State anxiety,psychological stress and positive well-being responses to yoga and aerobic exercise in people with schizophrenia: a pilot study

Purpose.?Worsening of schizophrenia symptoms is related to stress and anxiety. People with schizophrenia often experience difficulties in coping with stress and possess a limited repertoire of coping strategies. A randomised comparative trial was undertaken in patients with schizophrenia to evaluate changes in state anxiety, psychological stress and subjective well-being after single sessions of yoga and aerobic exercise compared with a control condition.

Method.?Forty participants performed a single 30-min yoga session, 20-min of aerobic exercise on a bicycle ergometre at self-selected intensity and a 20-min no exercise control condition in random order.

Results.?After single sessions of yoga and aerobic exercise individuals with schizophrenia or schizoaffective disorder showed significantly decreased state anxiety (p?<?0.0001), decreased psychological stress (p?<?0.0001) and increased subjective well-being (p?<?0.0001) compared to a no exercise control condition. Effect sizes ranged from 0.82 for psychological stress after aerobic exercise to 1.01 for state anxiety after yoga. The magnitude of the changes did not differ significantly between yoga and aerobic exercise.

Conclusion.?People with schizophrenia and physiotherapists can choose either yoga or aerobic exercise in reducing acute stress and anxiety taking into account the personal preference of each individual.     

Group aquatic training improves gait efficiency in adolescents with cerebral palsy

Purpose.?To evaluate the effect and feasibility of a 10-week group aquatic training programme on gait efficiency in adolescents with cerebral palsy (CP). The secondary purpose was to determine the exercise intensity during aquatic training in a heterogeneous group of adolescents with CP and to investigate the impact of the training programme on the musculoskeletal system.

Method.?Twelve ambulatory adolescents with spastic CP were recruited. They participated in 20 aquatic training sessions (45?min twice a week). Three physical therapists and a sports teacher supervised the training sessions. Participants wore a heart rate monitor to assess sessions' intensity and a floatation device as appropriate. The primary outcome measure was gait efficiency as measured by the gait energy expenditure index (EEI). The secondary measures were (1) gait spatiotemporal parameters, (2) maximal isometric knee strength and (3) gross motor function.

Results.?Ten adolescents completed the training programme. No adverse effect was reported. Average exercise intensity was mild to moderate for more than half of the training session. A significant reduction of the EEI and the heart rate during walking was observed following the training programme. No significant change was observed on secondary outcome measures.

Conclusions.?Group aquatic training increases gait efficiency in adolescents with CP. This improvement is related to systemic cardiorespiratory adaptations. Group aquatic training programme is feasible in adolescents presenting CP at different levels of severity.     

Outcomes and adverse events from physiotherapy functional restoration for lumbar disc herniation with associated radiculopathy

Purpose.?To report the outcomes and adverse events of people diagnosed with lumbar disc herniation with associated radiculopathy (LDHR) who were treated with a physiotherapy functional restoration programme.

Method.?Data on functional outcome (Oswestry score), work status, global rating of change, and adverse events were extracted from the files of all people with LDHR treated by three physiotherapists using functional restoration principles from 2001 to 2009.

Results.?Ninety-five participants were included. The Oswestry score reduced by a mean of 15.9 (95%% CI, 11.8–20.1) points between baseline and discharge following a mean (SD) of 8.7 (9.4) months of treatment. The proportion of participants working full-time increased from 37%% to 67%% between baseline and discharge (p < 0.001). Eighty per cent of participants reported overall improvement between baseline and discharge on the global rating of change scale (p < 0.001). Minor adverse events were reported by eight (8%%) participants, while one (1%%) participant developed adhesive capsulitis.

Conclusion.?People with LDHR who undertook a physiotherapy functional restoration programme achieved significant improvements in Oswestry disability scores, work status, and global rating of change, with few adverse events reported. A randomised controlled trial is warranted to determine the efficacy of functional restoration for people with this condition.     

Measuring participation in individuals with Parkinson disease: relationships with disease severity,quality of life,and mobility

Purpose.?Our aims were to: (1) describe participation in people with Parkinson disease (PD), (2) evaluate the relationship between quality of life and participation and (3) determine the mobliity measures which are predictive of participation.

Methods.?Participants with idiopathic PD (n == 62) were tested off medication for participation (Activity Card Sort), quality of life (PDQ-39), disease severity (MDS-UPDRS) and mobility (Berg Balance Scale, Five Time Sit to Stand (FTSTS), Six Minute Walk, forward walking velocity, dual-task walking velocity and Freezing of Gait Questionnaire (FOGQ)). Relationships of all variables to participation were examined using Pearson correlations. Subsequent regression analysis was employed to determine the mobility measures which best predicted the participation.

Results.?Participants with PD retained, on average, 78.3%% (SD == 15.6%%) of total activities. Participation was negatively correlated with all PDQ-39 domains (r range ?0.36 to ?0.78, all p < 0.005) with the mobility domain having the strongest correlation. All mobility measures were significantly correlated with participation, with the final regression model including only FTSTS and FOGQ which combined explained 37%% of the variance in participation.

Conclusions.?Participation is highly related to mobility-related QOL and may be most impacted by ability to stand up from a chair and freezing of gait in those with PD.     

Is walking endurance associated with activity and participation late after stroke??

Purpose.?After stroke, impaired walking ability may affect activity and participation. The aim was to investigate whether self-reported activity and participation were associated with walking endurance late after stroke.

Method.?A non-randomised sample of 31 persons with a mean age of 59.7 years and time since stroke of 7–10 years was studied. Walking endurance was measured by the 6-minute walk test (6MWT). Self-reported activity and participation were measured by the Physical Activity Scale for the Elderly and the Stroke Impact Scale. Relationships were analysed with linear regression.

Results.?A regression model including activities of daily living and 6MWT explained 44%%, mobility and 6MWT explained 25%% and a model including physical activity level and 6MWT explained 21%% of the variation in activity. Regarding participation, the explanatory level of the model of participation and 6MWT was 30%%.

Conclusions.?Walking distance several years after stroke was partly associated with self-reported difficulties in activity and participation.     

Use of the International Classification of Functioning,Disability and Health to identify preliminary comprehensive and brief core sets for Guillain Barre syndrome

Purpose.?To identify the preliminary comprehensive and brief core sets for Guillain Barre syndrome (GBS), in a Delphi process using the International Classification of Functioning, Disability and Health (ICF).

Method.?Focus groups and a consensus process were used to identify ICF core sets for GBS. This included: preliminary ICF studies; empirical patient data collection for 77 GBS participants; review of the evidence base and treatment in GBS literature followed by a Delphi exercise with 23 physicians and allied health professionals in Melbourne, Australia.

Results.?The expert consensus selected 99 second level ICF categories (in three rounds) which identify health domains relevant to GBS for multidisciplinary assessment. These domains were consistent with current practice and existing GBS literature. The comprehensive core set includes: 27 (23%%) categories from the component ‘body function’, 7 (12%%) categories from ‘body structures’, 43 (36%%) from ‘activities and participation’ and 22 (29%%) from the component ‘environmental’ factors. The brief set comprised 20 categories, 20%% of categories in the comprehensive core set.

Conclusion.?The core set categories for GBS-related health need to be addressed in multidisciplinary care programs. Future clinical ‘rating’ of this set may facilitate scale development using the ICF in GBS. Further research is needed to confirm the generalisability of this set in clinical settings.     

Hemiarthroplasty for displaced femoral neck fracture: good clinical outcome but uneven distribution of occupational therapy

Purpose.?To assess rehabilitation, type of follow-up visits and outcome after bipolar hemiarthroplasty for femoral neck fracture.

Method.?Two hundred thirty-six consecutive patients with femoral neck fractures treated with hemiarthroplasty were followed for 30 months.

Results.?One hundred sixty-eight (71%%) were women, 175 (74%%) over 80 years old and 53 (22%%) were demented. Of 150 patients with available 3-month data, 7 patients (5%%) had not regained their walking ability. Seventy (47%%) were pain-free and 112 (75%%) were back in their original habitat. A hip-related complication leading to a contact with the orthopaedic department occurred in 20 of all patients (8%%), and 7 (3%%) of these underwent a revision surgery. One hundred eighty-seven patients (79%%) received occupational therapy (OT). Demented patients received OT more seldom (p < 0.001), as did patients aged 90 and older (p == 0.049).

Conclusion.?Due to the low rate of orthopaedic complications, these patients are now referred to their general practitioners, without any further follow-up at the orthopaedic department. Rehabilitation efforts are unevenly distributed. The need of increased rehabilitation efforts for demented or ‘old old’ patients is discussed.     

Progressive resistance exercise for people with multiple sclerosis

Purpose. This study aimed to determine if participation in a progressive resistance exercise (PRE) programme can: (1) increase the ability to generate maximal muscle force, (2) increase muscle endurance, (3) increase functional activity, and (4) improve overall psychological function of people with multiple sclerosis (MS).

Methods. A pre-post single group research design with a 4-week baseline familiarisation phase was used. Nine people (mean age 45.6 years, SD 10.7) with MS attended a gymnasium three times over 4 weeks for familiarization. Participants then completed a twice-weekly 10-week PRE programme, with two sets of 10 – 12 repetitions of each exercise. Outcome measures of muscle strength (1RM for arms and legs), muscle endurance (repetitions at half 1RM), walking speed, the 2-min walk test (2MWT), a timed stairs test, and the impact of MS on physical and psychological function were taken at weeks 2, 4, and 14.

Results. Participants attended 94.3% (SD 8.2%) of the training sessions, with no adverse events. After accounting for baseline stability, significant improvements (P < 0.05) were found in arm strength (14.4%), leg endurance (170.9%), fast walking speed (6.1%), and there was a trend for increased distance in the 2MWT (P = 0.06). The perceived impact of MS on physical function was reduced (P = 0.02).

Conclusions. Adults with MS benefited from a PRE programme by improving muscle performance and physical activities, without adverse events. These findings suggest that PRE may be a feasible and useful fitness alternative for people with mild to moderate disability due to MS.     

Gait during hydrokinesitherapy following total knee arthroplasty

Purpose.?To obtain gait parameters during hydrotherapy (HT) in patients who were referred for rehabilitation after primary total knee arthroplasty (TKA).

Method.?The study had a cohort prospective design. Patients who had undergone TKA followed a HT rehabilitation programme. Twenty-two consecutive patients were enrolled. Four of them dropped out for various reasons, independently of HT. Therefore 18 patients could be evaluated (5 men and 13 women). Eighteen age-matched healthy volunteers were the control subjects. Nine patients had a right TKA and nine a left TKA. On the average HT duration was 18.4 days (SD 1.4).

Results.?The patients presented with a mean speed of 912 (SD 275) meters per hour (m/h) at the baseline. At the last session the mean speed was 1330 (SD 416) m/h. The mean stance duration was 1.75 s (SD 0.34) on the operated side and 1.83 s (SD 0.41) on the non-operated side. By contrast, the mean swing duration was 1.10 s (SD 0.25) on the operated side and 1.13 s (SD 0.34) on the non-operated side. The step duration was the same on both sides. At the beginning of HT the mean stance/swing ratio was 1.94 on the operated side, whereas it was 1.77 on the non-operated side. In the controls the ratio was 1.46. At the beginning the mean stride length was 0.526 m (SD 0.147) and the value became 0.556 (SD 0.138) after 18 training sessions. At the individual level, recovery occurred in a non-linear fashion (Best Fitting, 7th-grade Fourier finite series).

Conclusions.?The study design permits accurate definition of stride parameters during rehabilitation which allows optimization of the programme. Increase in speed and regain of balance are the main targets of a HT programme and are monitored on a daily basis.     

Adaptations to pain rehabilitation programmes for non-native patients with chronic pain

Purpose.?(i) To determine whether adaptations for non-native patients have been implemented in pain rehabilitation programmes; (ii) to determine whether characteristics of the rehabilitation institute are related to having adaptations for non-native patients in place.

Subjects.?Rehabilitation institutes and rehabilitation departments of general hospitals in The Netherlands who offer a pain rehabilitation programme.

Method.?A questionnaire was handed over in person or by e-mail to the rehabilitation physicians of the participating institutes. Twenty-seven (90%%) questionnaires were returned. The questionnaire concerned programme adaptations and institute characteristics. The data were analysed by χ² tests or Fischer's exact tests and logistic regression analysis.

Results.?Twelve institutes (44.4%%) reported having adaptations in place for non-native patients in their pain rehabilitation programme. The most common adaptations were as follows: increased number of consultations (25.9%% of the institutes); longer consultations (25.9%%) and education for employees regarding cultural competency (11.1%%). Institutes which treated a high percentage (≥11%%) of non-native patients had implemented significantly more frequently adaptations to their rehabilitation programme (p == 0.04). The number of adaptations was neither associated with the proportion of non-native citizens in the local population nor with the number of the institutes' employees.

Conclusion.?Less than half of the institutes had implemented one or more programme adaptations for non-native patients. Institutes which had made adaptations to their rehabilitation programme treated more non-native patients.     

Effectiveness of a community-based low intensity exercise programme for ambulatory stroke survivors

Purpose.?To establish the feasibility and effectiveness of a community-based exercise programme for ambulatory patients with stroke discharged from rehabilitation

Method.?Eighteen participants were recruited 3–12 months after onset of first stroke. Using a time series experimental design, the group completed a baseline period of 4 weeks (A1), a group exercise programme of low-intensity progressive resistive exercise and functional tasks for lower limb muscles (B) and repeat assessment after cessation of exercise (A2). Fitness instructors delivered sessions at Leisure Centres twice weekly for 14 weeks with physiotherapy support and the minimum attendance requirement was 16 sessions. Measures included muscle strength, gait velocity, Berg Balance Scale and Nottingham Extended Activities of Daily Living.

Results.?Lower limb muscle strength improved after training (ANOVA, p?<?0.02). Paretic knee extension strength increased from 43.4?±?5.9 to 60.4?±?6.8 Nm after 16 exercise sessions. Walking velocity increased significantly (ANOVA, p?<?0.001), from 0.54?±?0.07 to 0.75?±?0.08 m/s (t?=??3.31, p?<?0.01). Balance and everyday function were also significantly improved (p?<?0.003). There were marked individual variation in the response to training, and those who completed additional training did not show benefit.

Conclusions.?This community-based exercise programme was feasible and delivered positive improvements in physical function for participants. Further issues raised for investigation include the individual response to training and the benefits of extended training.     

Physical strain of comfortable walking in children with mild cerebral palsy

Purpose.?To evaluate the physical strain of comfortable walking in children with mild cerebral palsy ((CP)) in comparison to typically developing ((TD)) children. Physical strain was defined as the oxygen uptake during walking ((VO_2walk)) expressed as a percentage of their maximal aerobic capacity ((VO_2peak)).

Method.?Eighteen children ((aged 8–16 years)) participated, including eight ambulant children ((four girls, four boys)) with mild spastic CP ((three hemiplegia, five diplegia, GMFCS I: n == 7 and II: n == 1)) and 10 TD children. VO_2walk was measured during 5?min of walking on an indoor track at comfortable walking speed. VO_2peak was measured in a shuttle run test.

Results.?VO_2walk was significantly higher in CP ((19.7 ((2.8)) ml//kg//min)) compared to TD ((16.8 ((3.6)) ml//kg//min, p == 0.033)), while walking speed did not differ significantly between groups. VO_2peak was significantly lower in CP ((37.2 ((2.2)) ml//kg//min)) compared to TD ((45.0 ((5.3)) ml//kg//min, p == 0.001)). Consequently, the physical strain during walking was significantly higher in CP ((52 ((7.7)) %%)) compared to TD ((36 ((8.4)) %%, p == 0.001)).

Conclusions.?The higher physical strain during comfortable walking of children with mild CP compared to TD children may be related to reported problems with fatigue in this population, and suggest a need for physical aerobic training programmes.     

Specific treatment of Prader–Willi syndrome through cyclical rehabilitation programmes

Purpose.?To evaluate retrospectively the efficiency of our rehabilitation programme for patients with Prader–Willi Syndrome. In total, 49 patients were examined, 21 female and 28 male, the youngest in their late teens. Prader–Willi syndrome is generally characterised by cognitive impairment, behavioural abnormalities, and hyperphagia. Patients are usually considerably adverse to any form of physical exercise, and despite hormonal therapy, weight control in adult patients can be difficult.

Methods.?Four times a year, disease-specific residential programmes were organised, each lasting 4 weeks. The patients were restricted to a 1500 Kcal diet. In addition, they were required to do 6.5?h of physical exercise daily, stamina being built up by using music therapy, psychomotor therapy, education and entertainment activities.

Results.?BMI decreased by 2.1 average points in every residential session. For three patients who attended our treatments regularly, a reduction of 8.9 points over 6 years was recorded. An attendance of at least three sessions per year seemed to be necessary to substantially reduce weight.

Conclusions. A multidisciplinary approach and a daily calorie-counted diet can lead to significant weight loss in teenage and adult PWS patients. This approach would also be suitable in treating patients with other obesity syndromes with mental retardation.     

Gait during hydrokinesitherapy following total hip arthroplasty

Purpose.?To obtain gait parameters during hydrotherapy (HT) in patients who were referred for rehabilitation after total hip arthroprostheses.

Method.?The study had a cohort prospective design. Patients who underwent primary total hip arthroplasty (THA) followed a HT rehabilitation program. Twenty-one consecutive patients were enrolled. Five of them dropped out for various reasons, independently of HT. Therefore 16 patients could be evaluated (5 men and 11 women). Sixteen age-matched healthy volunteers were the control subjects. Nine patients had a right THA and 7 a left THA. On average HT duration was 15.7 days (SD 3.8).

Results.?The patients presented with a mean speed of 749 meters per hour (SD 146) at the baseline. At the last session the mean speed was 1175 meters per hour (SD 396). The mean stance duration was 1.59 s (SD 0.28) on the operated side and 1.67 (SD 0.27) on the non-operated side. By contrast, the mean swing duration was 1.02 s (SD 0.20) on the operated side and 0.95 s (SD 0.16) on the non-operated side. The differences in balance were statistically significant. The step duration was the same on both sides. At the beginning of HT the stance/swing ratio was 1.62 (SD 0.40) on the operated side, whereas it was 1.74 (SD 0.42) on the non-operated side. In the controls the ratio was 1.45. During HT both values fluctuated but the trend was toward a better coherence over time. At the beginning the mean stride length was 0.484 meters (SD 0.116) and the value became 0.628 (SD 0.131) after 15 training sessions. At the individual level, recovery occurred in a non-linear fashion, but the mean regression line had a coefficient of 27.1 and the intercept was at 560.3.

Conclusions.?The study design permits accurate definition of stride parameters during rehabilitation which allows optimization of the programme. Increase in speed and regain of balance are monitored on a daily basis and they appear as the targets of a HT programme.     

The effect of a foot gymnastic exercise programme on gait performance in older adults: A randomised controlled trial

Background.?Aged-related loss of ankle dorsiflexion range of motion (ROM) and toe plantarflexor strength play an important role in gait performance. Further, conventional strength, balance and gait training can significantly improve the lower extremity muscle power and functional abilities of older individuals. It remains unclear, however, whether training effects can be enhanced by augmenting ankle ROM and toe plantarflexor strength complementary to training.

Objective.?This study investigated the effect of physical exercise combined with foot gymnastics on the gait performance in older adults.

Methods.?Fifty-six independent living, older adults aged 66–91 years were randomly assigned to either foot gymnastics group (FG; n?=?28) or training group (TG; n?=?28). Further, 14 subjects were integrated as a control group (CG; n?=?14) (no exercise). The FG and TG completed the same training program consisting of aerobic exercises, progressive resistance strength training and stretching exercises twice per week for 12 weeks, whereas the FG performed additional foot gymnastic exercises at the end of the training session and a 10-min foot gymnastics home-program daily. Assessments included the Falls Efficacy Scale – International (FES-I), Expanded Timed Get-up-and-Go test (ETGUG), gait analysis and muscle power measurements of the knee and ankle joint at pre- and post-training.

Results.?No significant change in FES-I score occurred in either group. The FG showed a significant improvement of ankle ROM. There were significant time?×?group interactions in walking speed, step length, in several muscle power measurements and in ETGUG. The positive effects of gait parameters ranged between 1 and 11% and between 2 and 12%, of muscle power between 14 and 34% and 14 and 46% and of ETGUG were 10 and 8% for the FG and TG, respectively. The FG and TG did not differ significantly in their improvements. The CG showed a trend to deteriorations between 0 and??6% for gait parameters, between??4 and??14% for muscle power and 0% for ETGUG.

Conclusions.?The results of this study provide evidence of significant improvements in gait performance, muscle power and ETGUG after a conventional training program in independent living, older adults. However, there is no additional effect on physical performance after foot gymnastic exercises.     

EFFECTS OF EXERCISE ON MENTAL AND PHYSICAL HEALTH PARAMETERS OF PERSONS WITH SCHIZOPHRENIA

Although the benefits of exercise are well documented, few published research studies have examined exercise in persons with schizophrenia. This pilot examined a 16-week walking program for outpatients diagnosed with schizophrenia (N = 10). Six-minute walking distance, body mass index, percent body fat and severity of psychiatric symptoms were measured. Experimental participants in the walking group experienced significant reductions in body fat (p = 0.03) compared to a control group not participating in the exercises during the same time period. Experimental participants also had greater aerobic fitness, lower body mass indexes, and fewer psychiatric symptoms than controls at the conclusion of the program. Research is needed to identify effective exercise interventions and feasible delivery modalities for persons with schizophrenia in community settings.     

Do Multidimensional Pain Inventory Scale score changes indicate risk of receiving sick leave benefits 1 year after a pain rehabilitation programme??

Purpose.?To study whether scale score changes in the Multidimensional Pain Inventory ((MPI)) can predict which persons disabled by pain will receive sick leave benefits 1 year after completing a pain rehabilitation programme.

Method.?An observational study of MPI data derived from 1468 patients, 388 men and 1080 women, who had participated in multidisciplinary cognitive-behavioural oriented pain rehabilitation programmes in Sweden, collected from the Swedish Quality Register for Pain Rehabilitation, before, at the end and 1 year after the programme.

Results.?Most MPI scale scores showed improvements after completing a pain rehabilitation programme and this improvement was sustained after 1 year. Moreover, we found that a decrease in MPI scales scores for Pain severity and Interference immediately after the pain rehabilitation programme decreased the risk of being on full-time sick leave 1 year later [[OR 0.85, ((95%% CI 0.73–0.99)) and OR 0.73, ((95%% CI 0.61–0.87)), respectively]]. The Interference scale, which may be considered to include ICF components of both activities and participation, might represent the core of suffering among persons disabled with pain.

Conclusions.?A rehabilitation intervention directed to combating the consequences of pain in activities and participation rather than against pain per se might lead to improved working capacity.     

Physical capacity after 7 weeks of low-intensity wheelchair training

Purpose.?To simulate the effect of low-intensity exercise in early rehabilitation, we investigated the effect of a 7-week low-intensity norm duration hand rim wheelchair training on the physical capacity in untrained able-bodied individuals.

Method.?Twenty-five able-bodied participants were randomly assigned to an experimental and control group: 10 participants exercised 7 weeks, three times a week at 30% heart rate reserve (HRR) for 30?min (experimental group). The control group consisted of 15 participants who did not receive training. Physical capacity (maximal isometric strength, sprint power, peak power output and peak oxygen uptake) and submaximal performance [heart rate (HR), oxygen uptake (VO₂), mechanical efficiency (ME)] were assessed pre- and post-training. The levels of upper-body discomfort were determined with the use of a Local Perceived Discomfort scale.

Results.?Compared to the control group the experimental group significantly improved on sprint power (+31.2%), peak aerobic power output (+34%), submaximal HR, VO₂ and ME (+16.9%). The participants did not experience high levels of local discomfort in the upper body during the training.

Conclusions.?Low-intensity norm duration hand rim wheelchair training which significantly improved peak aerobic and sprint power output, efficiency and physical strain in able-bodied untrained individuals. Training at 30% HRR (3?×?/week, 30?min/session) may be appropriate in untrained individuals, such as novice wheelchair users at the start of their rehabilitation, to prevent early fatigue and overuse and enhance motivation.     

The effects of protracted graphomotor tasks on tripod pinch strength and handwriting performance in children with dysgraphia

Purpose.?To examine the impact of prolonged graphomotor tasks on tripod-pinch strength and on handwriting process and product measures of children with dysgraphia and typical peers.

Method.?Participants were 51 children in third to fifth grades, divided into two groups: 23 children with dysgraphia and 28 typical peers, as determined by the Handwriting Proficiency Screening Questionnaire. The procedure included two sessions, with a 15-min break between sessions. In each session, the participants performed two tasks: the visual-motor control subtest of Bruininks-Oseretsky and a handwriting copying task, both performed on an electronic tablet as part of the Computerised Penmanship Evaluation Tool. Tripod pinch strength was evaluated before and after each session.

Results.?Significantly lower tripod-pinch strength was found among children with dysgrphia in comparison to typically developed peers. This deterioration in tripod-pinch strength was associated with a significant deterioration in handwriting process and product measures along the protracted task.

Conclusions.?Pinch force that is required for mastering the handwriting tool needs to be considered in the evaluation process of children with dysgraphia. Combining the pinch factor with an evaluation of handwriting's process and product may supply a better insight about the child's deficits and assist in focusing treatment objectives.