RESEARCH OBJECTIVE(S) List study objectives.

CRITICALLY APPRAISED PAPER (CAP) Weintraub, N., Yinon, M., Hirsch, I. B. E, & Parush, S. (2009). Effectiveness of sensorimotor and task-oriented handwriting intervention in elementary school-aged students with handwriting difficulties. OTJR: Occupation, Participation and Health, 29(3), 125 134. https://doi.org/10.3928/15394492-20090611-05 CLINICAL BOTTOM LINE: Handwriting is a skill school-age children require to express their knowledge and complete tasks. Challenges with handwriting affect the participation and academic progress of many school-aged children. This single-blind, randomized controlled trial found that an 8-week taskoriented approach with the inclusion of higher level, self-instruction strategies was no different immediately after intervention or at 4-month follow-up than an 8-week task-oriented approach with higher level, self-instruction strategies combined with sensorimotor interventions (postural control, bilateral coordination, stability, fine motor skills). Outcomes measured on the Hebrew Handwriting Evaluation (HHE) included handwriting speed, overall legibility, letter formation, and spatial organization. Results suggest that sensorimotor strategies do not facilitate improved handwriting performance among school-age children and that a task-oriented approach with higher level strategies may be more effective. Higher level functions (e.g., self-assessment, selfediting) were used in both groups as part of the treatment strategies, which makes it difficult to determine the role of higher level strategies on study outcomes. Limitations of this study include the following: This training program was used to teach children Hebrew characters, which limits application to teaching the Roman alphabet. The small sample size was underpowered for long-term follow-up, and the outcome measure assessments were not based on students performance in the classroom environment. RESEARCH OBJECTIVE(S) List study objectives. 1

Understand the influence of sensorimotor intervention strategies on handwriting by comparing task-oriented training using higher level functions versus a task-oriented group using higher level functions coupled with sensorimotor interventions DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: A pretest posttest experimental design with random assignment of participants into one of three groups: sensorimotor group, task-oriented group, or control group PARTICIPATION SELECTION How were subjects recruited and selected to participate? Please describe. Purposive sampling occurred in this study. Letters advertising the study were sent to elementary schools and pediatricians offices in a large city in Israel. Teachers and physicians then referred to the program students who demonstrated difficulty with handwriting. Inclusion Criteria Students who received a standard score of one standard deviation below the mean on the Brief Assessment Tool for Handwriting, which was completed by the teacher Students who were in Grades 2 to 4 Exclusion Criteria Students who had average handwriting skills Students who received special education services Students who had a neuromotor dysfunction (e.g., cerebral palsy), sensory loss (e.g., deafness), or social emotional disorder SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 55 #/ (%) Male 50/(91%) #/ (%) Female 5/(9%) Ethnicity Caucasian, N = 55 (100%) Disease/disability diagnosis NR INTERVENTION(S) AND CONTROL GROUPS Group 1: Sensorimotor group 2

Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? A group of 4 6 students followed predetermined treatment protocols that outlined the activities that took place during each session. This intervention combined a multisensory handwriting program with a task-oriented approach, thus incorporating both lower and higher level functions (e.g., letter instruction using mnemonics, selfevaluation, transfer skills). The first 15 minutes were devoted to sensorimotor activities, such as postural control, bilateral coordination, stability, and fine motor skills. The participants then completed multisensory handwriting practice. The first five sessions included learning letters using a variety of methods (kinesthetic, tactile, auditory). Letters were grouped into five categories based on common formational patterns and were named with mnemonics. The final three sessions included handwriting components being taught and practiced, such as spatial organization, letter size, and alignment. Throughout handwriting letter formation and handwriting component practice, students completed self-assessments of their work. Students were asked to complete 10 minutes of homework per day at home. Stage 1: 19 participants Stage 2: 13 participants A child development center in a large city in Israel Two experienced pediatric occupational therapists who worked at the child development center conducted both intervention groups. A total of 8 sessions of occupational therapy were offered (once per week for 8 weeks), with each session lasting 60 minutes 8 weeks Group 2: Task-oriented group Brief description of the intervention A group of 4 6 students followed predetermined treatment protocols that outlined the activities that took place during each session. This group focused on higher level functions (e.g., letter instruction using mnemonics, self-evaluation, transfer skills) to improve handwriting. Letter groups were taught in the same sequence as in the sensorimotor group (grouped into five categories based on common formational patterns and named with mnemonics). Handwriting components were also taught and practiced, such as spatial 3

organization, letter size, and alignment. Students practiced the letter groups by writing words and sentences using different activities (word games or making cards). Throughout handwriting letter formation and handwriting component practice, they completed selfassessments of their work. Students were asked to complete 10 minutes of homework per day at home. How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Group 3: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Stage 1: 19 participants Stage 2: 13 participants A child development center in a large city in Israel Two experienced pediatric occupational therapists who worked at the child development center conducted both intervention groups. A total of 8 sessions of occupational therapy were offered (once per week for 8 weeks), with each session lasting 60 minutes. 8 weeks total No occupational therapy intervention took place while these students were waitlisted for intervention. 17 NA NA NA Up to 10 weeks total Intervention Biases: Contamination: Comment: Two procedures to ensure the fidelity of the study were in place: Therapists were rigorously trained for 10 hours in both intervention programs by a senior pediatric therapist. Also, 25% of the intervention sessions were recorded and analyzed for compliance with the prescribed protocols, with 90% of those found to be in compliance. Finally, intervention groups took place in alternating cycles, with the control group waitlisted 4

until the next cycle of intervention began. Co-intervention: NR Comment: Timing of intervention: Site of intervention: Comment: The timing of the intervention should not have biased the study, given that it took place over a long period of time that accounted for shortterm and long-term effects. The researchers conducted full assessment at referral and at 8 weeks of both control and treatment groups to determine whether maturation affected the results of the treatment group. Comment: The site of the intervention did not bias the results, because both interventions took place at the same site. Use of different therapists to provide intervention: Comment: The same two occupational therapists ran both interventions to control for personality or experience of the therapist. They were also rigorously trained for 10 hours in both intervention programs by a senior pediatric therapist. Baseline equality: Comment: Differences between groups were reported not to be significant in regard to grade level, gender, handedness, socioeconomic background, or body functions related to handwriting performance, as measured on sample identification measures, including the Brief Assessment Tool for Handwriting, Motor Accuracy Test, Developmental Test of Visual Perception (2nd ed.), Pediatric Examination of Educational Readiness in Middle Childhood, and the Balance and Upper-Limb Coordination subtests of the Bruininks Oseretsky Test of Motor Proficiency. MEASURES AND OUTCOMES Measure 1: HHE Name/type of measure used: HHE: a measure of handwriting speed (number of letters written in 1 minute), overall legibility (measured on a 4-point Likert scale), letter 5

What outcome was measured? Is the measure reliable? Is the measure valid? When is the measure used? formation (measured on a 4-point Likert scale), and spatial organization (made up of the sum of six components, all of which are measured on a 4- point Likert scale). There are two separate texts available for the test, which allows for retest within a short period of time. Handwriting speed Overall legibility Letter formation Spatial organization YES YES The HHE was administered to the intervention groups at pretest, at the end of Stage 1, and again at the end of Stage 2 (3 4 months after the end of Stage 1). The measure was also administered to the control group both at pretest and at 8 weeks postreferral to control for maturation effect. Measurement Biases Were the evaluators blind to treatment status? Recall or memory bias. Comment: Evaluator bias did not occur, because evaluators were blinded to group assignment. Comment: Measurement outcome data were not dependent on self-reported information. Recall bias was also accounted for in the HHE through the use of two versions of the test (two different texts): one at referral, and one after the intervention. RESULTS List key findings based on study objectives Stage 1 Key Findings When the researchers compared Stage 1 scores (pretest and immediately after intervention), analysis of variance (ANOVA) found a significant interaction between group and time for letter formation (p =.43). This indicated that the postintervention scores for letter formation varied among the three groups. Group effect was significant for overall legibility (p <.001), which indicates that postintervention scores changed. Post hoc analysis indicated that both the sensorimotor and the task-oriented intervention 6

groups had better overall legibility when compared with the control group. However, a significant difference was found only in the task-oriented group (p =.034). Within groups, immediately after intervention, there was an improvement from pretest to posttest in overall legibility (p =.09) and letter formation (p <.001). Post hoc analysis indicated that the control group did not improve in any area; the task-oriented group significantly improved, with a large effect size in overall legibility (p =.001, d = 0.71) and letter formation (p =.000, d = 0.86); and the sensorimotor group significantly improved, with a medium effect size in letter formation (p =.021, d = 0.53). Stage 2 (3 4 Months Postintervention) Key Findings The researchers compared results from pretest with testing results 3 4 months postintervention to determine long-term effects. No significant interaction between time and group was found, which indicates that posttest results 3 4 months postintervention did not differ significantly between the sensorimotor and task-oriented groups in any of the areas except spatial organization. Within the spatial organization area, the taskoriented group scored significantly higher, with a medium effect size, than the sensorimotor group (p =.024, d = 0.48). A significant within-group time effect was demonstrated for both the sensorimotor and the task-oriented groups, with scores at 3 4 months postintervention significantly better than at pretest in speed (p =.024), overall legibility (p =.001), letter formation (p =.001), and spatial organization (p =.000). Post hoc analysis indicated that a significant improvement was made in all four handwriting measures in both intervention groups (p <.05), with large effect sizes, except for speed, which did not significantly increase in the sensorimotor group. Was this study adequately powered (large enough to show a difference)? YES Comment: An initial power analysis was completed, indicating that a minimum group size of 16 was required to determine a significant difference between groups; in Stage 1, each group had more than 16 participants. In Stage 2, group size dropped to 13 participants per group, so the group size might not have been large enough to show a significant difference between the intervention groups. Were the analysis methods appropriate? YES Comment: The researchers used a two-way (Group Time) repeatedmeasures ANOVA to analyze each of the four handwriting subtests on the HHE, both at Stage 1 and at Stage 2. They calculated the magnitude of change using Cohen s d. They also conducted post hoc analysis to look for specific differences in handwriting subtests of the HHE. 7

Were statistics appropriately reported (in written or table format)? YES Comment: Both narrative and table formats were used to describe the findings of the study. Was participant dropout less than 20% in total sample and balanced between groups? YES Limitations: What are the overall study limitations? Comment: Six students from each intervention group dropped out before posttesting in Stage 2 (total of 12 students). No significant differences were found in any of the pretest or posttest measures between the students who participated and those who dropped out in Stage 2, which indicates that the participants in Stage 2 accurately represented the original study sample in Stage 1. Study limitations include the following: Stage 2 was underpowered, which could limit generalizability of the results. It is difficult to determine the importance of higher level function strategies in the intervention, because they were used in both the sensorimotor and the taskoriented intervention groups. The control group was not included in the long-term follow-up for ethical reasons; therefore, the researchers could not compare the intervention groups with the control group at the 4-month follow-up testing. The outcome measures did not include measure of student performance in the classroom environment, which would provide information regarding generalizability of skills. This training program was used to teach children Hebrew characters, not the Roman alphabet, which may limit generalizability to languages that use other symbols or alphabets in written communication. CONCLUSIONS State the authors conclusions related to the research objectives. This study concluded that short-term interventions combining sensorimotor strategies with taskoriented approaches were not more effective than a task-oriented approach alone with regard to handwriting speed, overall legibility, letter formation, or spatial organization when both groups also used higher level cognitive functions (e.g., self-assessment, self-editing) as additional treatment strategies. Therefore, higher level cognitive strategies seemed to be an important factor in the success of the interventions. Also, long-term effects remained at 4 months 8

postintervention in all four areas for the task-oriented group and in three areas for the sensorimotor group. Although it was not formally measured, parents involvement in treatment sessions and home programming might have contributed to students gains, in addition to the task-oriented approach with higher level strategies. This work is based on the evidence-based literature review completed by Erin E. O Neill, MS, OTR/L, and Alison Bell, OTD, OTR/L, faculty advisor. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 9