MOTOR IMPAIRMENTS, ACTIVITY LIMITATIONS AND PARTICIPATION
RESTRICTIONS AFFECTING CHILDREN WITH DEVELOPMENTAL
COORDINATION DISORDER: A SYSTEMATIC REVIEW
JULY 23 2009
Paul Conzatti, Lawren De Marchi, Aylee Fox, Jordan Monks & Jonathan YiuSupervisor: Jill Zwicker
Presentation Outline
1. Introduction2. Methods3. Results4. Discussion5. Limitations6. Conclusion and Implications7. Acknowledgements
Introduction
Developmental Coordination Disorder
Definition: A motor skill disorder characterized by a marked impairment in the
development of motor coordination abilities that significantly interferes with performance of daily activities and/or academic achievement1
DSM-IV Diagnostic Criteria1:
1. Marked impairment in development of motor coordination2. Interference with academic achievement or activities of daily living3. Coordination difficulties not due to a general medical condition or a
pervasive developmental disorder4. If mental retardation is present, motor difficulties in excess of those
expected
Developmental Coordination Disorder
Pathophysiology: Unclear No hard neurological signs are present2
Deficit may lie within the cerebellum3
Signs and Symptoms: Work at a slower pace, trading speed for accuracy4
Deficient at processing kinesthetic information but not visual information Rely more on visual cues as opposed to proprioception5
Difficulty maintaining postural stability6
Deficits contribute to repeated failures, which can cause avoidance of physical activities and socializing with peers7
International Classification of Functioning, Disability and Health (ICF)8
Framework for the description of health and health-related states8
Structures the assessment of children with complex conditions
Holistic approach to the individual9
Health and health-related characteristics are described from the perspective of8,9:
1. Body Functions and Structures Physiological and psychological functions of body systems
2. Activities Whole body activities or tasks
3. Participation Involvement in a life situation
International Classification of Functioning, Disability and Health (ICF)8
WHO, 2007
Literature Review and Rationale
Prevalence: 6-13% of school aged children display characteristics consistent with DCD children10
Physiotherapy intervention: Motor impairment changes can occur7
Focus on impairments at BFS level A more significant role can be played at the activity and participation levels 7
Are the foci of physiotherapy interventions a reflection of current literature?
No systematic review exists with the purpose of summarizing available literature regarding the presentation of DCD using a
structured framework such as the ICF
Question
What motor impairments, activity limitations and participation restrictions are common in children with Developmental Coordination Disorder?
Purpose
1. Summarize the existing literature to produce a comprehensive list of characteristics of children with DCD
2. Classify the motor impairments, activity limitations and participation restrictions affecting children with DCD according to the ICF framework
3. Highlight gaps in the research regarding the presentation of children with DCD in order to direct future investigations
Methods
Search Strategy
Comprehensive literature searches: MEDLINE, EMBASE, CINAHL, PEDro, PsychINFO, OTseeker and ERIC
Examples of Primary MeSH term: “developmental coordination disorder” “motor skills disorder” “motor performance” “motor dysfunction” “developmental disorder”
Examples of Secondary terms relating to the ICF: “body functions and structures” “activity” “participation”
Study Selection: Inclusion
Study types: Systematic reviews Randomized control trials Clinical controlled trials Cohort comparisons Case studies Pilot studies
Intervention and Descriptive studies: If baseline outcome measures could be classified as a
characteristic of children with DCD
Study Selection: Inclusion
English language
Published post 1994 Year which the nomenclature of DCD was standardized 11
Subjects: Both male and female Aged 2-18 DSM-IV diagnosed for DCD
Study Selection: Exclusion
Study types: Books Narrative reviews Theses Dissertations Letters to the editor Commentaries
Subjects: Participants with other significant neurological disorders,
medical disorders or intellectual disabilities Exception of those diagnosed with Attention Deficit
Hyperactivity Disorder (ADHD) or Learning Disability (LD) in conjunction with DCD
Potentially relevant citations retrieved from electronic literature search (n = 4250)
Abstracts put forward to review (n = 1002)
Full-text articles put forward to review (n = 278)
Studies included in systematic review (n = 27)
Citations excluded based on inclusion and exclusion criteria (n = 3248)
Abstracts excluded based on inclusion and exclusion criteria (n = 633)
Additional abstracts were excluded because publication dates prior to the year 1994, the official year that DCD was defined by the DSM IV (n = 101)
Studies excluded after full-text review (n = 199)
Additional studies were excluded as the participants were not DCD diagnosed using the DSM IV criteria (n = 52)
Figure 1. Flow Chart
Results
StudyStudy
Quality ( /6)
Study DesignAge Range or Mean
(SD) Sample Size DCD (N) Control (N)
Outcome Measure
BODY FUNCTIONS & STRUCTURES
Cherng et al. (2007) 2 Cohort
comparisonDCD: 5.5 (0.9)y
Control: 5.4 (0.9)y 20 20 COP sway area
de Castelnau et al. (2007) 2 Cohort
comparison 8-13y 24 60
Continuous Performance Test &Synchronization – Syncopation Test
ACTIVITIES & PARTICIPATION
Astill (2007) 2 Cohort comparison 8.6 (1.0)y
5 (7-8y)5 (9-10y)
5 (7-8y)5 (9-10y)
Ball catching scale
Cantin et al. (2007) 2 Cohort
comparisonDCD:9.1 (1.2)y
Control: 10.0 (1.3)y 9 11 PAT
Table 1. Example of Description of Studies
Results
27 included studies
19 at the Body Functions and Structures (BFS) level 9 at the Activity and Participation levels
Amalgamated due to high degree of overlap
1 study was classified under both Body Functions and Structures and Activity and Participation
Results
3 Qualitative studies
Related to the Activities and Participation level Unable to be subcategorized based on the ICF criteria Not included in the Results (Table 2)
Reviewed in Discussion
Results
ICF subcategories Some studies fall within 2 subcategories
Body Functions and Structures level: 12 at Neuromusculoskeletal and Movement related
Functions 6 at Sensory Functions and Pain 8 at Mental Functions 1 at Functions of the Heart and Respiration
Results
Activity and Participation level: 4 at Functions of Mobility 3 at Functions of Self Care 2 at Community Social and Civic Life 1 at Learning and Applying Knowledge 1 at General Tasks and Demands
Representation of Included Studies Based on ICF Classification
0
2
4
6
8
10
12
14
Nu
mb
er
of
Stu
die
s
Body Functions and Structures
Activities and Participation
Qualitative Studies
Figure 2. Included Studies Based on ICF Classification
Study ICF ClassificationSample Size
DCD (N) Control (N)Measure Variable
DCD OutcomesMean (SD)
Control OutcomesMean (SD)
BODY FUNCTIONS & STRUCTURESCherng et al. (2007)
Sensory functions and pain Hearing and vestibular functionsSeeing and related functions
20 20 Centre of Pressure Sway Area
1. Eyes open, fixed foot support (mm)2. Eyes closed, fixed foot support (mm)3. Unreliable vision, fixed foot support (mm)4. Eyes open, compliant foot support (mm)5. Eyes closed, compliant foot support (mm)6. Unreliable vision, compliant foot support (mm)
1. 668.95 (383.15)**2. 1051.07 (1001.09)**3. 755.15 (462.57)**4. 2136.29 (1881.96)**5. 3786.88 (3705.17)**6. 2616.69 (1413.57)**
1. 381.84 (234.11)**2. 437.85 (180.65)**3. 431.15 (158.95)**4. 781.04 (520.84)**5. 1414.92 (790.61)**6. 1413.89 (1056.98)**
ACTIVITIES & PARTICIPATIONCantin et al. (2007)
Mobility Carrying, moving and handling objects
9 11 Prism Adaptation Test
1. Baseline throwing accuracy (cm)2. Performance coefficient (PC) (cm): 3. After-adaptation affect (yes or no) 4. Adaptation prism phase (throws)5. Adaptation after prism phase (throws)
1. 30.0 (8.2)*2. 17.8 (6.7)**3. 7 yes, 2 no4. 10.4 (8.9)5. 10.3 (8.2)
1. 15.7 (5.1)*2. 8.2 (2.5)**3. 11 yes4. 9.8 (5.2) 5. 8.0 (4.1)
Table 2. Example of Study Outcomes
Discussion
Discussion
What motor impairments, activity limitations and participation restrictions are common in children with Developmental Coordination Disorder?
• Neuromusculosketetal and Movement Related Functions• Mental Functions• Sensory Functions and Pain• Functions of the cardiovascular, haematological, immunological
and respiratory systems
Body Functions and Structures
BFS: Neuromusculosketelal and Movements Related Functions
Ball catching tasks12,13
2 studies Video analysis of ball catching strategy Positions of the fingers and wrist Trajectory of the ball and velocity Acceleration values of limbs during catch
Results: Different and unstable catching profile compared to controls13
Slower moment of completion, smaller max hand aperture, slower max closing velocity12
Analysis: Children with DCD have multiple deficits that contribute to problems with
purposeful motor tasks
BFS: Neuromusculosketelal and Movements Related Functions
Movement Duration during Motor Tasks 3 studies14-16
Measured time to complete pointing tasks
Results: 2 out of 3 studies showed significantly slower movement duration in
DCD children compared to controls All 3 showed significantly slower imagined movement times (discussed
in mental functions)
Analysis: Suggests that children with DCD have slower movement duration
Involuntary Movement Functions3,17
2 studies Timing and amplitude of postural activity using a force plate EMG activity of postural muscles
Results: Significant slower onset of postural muscles17
Prolonged onset of postural activity with varied weight lifting3
Analysis: Confirmed deficits in involuntary movement functions (postural control)
BFS: Neuromusculosketelal and Movements Related Functions
BFS: Neuromusculosketelal and Movements Related Functions
Coordination Task18
1 study Clapping and marching task to a metronome beat: timing deviation
between limbs
Results: Significant difference in variability of relative phasing between DCD and
controls
Analysis: Children with DCD have difficulties with both the coordination and control
of the perception-action coupling of this task
BFS: Neuromusculosketelal and Movements Related Functions
Standardized Assessment Tools19,20
2 studies Measures of motor performance
Neurodevelopmental Physiotherapy Assessment (NDPA) Movement Assessment Battery for Children (MABC)
Results: Children with DCD scored significantly poorer than control children in both
measures Deficits listed in the analysis were found in 95% of subjects
Analysis: DCD children displayed deficits in gross and fine motor skills,
proprioception, stability, balance, postural control, tactile sense and motor planning 20
BFS: Mental Functions
Perceived Competence 3 studies19-21
Perceived Motor Competence Scale Pictorial Scale of Perceived Competence and Social Acceptance
Results: 2 of 3 studies found no significant deficits in self perceived competence in DCD
children 1 study did not compare data to controls, therefore conclusions unable to be
drawn
Analysis: Although children with DCD have deficits in several areas of function including
motor skills, they may not have an accurate self-perception of these deficits
BFS: Mental Functions
Imagined Movements and Sequences14-16
3 studies Timing of imagined movements during pointing tasks
Results: Magnitude of slowing between real and imagined movements was not
proportional DCD children did not demonstrate variance with imagined movement
amongst varying target width compared to controls who did show variance
Analysis: DCD children have an inability to generate internal representations of
volitional movements
BFS: Mental Functions
Attentional Tasks22,23
2 studies COVAT (Covert orienting of visuo-spatial attention task): Measured
reaction time Continuous Performance Test: Measured % of correct responses
Results: Although 1 study found significantly slower reaction times in DCD children
compared to controls, the other study did not find a significant difference
Analysis: Inconclusive evidence that children with DCD have deficits in attentional
tasks
BFS: Sensory Functions and Pain
Postural Control and Balance3,24-28
6 studies Center of pressure sway area Postural Sway
Results: All studies found deficits in postural stability 3 studies found increased deficits under conditions where vestibular input
was relied upon
Analysis: Children with DCD have problems with postural adaptations to different
movements and sensory conditions
BFS: Functions of the Cardiovascular, Haematological, Immunological and Respiratory systems
Ventilatory Function19
1 study Forced Vital Capacity (FVC)
Results: Found DCD children to have a mean FVC at the lower end of
normal range for their age and height
Analysis: No clear conclusions can be made about the cardiovascular
fitness of DCD children from this single study
• Mobility• Community Social and Civic Life• Self Care• Learning and Applying Knowledge• General Tasks and Demands
Activity and Participation
Activity and Participation: Mobility
Ball Handling Skills29,30
2 studies Catching and throwing
Results: Decreased completed catches, catching accuracy and score on catching
scale in children with DCD
Analysis: DCD children had significant impairments in ball handling skills compared
to controls Correlates with the BFS findings Children with DCD have motor impairments that result in difficulties with
activities such as ball catching and throwing
Activity and Participation: Mobility
Perceived Efficacy and Goal Setting31,32
2 studies PEGS (Perceived Efficacy and Goal Setting)
Perceived efficacy in different activities related to mobility31
COPM (Canadian Occupational Performance Measure) Identification of client-centered goals32
Activity and Participation: Mobility
Results: Areas of concern identified by both children and parents/teachers
Pencil skills Gross motor function/sports Academic/school activities
Identified goals related to: Mobility (carrying, moving and handling of objects)
Printing, Lego™, cutting, colouring
Analysis: Scores were not compared with controls, however, these scores can
be used to identify areas needing improvement and future goals
Activity and Participation: Community Social and Civic Life
Perceived Self Efficacy31,32
2 studies PEGS
Perceived efficacy in different activities related to recreation and leisure COPM
Identification of client-centered goals
Results: Goals included leisure activities:
Soccer, biking, basketball
Analysis: Scores were not compared with controls, however, these scores can be used to identify
areas needing improvement and future goals
Activity and Participation: Self Care
3 studies20,31,32
PEGS: Multiple activities related to self care COPM: Identification of client centered goals PEDI (Pediatric Evaluation of Disability Inventory): Participation in
Activities of Daily Living
Results: Children with DCD showed significantly lower mean functional self-care
skills than the normative mean20
Fine manipulation skills Organizing and sequencing of functional tasks such as dressing,
grooming and bathing
Analysis: Motor deficits at the BFS level affect activities of self care
Activity and Participation: Learning and Applying Knowledge
Copying Task33
1 study ActiveCube System
Similarity (copying) task
Results: Child with DCD had significant difficulty with copying task compared to
control
Analysis: Study only contained 3 DCD and 3 controls; however, only reported data for
1 DCD and 1 control, therefore conclusions are unable to be drawn
Activity and Participation: General Tasks and Demands
Time to Complete Copying Task33
1 study ActiveCube System
Time to complete task
Results: DCD child took less time than the control child
However, the DCD child only completed 3 of the 6 steps required to fully complete the task
Analysis: Few conclusions can be drawn regarding this study due to the lack
of available data, small sample size and lack of related studies
Qualitative Studies
Qualitative Studies
3 studies34-36
Not subcategorized according to the levels of the ICF
1 study Qualitative interviews with parents of children with DCD
Aimed at studying the importance of participation Results:
DCD children experience motor-based activity restrictions Analysis:
Far-reaching negative consequences on the children’s Activity and Participation
Parents felt that treatments aimed at Activity and Participation were necessary for the management of their child’s disorder
Qualitative Studies
Gross motor skills: Ball skills Balance Hopping Skipping Running Biking
Fine motor skills: Writing Drawing Dressing and tying
shoelaces
2 multiple case studies Investigated effectiveness of specific interventions for treatment of DCD Results:
Baseline evaluations demonstrated problems with gross and fine motor skills, low self-esteem and decreased confidence in their own abilities
Analysis: Motor deficits at the Body Functions and Structures level affect Activities and
Participation
Limitations
Limitations
1. Heterogeneity of DCD population and studies Wide variety of deficits well documented in the literature Numerous outcome measures used in application of
assessing children with DCD Diversity challenges ability to compare individual studies
2. Articles published prior to 1994 excluded Earlier articles may still provide valuable data despite the
differing terminology
3. Studies excluded if diagnostic criteria did not indicate DSM-IV diagnosis Other valid forms of diagnosing DCD children
4. Absence of a grey literature search Appropriate studies may have been overlooked
5. ICF amalgamates the Activity and Participation categories due to high degree of association Presents a limitation when assessing children with DCD
Generalizes their deficits
Limitations
Conclusion and Implications
Body Functions and Structures Impairments
Neuromusculoskeletal and movement related functions
Ball catchingOnset of postural musclesCoordination? Movement duration
Sensory functions and pain BalancePostural control
Mental functionsPerceived competenceImagined movements? Reaction time during attentional tasks
Functions of the heart and respiration ? Fitness
Activities and Participation Impairments
Functions of mobilityBall handling skillsPencil skills, Gross motor function, Academic activities
Functions of self care Fine motor manipulationDressing, Grooming, Bathing
Community social and civic life Soccer, Basketball, BikingLearning and applying knowledge Copying tasksGeneral tasks and demands No conclusive data
Qualitative studies
Gross and fine motor skills (Hopping, Skipping, Running, Biking)Low self esteemDecreased confidence in abilities
Figure 3. Impairments Based on ICF Classification
Conclusion
Body Functions and Structures level Impairments in various motor skills Vast majority of the studies at this level
Activity and Participation level Motor deficits impact activity and participation
Nature and magnitude of impacts remain unclear
This review highlights that current research is focused to impairments at the Body Functions and Structures level,
thereby, under-representing the Activity and Participation level
Implications
Vital for physiotherapists to consider all levels of the ICF Improve function and health related quality of life when activity
and participation are the foci of treatment7
This Systematic Review can help inform assessments and treatments of children with DCD Provides a more structured, holistic picture of the DCD child Future research needed using ICF model to guide physiotherapy
practice
• Supervisor• Ms. Jill Zwicker
• UBC Faculty Members• Dr. Darlene Reid• Dr. Elizabeth Dean
• UBC Librarian• Ms. Charlotte Beck
Acknowledgments
References
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13. Utley A, Astill SL. Developmental sequences of two-handed catching: how do children with and without developmental coordination disorder differ?. Physiotherapy Theory & Practice 2007 Mar-Apr;23(2):65-82.
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17. Johnston LM, Burns YR, Brauer SG, Richardson CA. Differences in postural control and movement performance during goal directed reaching in children with developmental coordination disorder. Human Movement Science 2002 Dec;21(5-6):583-601.
18. Whitall J, Getchell N, McMenamin S, Horn C, Wilms-Floet A, Clark JE. Perception-action coupling in children with and without DCD: Frequency locking between task-relevant auditory signals and motor responses in a dual-motor task. Child: Care, Health & Development 2006 Nov;32(6):679-692.
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19. Peters JM, Wright AM. Development and evaluation of a group physical activity programme for children with developmental co-ordination disorder: An interdisciplinary approach. Physiotherapy Theory and Practice 1999;15(4):203-216.
20. Rodger S, Watter P, Marinac J, Woodyatt G, Ziviani J, Ozanne A. Assessment of children with Developmental Coordination Disorder (DCD): motor, functional, self-efficacy and communication abilities. NZ J PHYSIOTHER 2007 11;35(3):99-109.
21. Pless M, Carlsson M, Sundelin C, Persson K. Pre-school children with developmental co-ordination disorder: Self-perceived competence and group motor skill intervention. Acta Paediatrica, International Journal of Paediatrics 2001;90(5):532-538.
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29. Astill S. Can children with developmental coordination disorder adapt to task constraints when catching two-handed?. Disability & Rehabilitation 2007 Jan 15;29(1):57-67.
30. Cantin N, Polatajko HJ, Thach WT, Jaglal S. Developmental coordination disorder: exploration of a cerebellar hypothesis. Human Movement Science 2007 Jun;26(3):491-509.
31. Dunford C, Missiuna C, Street E, Sibert J. Children's perceptions of the impact of developmental coordination disorder on activities of daily living. British Journal of Occupational Therapy 2005 May;68(5):207-214.
32. Taylor S, Fayed N, Mandich A. CO-OP intervention for young children with developmental coordination disorder. OTJR Occupation, Participation and Health 2007 Sep;27(4):124-130.
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Questions
Figure 3. Impairments Based on ICF Classification
Body Functions and Structures Impairments
Neuromusculoskeletal and movement related functions
Ball catchingOnset of postural musclesCoordination? Movement duration
Sensory functions and pain BalancePostural control
Mental functionsPerceived competenceImagined movements? Reaction time during attentional tasks
Functions of the heart and respiration ? Fitness
Activities and Participation Impairments
Functions of mobilityBall handling skillsPencil skills, Gross motor function, Academic activities
Functions of self care Fine motor manipulationDressing, Grooming, Bathing
Community social and civic life Soccer, Basketball, BikingLearning and applying knowledge Copying tasksGeneral tasks and demands No conclusive data
Qualitative studies
Gross and fine motor skills (Hopping, Skipping, Running, Biking)Low self esteemDecreased confidence in abilities
Appendix A: Sample Search Strategy from Embase Database
1. “developmental coordination disorder”.ti,ab.2. “developmental co-ordination disorder”.ti,ab.3. exp Developmental Coordination Disorder/4. dcd.ti,ab.5. dcd.mp.6. 1 or 2 or 3 or 4 or 57. exp Motor Performance/8. exp Motor Dysfunction/9. 7 or 810. exp Developmental Disorder/11. 9 and 1012. 6 or 1113. exp Psychomotor Performance/14. exp “Movement (Physiology)”/15. exp VISUOMOTOR COORDINATION/ or exp EYE HAND COORDINATION/ or exp COORDINATION/ or exp MOTOR COORDINATION/16. exp GAIT DISORDER/ or exp GAIT/17. exp BALANCE IMPAIRMENT/ or exp BALANCE DISORDER/18. exp Body Equilibrium/19. exp Proprioception/ or exp Body Equilibrium/ or exp Body Posture/20. exp Developmental Stability/21. exp Physical Disability/22. exp Motor Performance/23. exp Task Performance/24. exp Motor Activity/25. exp Sensorimotor Function/26. exp Visuomotor Coordination/27. exp Psychomotor Disorder/28. exp Object Manipulation/29. 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 2830. exp Daily Life Activity/ or exp ADL DISABILITY/31. adl*.mp.32. exp EXERCISE/33. exp Physical Activity/34. exp Human Activities/35. exp LEISURE/36. activit*.mp.37. 30 or 31 or 32 or 33 or 34 or 35 or 3638. exp SPORT/39. exp PLAY/40. exp RECREATION/41. exp Patient Participation/42. participat*.mp.43. 38 or 39 or 40 or 41 or 4244. 29 or 37 or 4345. 12 and 4446. limit 45 to (English and (child or preschool child <1 to 6 years> or school child <7 to 12 years> or adolescent <13 to 17 years>))
