J., Pollock, N., Wilson, B., Russell, D., Walter, S. D., Rosenbaum, P., et al. (2011). Focus on function: a cluster, randomized controlled trial comparing child-versus context-focused intervention for young children with cerebral palsy. Developmental Medicine and Child neurology. (53) 7, 621-629.