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

Abstract

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). 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.

Is length of experience an appropriate criterion to identify level of expertise?

“…Second, another means of developing expertise is through professional development (e.g. conferences and workshops) (19,40). Such training helps clinicians to remain current in theory and practice.…”

“…Twenty-nine therapists participated in this study with varying levels of experience, ranging from new graduates to therapists with more than 15 years of experience. Approximately one-third of therapists (38%) had more than five years and 62% had less than five years of experience in this field (40). Based on the work of Rassafiani et al (43), participants made treatment decisions and recorded them as described for Study 1, above.…”

The Clinical Utility of the Comparative Analysis of Performance — Motor (CAP-M) for Children with Cerebral Palsy

“…They reported that this unique feature of the CAP-M assisted them to work through systematically and document their clinical reasoning process. Recent studies have shown that in the area of upper limb hypertonicity management, clinical reasoning is a complex process which is difficult to learn and expertise does not necessarily increase with length of work experience (Rassafiani 2006, Burgess et al 2008. The findings suggest that the CAP-M would therefore be a useful addition to the current upper limb assessments used by both novice and experienced therapists working with children with cerebral palsy.…”

Building Expertise in the Workplace: Occupational Therapists Learning Upper Limb Hypertonicity Practice

“…Previous research has investigated the development of expertise in hypertonicity practice (Burgess et al, 2008;Kuipers & Grice, 2009;Kuipers & McKenna, 2009;Rassafiani, 2009;Rassafiani et al, 2009). Previously, years of experience has commonly been used to identify clinical experts (Rassafiani, 2009).…”