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Talk:Chi-squared distribution
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- 1 Image
- 2 clean up derivation of 1 parameter pdf
- 3 needs historical treatment
- 4 What does this sentence mean to tell me?
- 5 Generalized chi-squared distributions
- 6 Simplify, Please
- 7 Notation
- 8 Approximately normal
- 9 Skewness
- 10 Scaled Chi square distribution
- 11 Log
- 12 Connection with Laplace distribution
- 13 CDF graph is wrong
- 14 Ambiguous reference to "shape parameterization of the gamma distribution"
- 15 The probability distribution graph is wrong, now
- 16 Needs work
- 17 Made property more explicit
- 18 Medians missing
- 19 Arrow notation
- 20 Mistake in Intro
- 21 Pronounciation
I would like to contribute this image if folks feel it would improve the Wiki. Since I have a COI with SAS Software and these charts are modeled in SAS, I wanted to post here first. Let me know if you feel the image would be useful.
clean up derivation of 1 parameter pdf[edit]
The current notation has F_x and other symbols that are no defined. —Preceding unsigned comment added by Wilgamesh (talk • contribs) 17:28, 7 August 2009 (UTC)
needs historical treatment[edit]
I just came here looking for the history of Chi-Squared, credit for initial development, historical context, time line, rise in popularity, etc. I think a growing criticism of wikipedias math treatment is an inconsistant voice about whether or not it wants to be a technical encyclopedia or have elements of the history of the math. It probably needs both for completeness; however, in this case the article is sharply skewed in the technical direction with very little historical merit.
22.214.171.124 15:33, 3 June 2007 (UTC)
I am a grateful reader of many math articles on wikipedia. Access to the explanations of the knowledgeable editors of these pages has helped me many times. However, I agree with the comment posted on this talk page nearly two years ago. I suspect that those who can learn from an article in this style are already familiar with much of the information it contains. This article is too technical for me. I have a basic undergraduate education in math (through multi-variable calculus, but no separate statistics class). I post this simply as feedback to the editors as they reflect on the situation of their readers. —Preceding unsigned comment added by 184.108.40.206 (talk) 22:28, 27 March 2009 (UTC)
What does this sentence mean to tell me?[edit]
"If Xi are k independent, normally distributed random variables with mean 0 and variance 1..." Does it mean that X1 is a normal variable whose mean is 0 variance is 1, X2 is a normal variable whose mean is 0 and variance is 1, etc, or does it mean that if you looked at all k of the variables, their collective mean is 0 and variance is 1, or does it necessarily imply both meanings? I'm confused because I am accustomed to being told that we have a single variable X that we sample k observations of, not a whole bunch of different variables at once. 18.104.22.168 (talk) 07:16, 8 June 2009 (UTC)
- There is no such thing as a "collective mean"; the mean is a property of a single random variable. Your first interpretation is correct, with the additional information that the different variables are also independent. --Zvika (talk) 07:41, 8 June 2009 (UTC)
Generalized chi-squared distributions[edit]
What is in this section? —Preceding unsigned comment added by 18.104.22.168 (talk) 00:37, 6 August 2009 (UTC)
- Do the results in this section assume that for all i? (Real and imaginary parts uncorrelated.) If so, that should be noted. —Preceding unsigned comment added by 184.108.40.206 (talk) 16:49, 13 August 2009 (UTC)
- You're right, it isn't clear if real and imaginary are uncorrelated. It's also unclear if the variances of real and imaginary parts are equal. And the variable mu was already defined to be something else in a previous section. It's all very confusing.
This section is a blind copy&paste from the paper written by Björnson et al. At least we need to make sure the notations/symbols are consistent with the rest of this wiki entry. —Preceding unsigned comment added by Qiuxing (talk • contribs) 15:35, 22 October 2009 (UTC)
- Is there any reason to think that the information in this section is notable? Has this "generalization" been used anywhere except in the two quoted papers? Both of them are very recent and written by the same people. Has this even been called a generalized chi-squared distribution anywhere? --Zvika (talk) 17:44, 22 October 2009 (UTC)
- It is not clear how this case of complex normals relates to that for real normals, but I guess it must be close given some reparameterisation. I think a common non-standard problem is to find the distribution of quadratic forms of normal random variables (seen in questions on stats newsgroups) and, given this, a version of the present section relating more directly to real-valued normals would be notable ... perhaps in separate article, or here, or as an addition to Quadratic form (statistics). Melcombe (talk) 10:18, 23 October 2009 (UTC)
- Since this is a sum of squares of absolute values of complex Gaussians, it seems to me that it's exactly the same as the sum of twice as many real Gaussians; the real and imaginary parts of a complex Gaussian are real Gaussians. So, indeed, perhaps the discussion should be about quadratic forms of real Gaussians. Have you got a reference for that? I would think that should appear in a textbook rather than requiring a quote from a recent paper. --Zvika (talk) 17:19, 23 October 2009 (UTC)
- I don't think text books are strong on stuff related to this. But Johnson et al. Continuous Univariate Distributions vol 1 (2nd edition) has three things:
- (p 442) conditions for a quadratic form to be exactly chi-squared;
- (p 444) references to results for the cdf of a weighted sum of chi-squareds as weighted sum of cdf's of F-distributions (although theweights are not given explicitly;
- (p 450) references to numerical algorithms, including one which deals with a general quadratic form using numerical inversion of the characteristic function.
- The dates for the references are 1962-1980 so it is not exactly new. The reference list to this paper (I can't see the paper itself) seems to contain many of the basic references. Melcombe (talk) 10:46, 26 October 2009 (UTC)
- I don't think text books are strong on stuff related to this. But Johnson et al. Continuous Univariate Distributions vol 1 (2nd edition) has three things:
This section should be removed. It isn't about chi-squared distributions. There are an infinite number of ways to generalize a chi-squared distribution. Are we going to try to list them all? And can anyone make an argument for why this generalization is significant? —Preceding unsigned comment added by 22.214.171.124 (talk • contribs)
- I tend to agree.. I don't see much added value in the section as it currently stands. I suggest replacing the whole section with an {{expand section}} template. --Zvika (talk) 04:58, 29 October 2009 (UTC)
- P.S. I don't mean that generalized chi-squared distributions don't have a place here, only that the current generalization doesn't seem to be notable. There are others which Melcombe mentioned which very well may be. --Zvika (talk) 04:59, 29 October 2009 (UTC)
- A little care is needed regarding other articles linking here. There is a link from Erlang distribution directly to this section, but it doesn't actually relate to the present contents. Possibly the section should be made to fit in with this.
- A very quick search showed that "generalized chi-square(d) distribution" is often used for one of the special cases of the quadratic form of normal variables, although one source meant a distribution as in Generalized gamma distribution. And of course there is the noncentral chi-squared distribution.
- So, I suggest moving the present contents of the section to form a basis for an article "Generalized chi-squared distribution" (but noting that it is just a special case). Then replace the contents here with a brief section stating the various types of generalisation, with links to appropriate articles. The links to Wishart distribution and noncentral chi-squared distribution can then be moved out of the "see also" section and thus made more meaningful. Melcombe (talk) 10:45, 29 October 2009 (UTC)
- Your proposed change to the current article sounds great. However, in my opinion moving the existing section to a new article doesn't solve the basic problem, which is that this material doesn't seem to be notable. In fact it seems to me that this material was written by a single IP who is apparently no longer watching this page (or at least not the talk page). Furthermore, that IP is registered to KTH which is where the authors of the only two papers citing this "generalization" are from. In short, this seems like a SPA with COI. --Zvika (talk) 16:40, 29 October 2009 (UTC)
- They don't seem to be pushing anything too strongly. I would be reluctant to delete the citations .... after all the stats articles in general, including this one, contain far too few inline citations. But the material here might be reduced somewhat ... it may be rather a case of looking for an explicit formula which turns out not to be useful for anything further mathemtically, in preference to accepting that a more general computer algorithm may be more useful in practice. Melcombe (talk) 09:57, 30 October 2009 (UTC)
- I have started Generalized chi-squared distribution based on one source I know of, but there is not yet an obvious place in it to move the stuff from the subsection here. Melcombe (talk) 14:48, 30 October 2009 (UTC)
The material referred to above was deleted ( 21:55, 22 December 2009 by 184.108.40.206) as not being directly relevant here, but I haved placed a slightly edited version in Generalized chi-squared distribution as being more appropriate there. Melcombe (talk) 09:54, 23 December 2009 (UTC)
Simplify, Please[edit]
Could this please be translated into English? I'm sorry, but I'm sure this is perfectly clear for people who already know what it all means. I've got a degree in Mathematics, and I'm completely lost. Could the lead paragraph, at least, be modified so that somebody who has no background in statistics could at least get the general idea of what a Chi-squared distribution is? 184.108.40.206 (talk) 00:52, 19 August 2009 (UTC)
- No offence intended, but how on earth did you get a degree in mathematics without learning about the Chi-squared distribution?! We learnt this at age 16 as part of the standard syllabus for English maths AS level. 220.127.116.11 (talk) 16:04, 20 August 2009 (UTC)
- I have a maths degree from Cambridge University, and I didn't study this distribution either (I think it was taught in the second year stats course, but I only took first year probability). It's hardly the most common distribution, and learning lots of specific distributions isn't as important as understanding axiomatic probability theory anyway. In any case, it's hardly unreasonable to ask for clarity. I agree that the final sentence of the first paragraph is a bit unclear. Quietbritishjim (talk) 10:13, 21 August 2009 (UTC)
I agree that this needs to be simplified. If I knew more than the very basics of Chi-squared then I would not need to come to Wikipedia. The assumption needs to be that the reader has come to Wikipedia to find out how to use Chi-squared from scratch. This might best be achieved by having a more specific Introduction to Chi-squared section written to get the complete novice up to a level of using Chi-squared. This is an Encyclopedia. AussieRob (talk) 01:09, 11 February 2011 (UTC)
I have done quite a bit of statistics in the past and just came here to refresh myself for seeing if I should be using this distribution/test for some data. The article is utterly useless. It is only understandable if you already know what it is talking about and it reads more like collage notes than an explanation in an encyclopaedia. It needs an introduction which describes the sort of data and relationships it works on and this needs to be in language that is as close to layman's as possible. Then it can define terms. Then it can get mathsy. —Preceding unsigned comment added by 188.8.131.52 (talk) 08:17, 2 March 2011 (UTC)
I agree with the foregoing. This article, and all mathematics articles on Wikipedia, are apparently the province of a small cadre of experienced mathematicians who enjoy writing for each other. None of them are of any use to an intelligent but uninformed layman. Please, somebody, rewrite this article with an introduction that explains what chi-squared probability distributions actually describe in real-world terms, and what they are USED for. EWAdams (talk) 19:44, 29 April 2014 (UTC)
- I don't think this article can be simplified much. The chi-squared distribution is a less intuitive distribution than say the binomial or Poisson distribution (which can come from very easy-to-understand processes). The article starts with:
- the chi-squared distribution (also chi-square or χ²-distribution) with k degrees of freedom is the distribution of a sum of the squares of k independent standard normal random variables.
- The hyperlinked terms here are prerequisite knowledge (except for "degrees of freedom"). If you don't understand any of these, you won't understand the definition of the Chi-squared distribution, so you should learn these things first.
- It would be like complaining that the article on Quantum Entaglement is too technical. Would you really expect to understand Quantum Entanglement without understanding Quantum Mechanics? The article could use analogies to explain it but then they would be straying from the truth. Monsterman222 (talk) 20:54, 1 October 2014 (UTC)
I suggest that we change the notation for chi² distribution from to (both of them can be encountered in the literature). The reason for such change is to have more uniform notation for different distributions across the Wikipedia: <name of distribution>(<parameters>). For example, we have N(μ,σ2) for normal, Poisson(λ) for Poisson, F(k1,k2) for F-distribution, Binomial(n,p) for binomial, etc. Such notation is also more convenient to display in-line using HTML: χ2(k). … stpasha » 20:54, 29 November 2009 (UTC)
- I think either is OK, but the change will have to be in the entire article. --Zvika (talk) 07:01, 30 November 2009 (UTC)
isn't the conventional notation for degrees of freedom ν not k? —Preceding unsigned comment added by 126.96.36.199 (talk) 15:26, 5 June 2010 (UTC)
- I have seen d, k, v, f (and obviously n, m etc when there's more than one) used for the degrees of freedom. I can't really tell which is the most common. --Paulginz (talk) 20:24, 22 July 2010 (UTC)
I was under the impression that for Z1,...,Zk, the number of degrees of freedom was in fact k-1, following from the fact that — Preceding unsigned comment added by 188.8.131.52 (talk) 23:51, 2 June 2015 (UTC)
Approximately normal[edit]
Regarding the central limit theorem, the article makes the assertion
- k > 50 is "approximately normal"
I don't know if this is a quote from the source or what but, regardless, the statement needs to be qualified in some fashion. Any value of of k could be considered "approximately normal" depending on how one defines that. What is the criterion being applied to make this assertion?
--Mcorazao (talk) 20:37, 4 May 2010 (UTC)
I have the 1978 edition of the book cited, and it says that, for k > 50, the difference between the chi squared and normal distributions is negligible[1]. Still, this is a matter of opinion rather than fact. One person's negligible is another's catastrophe. I think a link to the Berry Esseen theorem would qualify the statement somewhat (or, at least, allow others to work it out for themselves), although the bounds it provides tend to substantially overestimate the error.
DonaghHorgan (talk) 12:34, 26 April 2013 (UTC)
how to find it? 184.108.40.206 (talk) 18:21, 28 November 2010 (UTC)
Scaled Chi square distribution[edit]
I feel that it is very important to mention scaled chi square distribution. Suppose Y is chi square with df k, what is the distribution of cY where c>0??? Jackzhp (talk) 03:21, 5 January 2011 (UTC)
suppose Y has chi square distribution, what is the distribution of log(Y)? Jackzhp (talk) 02:51, 9 February 2011 (UTC)
Connection with Laplace distribution[edit]
The assertion that If then seems unlikely. In fact, , so it seems far more likely that .
Primrose61 (talk) 22:42, 18 October 2011 (UTC)
You are correct; I was reading the article and noticed the same error. The same error was on the Laplace distribution page. I fixed them both.John Lawrence (talk) 18:09, 21 November 2011 (UTC)
CDF graph is wrong[edit]
The graph shows that CDF at 0 = 0.1 for k = 1. --Yecril (talk) 14:34, 24 March 2012 (UTC)
Ambiguous reference to "shape parameterization of the gamma distribution"[edit]
In the subsection "Gamma, exponential, and related distributions", the first sentence refers to "the shape parameterization of the gamma distribution". If one visits the wikipedia page for the gamma distribution, all three parameterizations contain a "shape" parameter. Hence, referring to the "shape parameterization" does nothing to disambiguate the parameterization being referred to here. Craniator (talk) 01:58, 18 March 2013 (UTC)
The probability distribution graph is wrong, now[edit]
I think somebody meant to change the CDF, but changed the graph for the PDF, instead. — Preceding unsigned comment added by 188.8.131.52 (talk) 23:48, 26 April 2013 (UTC)
Needs work[edit]
This article literally makes no sense to me. I'm wondering if I can decode even a single sentence or equation. It is written as if the reader already knows much about the distribution. As it stands, you need a bachelors in math just to figure out what the article is saying. ~EDDY (talk/contribs)~ 14:03, 1 July 2014 (UTC)
Made property more explicit[edit]
The article stated:
- If Y is a vector of k i.i.d. standard normal random variables and A is a k×k idempotent matrix with rank k−n then the quadratic form YTAY is chi-squared distributed with k−n degrees of freedom.
I've added the necessary condition that A be symmetric. I get the impression that most experts would have assumed this from the fact that we have a quadratic form, but making this requirement explicit will help beginners. BTW, a counter-example to the theorem as originally stated would be: , which is idempotent and leads to $Y_1^2+Y_1 Y_2$ which is not Chi-squared since it could potentially take on negative values. — Preceding unsigned comment added by Monsterman222 (talk • contribs) 20:44, 1 October 2014 (UTC)
Medians missing[edit]
Please add to the article … what is the exact median of the χ2 distribution for the first few integer values for degrees of freedom? 220.127.116.11 (talk) 17:55, 11 June 2015 (UTC)
Arrow notation[edit]
In the "Relation to other distributions" section, the first entry gives the limit as . What does the arrow with the d on top mean? It's not obvious to me. MystRivenExile (talk • contribs) 15:39, 22 August 2016 (UTC)
Mistake in Intro[edit]
Second paragraph. First sentence. I'm not sure what the author intended from this word. Perhaps something related to statistical independence since the first portion of this word links to an article on statistical independence. (indeution) Bradybray (talk) 17:08, 14 June 2017 (UTC)
"Pronounced like chai tea, the chi-square,"
I think this is: 1) Wrong; and 2) Unhelpful.
1) The Greek letter chi starts with a 'k' sound, while chai tea starts with a 'ch' sound.
2) One unfamiliar foreign word is being illustrated with another unfamiliar foreign word?!
GeneCallahan (talk) 16:07, 29 June 2017 (UTC)
- ^ Box, Hunter and Hunter (1978). Statistics for experimenters. Wiley. p. 118. ISBN 0471093157.


text:
So, I've noticed that there are dozens upon dozens of singles events, dating apps and websites, meetup groups and the like which are focused solely upon bringing older women and younger men together, offering places for self-declared 'cougars' to find 'toyboys'. But I've yet to see a single one which went the other way, and offered a venue for older men and younger women to hook up with each other- in spite of the fact that, reputedly, this would be far more popular and lucrative. Why is that? And do you think it might be worthwhile to create a meetup group, dating app or singles event which would cater to this massive market, largely untapped save for one-sided, extortionate sugar-baby service providers?
Why are there so many dating services for 'Older Women and Younger Men', but none for 'Older Men and Younger Women'?
What Girls Said 1
Its a common hot topic - older men and younger women00|00|0
I know, but for some reason, no-one seems to be tapping into it. Is there some reason why- would you be accused of being misogynistic or politically incorrect to hook older men up with younger women, as opposed to the other way round? Are there none out there because people are too scared that they'd invite the ire of the radical feminist crowd and get shut down?
What Guys Said 2
aren't these sugary daddy things not dating sites for young girls and old men?00|00|0
Not really. I'd say the sugar-daddy sites are more like a cross between offering old folks' carers and offering prostitution services. There's practically no dating offered there at all- either the sugar-daddies pay up-front for each and every moment of contact, even through the phone or online, or they remain lonely and alone.
what seriously? what a joke.
They just use normal dating sites.10|10|0
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subset: commoncrawl


text:
Two, maybe three weeks ago, a new friend had the courage, one might say foolhardiness, to entrust to me a whole knapsack full of years of his poetry handwritten on everything from bound journals to loose sheets to cocktail napkins. In one of those moments of overreaching, of which I am always more capable than actually grasping the task ahead, I promised this worthy poet that I would review his work, organize it, and even make edits where I thought necessary.
Silent Reproach
It won't surprise any longtime readers of this space that here I am, two, maybe three weeks later having done nothing more than sort this most private of collections into a tidy stack on my desk where it has been confronting me daily with reproachful looks, and that if this were not enough of a manifestation of my malingering ways, I am now bringing procrastination of this project to a whole new level by spending time writing about continuing to ignore it rather than just doing it. So, obviously the problem here isn't lack of time or energy. What then could it be?
Sharp Reflections
My taking on of this project gave me some misgivings at first, and when something gives me misgivings, I take it as a sign that here is an opportunity to go beyond my comfort zone, which is good for an artist, right? Well, it turns out that going outside your comfort zone is, well, uncomfortable. But not in that invigorating challenging way – it just plain feels weird – and not a good weird. I thought this would be a wonderful way to make use of some of my unused expertise to help someone while also helping myself, because that unused expertise, by which I mean the writing of poetry, seemed long overdue for some using. Now it turns out there may be a good reason why this thing, which used to be the center of my life, has been so neatly pushed aside, but continues to reproach me, much like a neatly stacked but stubbornly neglected collection of someone else's words.
A Long Time Ago
Because that is how poetry feels to me now: poetry is something someone else does. I have great sympathy and appreciation for this activity; I can even offer advice, but most of the experiences I am drawing on happened a long time ago. I may take poetic photographs, and lord knows I will never stop pouring out words in one form or another, but the majority of my poems happened in another millennium. Becoming deeply engaged in someone else's poems makes me feel like one of those poor deluded souls who dress twenty pounds thinner or younger than they really are. I am much more comfortable in my new wardrobe, appropriate to this particular creative stage of my life.
Life of its Own
But being a good editor of poems of necessity requires a temporary wearing of someone else's creative clothing. It isn't good enough to spot and correct the misspellings and grammatical errors. It isn't good enough to point out where the rhythm falls off, where anyone but the writer himself would stumble over lapses in music and sense. To do justice to a poem under review, a good editor owes it to the poem to go one step further. Most writers are pretty good, too good sometimes, at getting the spelling, grammar, music and sense right. But a really great poem has a life of its own, a personal passion of its own, so convincing and compelling you can forgive superficial inconsistencies, if you are not too busy falling in love to even notice them.
Out of Sorts
When I do make my move and make good on my promise to my friend the poet, my plan is to somehow sort his work into four categories of poems: ones that have perfect insides and just need a little polishing up on the surface, ones that have perfectly adequate outsides but feel false or empty inside, ones that may or may not have all kinds of flaws, but for what they are somehow come across as finished, entire unto themselves, untouchable, and those that are in such an embryonic state, I can't really do anything until I have more to work with. Once I've completed this sorting process, the latter two categories I will hand back over to my friend as a kind of peace offering, just so he knows I am not planning on keeping his work so long I have to leave town in shame.
Held Back by Fear
It's the first two categories that trouble me. Just as with human interaction, it isn't impossible, but neither is it easy to tell the difference between a poem that is lying to you, and one that is just not speaking its truth clearly enough. Both leave you with a sense of misgiving, a desire to extend benefit of the doubt, but held back by fear that it may not be worth the trouble. Which is worse – falling for something that sounds too good to be true because it isn't, or walking away too soon from something that makes a bad first impression but may be worthwhile after all? Which brings us back to being outside the comfort zone.
On its Way to the Light
The only way to tell if a poem makes you uncomfortable because it is using words to cover its emptiness, or has something true and beautiful inside to express if it could only find the right words, is to become the poet writing it. You have to go back to how it felt to be who, what and where they were when they first turned that moment into poetry and figure out what went wrong. You have to get inside that mind, that moment, and challenge its truth. Most of the time there is something beautiful in the deep darkness that was simply mishandled on its way to the light. Sometimes you have to be honest with the poet and let them know that however valid their experience may have been, somewhere along the way the desire to write a poem about it took over, and the poem that resulted ended up not being true to its own inspiration. And the only way to fix something like that is to challenge the poet to go back to that inspiration and basically try again. That's one of those suggestions just as much fun to deliver as it is to receive. You don't tell a proud parent their kid is no good.
My Truth
The night my friend gave me his work I took a quick first look and immediately felt as if I had been hit by a shovel. I had not fully realized the emotional magnitude of his writing, and thus the task ahead. In the days that followed I missed him with the kind of intense yet vast melancholy I usually feel for places I've visited briefly and loved deeply, but knew I would never live in. I postponed beginning my work the way you play cat and mouse with a novel you know will change your life but once you start reading it you will get closer to the point of finishing it, and thus closer to never again being that person who had yet to touch the first page. And that's how I've been ever since – hesitant and confident, eager and afraid. I write to get at the truth of things, my truth, my things, with which I can be as careful or carefree as I choose. Now I have a roundtrip ticket out of my comfort zone and into someone else's truth, someone else's things. I don't want to go, but I wouldn't miss this trip for the world.


text:
Modified constraint-induced movement therapy or bimanual occupational therapy following injection of Botulinum toxin-A to improve bimanual performance in young children with hemiplegic cerebral palsy: a randomised controlled trial methods paper
Use of Botulinum toxin-A (BoNT-A) for treatment of upper limb spasticity in children with cerebral palsy has become routine clinical practice in many paediatric treatment centres worldwide. There is now high-level evidence that upper limb BoNT-A injection, in combination with occupational therapy, improves outcomes in children with cerebral palsy at both the body function/structure and activity level domains of the International Classification of Functioning, Disability and Health. Investigation is now required to establish what amount and specific type of occupational therapy will further enhance functional outcomes and prolong the beneficial effects of BoNT-A.
A randomised, controlled, evaluator blinded, prospective parallel-group trial. Eligible participants were children aged 18 months to 6 years, diagnosed with spastic hemiplegic cerebral palsy and who were able to demonstrate selective motor control of the affected upper limb. Both groups received upper limb injections of BoNT-A. Children were randomised to either the modified constraint-induced movement therapy group (experimental) or bimanual occupational therapy group (control). Outcome assessments were undertaken at pre-injection and 1, 3 and 6 months following injection of BoNT-A. The primary outcome measure was the Assisting Hand Assessment. Secondary outcomes included: the Quality of Upper Extremity Skills Test; Pediatric Evaluation of Disability Inventory; Canadian Occupational Performance Measure; Goal Attainment Scaling; Pediatric Motor Activity Log; modified Ashworth Scale and; the modified Tardieu Scale.
The aim of this paper is to describe the methodology of a randomised controlled trial comparing the effects of modified constraint-induced movement therapy (a uni-manual therapy) versus bimanual occupational therapy (a bimanual therapy) on improving bimanual upper limb performance of children with hemiplegic cerebral palsy following upper limb injection of BoNT-A. The paper outlines the background to the study, the study hypotheses, outcome measures and trial methodology. It also provides a comprehensive description of the interventions provided.
Trial Registration
Cerebral palsy is "a group of permanent disorders of the development of movement and posture causing activity limitation(s) that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain" [
Hemiplegic cerebral palsy, characterised by a clinical pattern of unilateral motor impairment, accounts for 35.1% of all cerebral palsy types in Victoria, Australia
The spastic motor type of cerebral palsy is the most common, comprising about 80% of all reported cases
Botulinum toxin-A in the treatment of the upper limb in children with cerebral palsy
BoNT-A is a powerful neuromuscular paralysing agent that is produced by the anaerobic bacterium
Use of BoNT-A for the treatment of upper limb spasticity in children with cerebral palsy has become routine clinical practice in many paediatric treatment centres worldwide. In Australia, injection of BoNT-A (Botox(r) only) is now an approved and government funded treatment for moderate to severe spasticity of the upper limbs children with cerebral palsy, 2 to 17 years of age inclusive
Intramuscular injection of BoNT-A results in relaxation of the affected muscle providing a window of opportunity for maximising therapy outcomes. For children with hemiplegia however, injection of BoNT-A alone does not improve the ability of the child to use the affected limb and clinical experience suggests attempts to use the limb immediately following injection often remain effortful, inefficient and result in clumsy movement. Persistent verbal and physical encouragement by therapists and parents may frequently lead to further frustration and negative or defiant behavior. Therapy must, therefore, create the opportunity, motivation, experience and environment in which a child can learn how to use their affected limb to maximize the effectiveness of the BoNT-A.
A recent systematic review of all upper limb interventions in children with cerebral palsy found that occupational therapy in combination with BoNT-A produced the largest treatment effect of all upper limb interventions on activity level outcomes
Movement-based therapies in the upper limb
For occupational therapists, bimanual occupational therapy training (BOT) in children with hemiplegia is a commonly applied intervention. Theories of practice have previously been described in the literature
In 2007, Gordon and colleagues comprehensively described and evaluated a bimanual approach to upper limb training in children with hemiplegic cerebral palsy called Hand Arm Bimanual Intensive Training (HABIT)
Constraint-induced movement therapy (CIMT) has been adopted as a method of teaching a child to use his/her affected upper limb through use of a restraint on the non-affected limb and massed practice of movements of the affected limb
CIMT is a multi-faceted intervention and studies describing its use in children with cerebral palsy present wide variation in its application in relation to: method of restraint; length of restraint (per day, number of weeks); type and duration of therapy; intervention environment (that is home, school, or clinic) and intervention provider (therapist, parent, or teacher). Children included in studies have also varied in age, diagnosis, severity of motor and sensory impairment, cognitive abilities and behavior. Despite the emerging popularity of CIMT in children with hemiplegic cerebral palsy, a Cochrane review
Studies published to date have provided limited evidence of factors that may impact on the effectiveness of CIMT. Response to CIMT does not appear to be age-dependent and children with more impaired bimanual hand function demonstrate greater improvement than less impaired children
There is currently no published trial directly comparing a BOT protocol with a CIMT protocol. However, in 2008 Gordon and colleagues
The aim of this current paper is to describe the methodology of a randomised controlled trial comparing the effects of modified constraint-induced movement therapy (a uni-manual therapy) versus conventional bimanual occupational therapy on improving bimanual upper limb performance of children with hemiplegic cerebral palsy following upper limb injection of BoNT-A. Bimanual upper limb performance, assessed using the Assisting Hand Assessment, was selected as the primary measure as the central aim of all upper limb motor-based interventions in children with hemiplegia is to improve a child's actual use of their affected upper limb in a range of daily tasks, including those requiring bimanual performance; rather than what they can do in a clinical setting or how normal their movement appears. This RCT builds on the existing evidence supporting the use of BoNT-A in the upper limb of children with cerebral palsy. It aims to identify the most effective intervention following injection of BoNT-A. A further aim is to explore the individual characteristics of children that impact on response to treatment. Finally, it will also provide additional evidence regarding dose response to treatment, specificity of training effects, and the retention of treatment effects.
Primary objective
To compare the effects of modified CIMT versus bimanual occupational therapy (BOT) in improving the bimanual performance of children with hemiplegic cerebral palsy following upper limb BoNT-A injection.
Hypothesis 1
Modified CIMT is more effective than conventional BOT in improving the bimanual performance of children with hemiplegic cerebral palsy following upper limb BoNT-A injection.
Hypothesis 2
Relative to baseline performance on the Assisting Hand Assessment, modified CIMT results in greater retention of gains in bimanual performance compared with BOT.
Secondary objectives
A. To compare the effect of modified CIMT versus bimanual occupational therapy (BOT) on secondary outcomes relating to: the performance of activities of daily living; the quality of upper limb movement; occupational performance; individual goal achievement; and frequency of use of the affected upper limb of children with hemiplegic cerebral palsy following upper limb BoNT-A injection.
Hypothesis 3
Modified CIMT is more effective than conventional BOT in improving performance of activities of daily living, quality of upper limb movement, occupational performance, individual goal achievement and frequency of use of the affected upper limb in children with hemiplegic cerebral palsy following upper limb BoNT-A injection.
B. To evaluate the clinical significance of change identified on the primary outcome, the Assisting Hand Assessment.
Hypothesis 4
That changes on the Assisting Hand Assessment associated with intervention are of a clinically significant magnitude. Clinical significance was defined as a change score of more than 5 raw score points (2.6 logits) on the AHA (Lena Krumlinde-Sundholm, personal communication).
C. To evaluate the impact of age and actual treatment dosage on the primary outcome, the Assisting Hand Assessment.
Hypothesis 5
Younger children (irrespective of treatment type) will show greater improvement in bimanual performance following uni-manual or bimanual therapy and upper limb BoNT-A injection.
Hypothesis 6
Children who undertake treatment of greatest intensity (irrespective of treatment type) will show greater improvement in bimanual performance.
Study design
Randomised, controlled, evaluator-blinded, prospective parallel-group trial based on Consolidated Standards of Reporting Trials (CONSORT) Statement for Randomised Trials of Non-Pharmacologic Treatment
Children were eligible to participate if they met the following criteria:
Inclusion Criteria
• Diagnosis of congenital spastic hemiplegic cerebral palsy as diagnosed and reported in the medical history by a medical specialist (i.e. neurologist, paediatrician).
• Aged 18 months to 6 years at time of recruitment.
• Active movement of the shoulder, elbow, wrist, digits and thumb of the affected upper limb, such that the:
• child is able to reach forward to an elevated position in front with mid range shoulder flexion.
• child is able to grasp a 2.5 cm cube from a table top and release it in a large container (20 cm × 14 cm).
• Able to attend to tasks and follow simple one stage commands.
• child is able to actively perform reach and grasp/release activities with verbal prompting.
• Moderate levels of muscle tone (i.e. 1-2, modified Ashworth scale) and spasticity (i.e. 1-2, Tardieu scale) and no fixed contracture in target group of muscles to be injected with BoNT-A.
• Parents able to commit to an intensive therapy program and agree to cease all other upper limb therapeutic interventions for the 6-month period of the trial.
• Assessed as appropriate for upper limb BoNT-A at neuromuscular clinic by rehabilitation specialist (BR).
Exclusion Criteria
Children who otherwise met the inclusion criteria were excluded if they had:
• Congenital quadriplegic or diplegic cerebral palsy.
• Previous BoNT-A injections in the upper limb in the past 12 months.
• Prior upper limb surgery (i.e. tendon transfer/tendon lengthening).
• Existing treatments that are not compatible with those those included in the study treatment package.
There were no criteria relating to exclusion of children with mother tongue other than English, presence of co-morbidity or socio-economic status.
Potential participants were identified from the Physical Rehabilitation Clinic of a major paediatric metropolitan hospital. In addition, postal and email advertising were sent to local medical practitioners and paediatric therapy networks in metropolitan Melbourne. Potential participants were screened by the chief investigator (BJH) to determine eligibility. Children eligible for inclusion were then assessed by an experienced rehabilitation specialist for suitability for upper limb BoNT-A injection (HBR). Suitable children were then invited to participate in the RCT and informed consent obtained for the participation of the child and the child's parent prior to enrolment in the RCT.
The RCT was approved by the Ethics Committee of both Southern Health and La Trobe University. The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12605000002684)
Reliability training for assessment and scoring of outcome measures
Prior to commencement of the RCT, two highly experienced paediatric therapists (one occupational therapist, one physiotherapist) were trained in the administration of all outcome measures. A manual was developed for both therapists to ensure consistency in measurement over the recruitment period. The same occupational therapist collected data for the Assisting Hand Assessment, Quality of Upper Extremity Skills Test, Pediatric Evaluation of Disability Inventory, Pediatric Motor Activity Log, Canadian Occupational Performance Measure and Goal Attainment Scaling for the entire recruitment period. Two physiotherapists collected data for the modified Ashworth and modified Tardieu Scales. Scoring of the Assisting Hand Assessment was undertaken by the assessment developers. The Quality of Upper Extremity Skills Test was scored by a highly experienced paediatric occupational therapist who had significant experience in the assessment and treatment of children following upper limb BoNT-A injections.
Sequence generation
Children were block randomised into pairs matched by age (± 6 months) using a computer generated set of random numbers.
Allocation Concealment
A set of random numbers was used to create an allocation sequence which was contained in individual opaque envelopes for use by the chief investigator (BJH). As children were recruited, the next envelope in the sequence was opened and the child assigned to the stated group.
All randomisation, sequence generation, and preparation of group allocation materials were performed by a third party (the Monash Institute of Health Services Research) who had no direct contact with the clinical aspects of the trial. The master list of random numbers was located in locked cabinets at the Institute and only accessible at completion of the RCT for analysis.
Due to the overt nature of the interventions, children, their parents and the treating therapist were not blinded to group assignment, however, children and parents were blind to the RCT hypotheses. Outcome measures were administered by a therapist blind to group assignment and scored by different assessors who were blind to group allocation. The Assisting Hand Assessment and Quality of Upper Extremity Skills Test was videotaped, randomised and scored by assessors blind to group allocation and order of assessment.
Sample Size
Sample size estimates were based on projected treatment effect on the primary outcome measure, the Assisting Hand Assessment. In 2005, the authors suggested that a change of more than 5 raw score points may represent a clinically meaningful difference on the Assisting Hand Assessment (Lena Krumlinde-Sundholm, personal communication). This was the equivalent to a change in 2.6 logits. Calculation for fractions of logits undertaken by a statistician indicated that in order to detect a change of 2.6 logits a minimum sample size of 17 per group was required. As the RCT design involves a two-group design, a total sample size of 34 was required to provide 80% power to detect clinically meaningful change between groups. Therefore, the study aimed to recruit 40 children to allow for a 10-12% drop-out rate.
Outcome measures
Outcomes measures were completed on four occasions: baseline (1 to 2 weeks prior to injection), and at 1, 3 and 6 months after injection. Outcomes included measures from across the International Classification of Functioning, Disability and Health (ICF)
Table 1
Outcomes classified according to International Classification of Functioning, Disability and Health (ICF)
Body Function
modified Tardieu Scale (MTS), modified Ashworth Scale (MAS), Quality of Upper Extremity Skills Test (QUEST; dissociated movement subscale)
Quality of Upper Extremity Skills Test (grasps subscale)
Assisting Hand Assessment (AHA), Canadian Occupational Performance Measure (COPM), Goal Attainment Scaling (GAS), Pediatric Evaluation of Disability Inventory (PEDI), Pediatric Motor Activity Log (PMAL)
The effects of upper limb BoNT-A injection in both groups were monitored using measures of muscle spasticity and muscle tone including the Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS).
Primary Outcome
The primary outcome measure was the Assisting Hand Assessment (AHA)
The AHA is conducted by video observation of the child involved in a 10-15 minute play session using the AHA test kit with specific toys. The twenty-two items defining different actions are then scored on a 4-point scale rating the quality of the performance. Four being effective, 3 somewhat effective, 2 ineffective and 1 indicating the child does not perform the action. The sum of raw scores (sum score) varies between 22 (low ability) to 88 points (high ability). Raw scores are converted to scaled scores ranging from 0 to 100. Using a computer generated logarithmic transformation, ordinal data are then converted to equal intervals in the unit logits
The psychometric properties of the AHA have been described in several studies
Monitoring responses to Botulinum toxin-A injection
The Modified Ashworth Scale (MAS) is a 6-point, criterion referenced ordinal scale deigned to measure the resistance that is encountered when a limb is moved passively
The MAS has often been described in the literature as a measure of spasticity
The modified Tardieu scale (MTS) was adapted from the original scale developed by Tardieu and colleagues
In this RCT, administration of the MTS was jointly performed by an occupational therapist and physiotherapist both blinded to group assignment. Movements measured included: shoulder abduction and flexion; elbow extension and flexion; forearm supination and pronation; wrist extension and flexion; ulnar and radial deviation and thumb abduction. The velocity used to determine the angle of catch was V3 (as fast as possible), as recommended by Morris
Secondary Outcomes
The secondary outcomes included measures of: quality of upper limb movement (Quality of Upper Extremity Skills Test (QUEST)); caregiver questionnaires relating to functional status of the child (Pediatric Evaluation of Disability Inventory (PEDI)) and perceived use of the affected upper limb (Pediatric Motor Activity Log (PMAL)); individual occupational performance (Canadian Occupational Performance Measure (COPM)); individual goal attainment (Goal Attainment Scaling (GAS)); muscle tone (the modified Ashworth Scale (MAS)); and spasticity (the modified Tardieu Scale (MTS)).
The Quality of Upper Extremity Skills Test (QUEST) is a descriptive, impairment-based measure designed to evaluate movement patterns and hand function in children with cerebral palsy
The QUEST is a reliable and valid measure for evaluating the quality of movement in children with cerebral palsy. Inter-observer ICC's range from 0.90 to 0.96 with test-retest correlations of 0.95
The Pediatric Evaluation of Disability Inventory (PEDI)
Due to the nature of interventions provided in this trial being targeted at upper limb function rather than mobility and social function, only the self-care domain of the PEDI was administered. This is consistent with the use of the PEDI in many other trials evaluating BoNT-A and occupational therapy
PEDI scale construction was developed using Rasch measurement model and analytic techniques to evaluate construct validity and develop scaled scores. The PEDI has established validity
The Canadian Occupational Performance Measure (COPM)
Due to the age of the children in this RCT, parental responses to the COPM were obtained rather than the child's. This adaptation has been supported in findings by Cusick et al.
The Goal Attainment Scale (GAS) is an individualized, criterion-referenced measure of treatment-induced change
Using mathematical formulae, Kiresuk et al.
The GAS has been used in five out of ten RCT's evaluating the use of BoNT-A and occupational therapy in children with cerebral palsy making it the most commonly used outcome measure across these trials. Despite its popularity and reported sensitivity to detect change, the validity and reliability of GAS is largely unknown
The Pediatric Motor Activity Log
Despite its use in studies evaluating CIMT
Botulinum toxin-A
Each child in the study received injections of BoNT-A (Allergan Australia P/L, Gordon, NSW, Australia) by a single, highly experienced rehabilitation specialist (HBR). Muscles injected were determined by the rehabilitation specialist in consultation with the chief investigator (BJH) at the Physical Rehabilitation clinic based on whether they appear to contribute to abnormal limb position and impair functional use of the limb. Injected muscles included
Children with increased resistance to passive stretch or who exhibit early signs of muscle shortening were provided with a thermoplastic stretching splint designed for use overnight for a minimum of 6 hours per night. This protocol has been based on scientific support from a small number of animal studies reporting that muscles increase in length when immobilised in a lengthened position
Movement-based therapy: General Considerations
One-month following injection of BoNT-A, children randomised to the experimental group received modified constraint-induced movement therapy (mCIMT). Children randomised to the control group received conventional bimanual occupational therapy (BOT). The individual-based treatment sessions of 45 to 60 minutes were conducted by the same occupational therapist (BJH) twice weekly for 8 weeks in an outpatient paediatric treatment room. In addition, children in the mCIMT experimental group were required to complete 3 hours of home program (with the mitt on), 7 days a week for the 8 week treatment period. Children in the BOT control group were also encouraged to undertake a home program but no time requirements were specified. A checklist was completed after each treatment session, identifying the activities used and general observations. Important general considerations for both groups related to establishing and maintaining rapport, equipment, preparing and implementing the sessions are described below.
Building rapport and establishing the therapist-child/therapist-parent relationship was a primary focus for initial treatment sessions. Along with identifying individual movement, hand skill and motor planning abilities of each child, this time allowed for selection of toys to match the demands of the task with the child's developmental level and specific hand skill goals. It was also necessary to establish expectations for future sessions, create an understanding of acceptable behaviour and to establish patterns of on-task behaviour for the child.
Most treatment was undertaken with the child sitting at a height adjustable table (See Figure
Figure 1
Table and chair used in therapy sessions
Table and chair used in therapy sessions
Prior to each session a carefully selected range of fun and motivating toys were placed in the treatment room on an uncovered bench behind or to the side of the child's chair. To improve motivation the child was actively encouraged to choose the toys with which they wished to play. Periods without the child actively engaged in play were avoided to maintain motivation, attention and concentration. If the child became distracted, techniques such as using noise and sensory input (e.g. tapping the table with a toy, tapping the child's affected hand, raising volume of voice) were used to redirect their attention to the task. Because task repetition and practice are key components of training, any attempt by the child to prematurely stop task performance (i.e. by focussing on something else in the room) was ignored by the therapist and parent and the child's attention redirected to the task. The child was required to indicate when an activity had been finished through verbalisation or physical signs. If this occurred after only a few repetitions, further repetitions were negotiated before the activity is stopped. This was seen as important for compliance and motivation as the child felt included in the decision making process whilst further task repetition was achieved. No new activities were chosen until all parts of the activity had been packed up. This was crucial as repetitions of movement/hand skills achieved through packing up were often greater than in the activity itself.
With novel and/or challenging tasks, an inability to independently and successfully complete the demands of the task often leads to a child becoming disinterested or frustrated after only a few trials or repetitions. To facilitate learning, improve skills and task performance, develop resilience, and for the therapist to assist the child to establish patterns of on-task behaviour it was important not to allow the child to "give up" or avoid tasks. A variety of task-avoidant behaviours can be successfully used by children from a very early age. Initial and ongoing parent/therapist reinforcement can inadvertently condition task-avoidant behaviour, impeding the participation and engagement of the child and therefore the effectiveness of treatment. It was crucial for the therapist to establish a collaborative partnership with the parents to ensure consistent responses to these behaviours. On occasions where task avoidant behaviours became evident, the therapist provided advice and strategies to the parent(s) on appropriate responses to avoid reinforcement. Examples of typical task-avoidant behaviours displayed by children included:
• Throwing objects - this often occurs when a child does not understand the requirement of the task (poor motor planning) or the task is too challenging for the child's abilities. In this RCT the therapist always modelled novel task performance to demonstrate task demands. During early attempts at a task, significant physical assistance and/or verbal cuing were provided to ensure successful performance. The amount of assistance was then gradually decreased with future attempts. Any object thrown by the child was not collected by the therapist/parent and the behaviour was ignored. The object remained on the floor to ensure the child did not receive a response that reinforced the behaviour (i.e. stopping of activity, collection by parent). If the behaviour persisted the therapist pre-empted the throw preventing it from happening. The child's attention was redirected to the task and, if required, additional modelling of task performance or increased physical assistance was provided.
• Mouthing objects - young children can learn that mouthing objects leads to a quick and alarmed reaction from the parent/therapist that leads to diversion of attention away from the task. During treatment if a child demonstrated this behaviour, objects small enough for ingestion were avoided in all sessions until the behaviour ceased. To avoid encouraging this behaviour, larger objects were used (to ensure ingestion was not possible) and the behaviour was ignored when displayed. Any direct eye contact with the child from the parent and therapist was also avoided and directed to the task, so the child did not receive a response (i.e. facial expression from parent/therapist, verbal feedback).
• Crying can be an extremely effective strategy for task-avoidance by young children. The reinforcement of this behaviour occurs when the therapist immediately stops the task or parents intervene to provide comfort and reassurance through physical contact or removal of the child from the activity. The child can associate crying with successful task avoidance with resultant disruption to the session. During treatment, it was important for the therapist to quickly evaluate the situation. If the child was obviously distressed, parental comfort and reassurance was used to settle the child. Removal from the seat was avoided if at all possible. If the child was not obviously distressed and crying was deemed by the therapist/parent as task-avoidant behaviour the task was continued. A graded level of response was initiated: 1) child was not removed from position; 2) therapist negotiated with the child for one or two more repetitions prior to task completion; 3) therapist verbalised when task was completed 4) child was required to pack up the activity before choosing next activity; 5) if the child remained uncooperative the therapist and parent engaged in conversation or played the task/game whilst ignoring the child's behaviour; 6) if the child remained uncooperative the therapist asked the child if they would like the parent to leave the room; 7) as a last resort, if the child remained uncooperative the parent left the room until the child settled. As soon as the child settled the parent was invited back into the room. Great care was taken with this final response as it had the potential to cause significant anxiety and stress to the child. Over time, with consistent responses to crying from the parent and therapist, it was expected that the child would stop using crying as a technique for task avoidance.
Constraint-induced movement therapy
The modified constraint-induced movement therapy (mCIMT) protocol incorporated the two fundamental components of CIMT as described by Taub et al.
Figure 2
Neoprene glove used in modified constraint-induced movement therapy.
Neoprene glove used in modified constraint-induced movement therapy.
The implementation of mCIMT was based on the principles of motor-learning theory
Activities deemed too difficult by the therapist were avoided to prevent experiences of failure and frustration. This was particularly important in initial sessions where simple cause and effect activities were used (e.g. battery operated switch activated toys). Parents were educated that use of the glove must be perceived by the child as fun and enjoyable. Rewards, such as playing with favourite toys when the glove was used, was highly encouraged. Negative experiences, such as verbal threats and withdrawal of activities, were discouraged. The child was always kept busy and periods without the child actively engaging in play was avoided. If the child became distracted by the glove their attention was immediately redirected to the task by using noise and sensory input (e.g. tapping the table with a toy, tapping the child's affected hand, raising volume of voice). Any discussion regarding the glove was avoided. At the conclusion of each session the child was praised and informed the session had finished and the child was encouraged to independently remove the glove using his or her affected hand.
Bimanual Occupational Therapy
The bimanual occupational therapy (BOT) was underpinned by components of motor learning
Motor skill acquisition, motor learning and motor control theory
Practical application of a
• Initial and ongoing task analysis to identify if the child's performance was limited by execution of movement or motor planning difficulties (i.e. sequencing of movements)
• Repetitive whole-task practice of challenging, motivating and purposeful bimanual activities (i.e. toys and games), carefully selected to facilitate learning and development of goal-based skills and independence with task completion
• Use of modelling, physical assistance, verbal cues or environmental adaptation to enable the child to understand the critical features of the task and the environment.
• Facilitation of the child's learning and understanding of the role of their assisting hand (i.e. hemiplegic hand) using active problem solving.
• Grading of physical and/or verbal assistance provided to complete tasks.
• Provision of feedback focusing on the outcome, task and environment rather than specific movement performance.
• Provision of opportunities for the child to repetitively practice tasks in a range of contexts and environments.
Understanding and grading task difficulty in bimanual intervention
The Assisting Hand Assessment (AHA), designed specifically for children with unilateral impairment, was developed using a Rasch measurement model. This model allowed identification and ordering of the AHA test items on a scale from easiest to hardest. For example, simply approaching an item using the affected hand (easier item) to using in-hand manipulation skills to move objects in the affected hand (more difficult item). Based on the Rasch model, easier items are more likely to be easier to perform for all children than more difficult items. More able children are also more likely to perform better on more difficult items than less able children. The unique construct allows children's bimanual upper limb ability levels to be placed along a continuum of low ability to high ability. This knowledge can be used to design intervention and guide graded task performance
Figure 3
Using the Assisting Hand Assessment hierarchy to grade treatment.
Using the Assisting Hand Assessment hierarchy to grade treatment. DH = Dominant Hand; AH = Assisting Hand
Cognitive approach
Children with hemiplegic cerebral palsy have varied abilities to perform bimanual activities. Often children have the underlying motor abilities (i.e. adequate range of movement, ability to grasp, hold and release) to execute the required movements for task performance, however they are unable to independently identify the specific role for each hand, appropriately position the hands and object or sequence the movements or direction of force required to complete the task. These motor planning difficulties may be just as limiting for the performance of activities of daily living as is movement execution in children with cerebral palsy
Cognitive-based approaches
Figure 4
Development of grasp, hold and release using verbal mediators
Development of grasp, hold and release using verbal mediators
Figure 5
Development of stability of grip using a cognitive-motor approach to treatment.
Development of stability of grip using a cognitive-motor approach to treatment.
Identifying and breaking down the specific sequences of a task allowed the therapist to assist the child to discover deficient sequences and to prompt them to consider the error before the end of the whole task. This inhibits failure of the task at an incipient stage thereby reducing the likelihood that the child will become frustrated or non-compliant
Statistical analysis
Data were managed and analysed using the Statistical Package for Social Sciences (SPSS version 16.0). Descriptive statistics were calculated to summarise the data set for both groups and to identify potential baseline differences between the groups;
Testing the effectiveness of therapy (Hypotheses 1 and 2)
Using continuous, interval level data from the AHA, differences between the two groups were assessed using a linear regression approach to analysis of covariance (ANCOVA). This controlled for the covariates of baseline AHA scores and the child's age. These variables were included as covariates as they might provide alternative explanations for any observed changes in scores. The size of treatment effect was estimated by comparing differences in group means and their 95% confidence intervals. Regression analyses and scatter-plots were used to investigate the relationship of post-treatment outcome with initial deficit.
Testing the effect of therapy on secondary outcomes (Hypothesis 3)
Between group differences were assessed using ANOVA for continuous data (following tests of normality). Outcomes that had non-continuous data or did not meet usual assumptions of linear regression were investigated using non-parametric statistics.
Testing the clinical significance of the effect of therapy on primary outcome (Hypothesis 4)
The magnitude of treatment effect was evaluated relative to defined criterion of clinical significance.
Testing the effect of age and intensity of therapy (Hypotheses 5 & 6)
Data related to the number of minutes spent by all children undergoing treatment was extracted from the log book for each child. Associations between the intensity of therapy and outcome and age of children and outcome were determined, while controlling for the covariate of group, using ANCOVA.
Safety evaluation
Each child was monitored throughout the trial period by the chief investigator. Following trial completion, all medical and research records were retrospectively audited. Any adverse events were recorded and classified according to whether they could be attributed to BoNT-A injection, general anaesthesia or movement-based treatment.
Current study status
The study commenced recruitment in May 2003 and achieved target recruitment in September 2008. Participant follow-up was completed in March 2009. Data analysis is currently being undertaken.
Amendments to the study since commencement (2003)
(1) Extension for completion date
Approval was granted by Southern Health and La Trobe University Ethics Committees to extend the completion date of the project to June 2010. Approval was requested due to the trial being behind schedule due to slow recruitment rates.
(2) Inclusion criteria
In March 2005 approval was granted by Southern Health and La Trobe University Ethics Committees to extend the upper age limit of children included in the trial from 4 to 6 years of age. Modification was requested due to the development of the upper age limit for the AHA, allowing the effective/valid measurement of children aged 4 to 6 years old. Children in this age range were also considered to potentially benefit from the treatments provided in the trial and therefore would be a clinical population these treatments would be offered to in the future.
This paper describes the methodology of a randomised controlled trial comparing the effects of modified constraint-induced movement therapy (a uni-manual therapy) versus conventional occupational therapy (a bimanual therapy) on improving bimanual upper limb performance of young children with hemiplegic cerebral palsy following upper limb injection of BoNT-A. The results of the paper will be disseminated through peer reviewed journal publications.
AHA: Assisting Hand Assessment; BoNT-A: Botulinum toxin-A; BOT: Bimanual occupational therapy; CIMT: Constraint-induced movement therapy; COPM: Occupational Performance Measure: GAS: Goal Attainment Scaling; HABIT: Hand arm bimanual intensive training; ICF: International Classification of Functioning, Disability and Health; MAS: Modified Ashworth Scale; mCIMT: Modified constraint-induced movement therapy; MTS: Modified Tardieu Scale; PEDI: Pediatric Evaluation of Disability Inventory; PMAL: Pediatric Motor Activity Log; QUEST: Quality of Upper Extremity Skills Test; RCT: Randomised controlled trial.
Competing interests
Allergan Australia provided partial support by providing the BoNT-A (Botox(r)) used in the study, by payment of research assistants blind to group allocation, a blinded rater for the QUEST, and video editing services. The authors have no pecuniary interest in Allergan.
BJH is an occupational therapist and has received sponsorship from Allergan Australia to attend and teach at conferences and meetings but has no personal financial interest in Botox(r) or any related product.
CI is co-investigator of a randomised controlled trial investigating the effect of repeat injections of BoNT-A and occupational therapy in the upper limbs of children with hemiplegic cerebral palsy that has received support from Allergan Australia. In 2008, CI received a grant from Allergan Australia to present results of this trial at the American Academy of Cerebral Palsy and Developmental Medicine in Atlanta but has no personal financial interest in Botox® or any related product.
HBR has received sponsorship from Allergan Australia to attend and teach at conferences and meetings but has no personal financial interest in Botox(r) or any related product.
LC - No competing interests
Authors' contributions
BJH: PhD candidate, designed the RCT and wrote the paper. CI: PhD supervisor, designed the RCT and monitored progress revising the paper critically for intellectual content. HBR: monitored progress revising the paper critically for intellectual content. LC: PhD supervisor, designed the RCT and monitored progress revising the paper critically for intellectual content. All authors have read and approved the final manuscript.
The authors wish to express their gratitude to the children and their families who participated in the trial. They would also like to sincerely thank Trisnawati Tanumihardjo, Melanie Toy-Laing and Cate Clancy for administering the assessments and Lena Krumlinde-Sundholm, Marie Holmefur and Sue Greaves for scoring all the videos. Finally they would like to acknowledge the Allergan Australia and Southern Health and La Trobe University for supporting this research
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Both constraint-induced movement therapy and bimanual training lead to improved performance of upper extremity function in children with hemiplegia
Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration
A randomised controlled trial to evaluate the effect of modified constraint induced movement therapy or conventional occupational therapy following injection of botulinum toxin-A to improve bimanual performance in children with hemiplegic cerebral palsy
Development of the Assisting Hand Assessment: a rasch-built measure intended for children with unilateral upper limb impairments
The Assisting Hand Assessment: current evidence of validity, reliability, and responsiveness to change
Interrater and intrarater reliability of the Assisting Hand Assessment
Retest and Alternate forms reliability of the Assisting Hand Assessment
Interrater reliability of a modified Ashworth scale of muscle spasticity
Reliability of the tone assessment scale and the modified Ashworth scale as clinical tools for assessing poststroke spasticity
The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it
Ashworth and Tardieu Scales: Their clinical relevance for measuring spasticity in adult and paediatric neurological populations
Measures of muscle and joint performance in the lower limb of children with cerebral palsy
Interrater reliability of modified Ashworth Scale and modified Tardieu Scale in children with spastic cerebral palsy
Repeat botulinum toxin-A injections in the upper limb of children with hemiplegia: a randomized controlled trial
A la recherche d'une technique de mesure de la spasticite
Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy
Intraobserver reliability of the modified Tardieu scale in the upper limb of children with hemiplegia
Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments
The reliability and validity of the Quality of Upper Extremity Skills Test
Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy
An evaluation of Botulinum-A toxin injections to improve upper extremity function in children with hemiplegic cerebral palsy
A content validity study of the Pediatric Evaluation of Disability Inventory
The central and peripheral effects of botulinum toxin A in children with cerebral palsy
A randomized controlled trial comparing botulinum toxin A dosage in the upper extremity of children with spasticity
Concurrent and construct validity of the Pediatric Evaluation of Disability Inventory
Concurrent validity of the Functional Independence Measure for Children (WeeFIM) and the Pediatric Evaluation of Disabilities Inventory in children with developmental disabilities and acquired brain injuries
Melbourne Assessment of Unilateral Upper Limb Function: construct validity and correlation with the Pediatric Evaluation of Disability Inventory
Reliability and validity of the Pediatric Evaluation of Disability Inventory
Reliability of the Pediatric Evaluation of Disability Inventory (PEDI)
Establishing minimal clinically important differences for scores on the Pediatric Evaluation of Disability Inventory for Inpatient Rehabilitation
The Pediatric Evaluation of Disability Inventory (PEDI): validation of a new functional assessment outcome instrument
Pilot testing of the Canadian Occupational Performance Measure: clinical and measurement issues
The clinical utility of the Canadian Occupational Performance Measure
Validity of the Canadian Occupational Performance Measure
The Canadian Occupational Performance Measure: a research and clinical literature review
Use of the Canadian Occupational Performance Measure as an outcome measure for intrathecal baclofen therapy
The impact of community paediatric occupational therapy on children with disability and their carers
A pilot of a cognitive treatment for children with developmental coordination disorder
A comparison of Goal Attainment Scaling and the Canadian Occupational Performance Measure for pediatric rehabilitation research
Goal attainment scaling: Current methodological challenges
Goal attainment scaling in paediatric rehabilitation: a critical review of the literature
Goal attainment scaling: Clinical implications for paediatric occupational therapy
Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor impairment
Psychometric properties of the Pediatric Motor Activity Log used for children with cerebral palsy
Connective tissue changes in immobilised muscle
The importance of stretch and contractile activity in the prevention of connective tissue accumulation in muscle
Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures
Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents
The effectiveness of passive stretching in children with cerebral palsy
Motor learning: a practical framework for paediatric physiotherapy
Reflection impulsivity and verbal control of motor behavior
Training impulsive children to talk to themselves: A means of developing self-control
Motor planning in congenital hemiplegia
Activity limitation in hemiplegic cerebral palsy: evidence for disorders in motor planning
Using the Assisting Hand Assessment for treatment planning: Advanced practitioners workshop
A clinical trial of the process-oriented treatment approach for children with developmental co-ordination disorder
Malloy-Miller: Cognitive orientation to daily occupational performance (CO-OP): Part 1
Assessment of a cognitive training program for hyperactive children
Sifting the evidence-what's wrong with significance tests?
Pre-publication history
The pre-publication history for this paper can be accessed here:


text:
Blue Pleasure Wand Deuce
Glass Prodigy
The Pleasure Wand Deuce dildo is a step up from our original Pleasure Wand. Both ends feature a ball that have a soft faded blue swirl. One end has a ball that is straight which works wonders with foreplay, the other end has the ball on a slight tilt to help reach the g-spot. The shaft by the tilted ball features two elevated stripes that add just enough friction to help bring you the pleasure you deserve. The rest of the shaft is completely smooth. This toy is both highly functional and beautiful. 7 inches in length and with a 1 inch diameter. Each ball is 1.5 inches in diameter. Each Glass Prodigy toy is made from the highest quality Pyrex glass; which is the only type of glass that has been proven to be safe to use internally. Every piece goes under extensive quality control testing.
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Glass Prodigy


text:
GFI MAX RemoteManagement™ will soon monitor, report and alert on all important aspects of Linux servers via the dashboard. The beta agent will cover Red Hat, Cent OS and FC. Following the beta launch, we'll develop SUSE, OpenSUSE, Debian and Ubuntu monitoring.
Check out this Sneak Peek Video for Spiceworks community.
So, if you've got a number of different server systems you will soon be able to keep your eye on ALL of them from one dashboard. GFI MAX's 24x7 monitoring will alert you to problems with your customers' servers. You'll always know about an issue before they do, so you can fix problems fast and minimize their business disruption. What's more, using the Daily Safety Check you will gain an excellent understanding of your clients' servers. This means, when it comes to pricing a full-fledged Managed Services contract, you have all the information needed to make an accurate assessment.
1 Reply
Aug 1, 2012 at 4:36 UTC
Brand Representative for MAXfocus
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Coming soon
»Hardware Resources and Performance Monitoring, Application monitoring on SUSE, openSUSE, Debian and Ubuntu
»Work has also started on OS X Monitoring Agent
This discussion has been inactive for over a year.
You may get a better answer to your question by starting a new discussion.


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|Message view
|« Date » · « Thread »
|« Date » · « Thread »
|"Jukka Zitting" <jukka.zitt...@gmail.com>
|Re: residual definition xml implementation
|Sat, 15 Apr 2006 09:06:50 GMT
Hi, On 4/15/06, Greg Kick <email@example.com> wrote: > your response actually outlines the reason i brought it up. although > the spec uses the * notation in its definitions, it pretty clearly > states: You are right. However, the "*" in the item definitions is rather treated as a special marker than a real name. There are predicates like def.getName().equals(ItemDef.ANY_NAME) and the more "correct" def.definesResidual() in Jackrabbit sources that explicitly decide whether a definition is residual or not, and if it is, then the name is not used for anything else. > further, it seems that the only reason that new QName("", "*") > doesn't fail with an exception is that "The local part is not > validated as a NCName as specified in Namespaces in XML" as stated in > the javadoc for QName. I kind of agree with you here; having an invalid QName instance feels a bit troublesome even if it is just a marker constant. Enforcing the use of ItemDef.definesResidual() throughout Jackrabbit sources would allow us to hide the QName.ANY_NAME constant and allow us to use some other way to identify residual definitions (a null name for example). > specifically, the fact that many node type definitions aren't valid > under nt:nodeType is worrisome. I just doublechecked that Jackrabbit is conformant in that there is no jcr:name property in residual item definitions under /jcr:system/jcr:nodeTypes. You can find definesResidual() calls in VirtualNodeTypeStateProvider guarding whether the jcr:name properties are exposed in item definition nodes. So this is already being taken care of. BR, Jukka Zitting -- Yukatan - http://yukatan.fi/ - firstname.lastname@example.com Software craftsmanship, JCR consulting, and Java development
|View raw message


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Question: The current standard audit report differs significantly from the version
The current standard audit report differs significantly from the version issued during the 1920s. Identify the key differences in the two reports and discuss the forces that accounted for the evolution of the audit report into its present form.
View Solution:
View Solution:
Answer to relevant QuestionsWhy was it common in the 1920s for companies to have only an audited balance sheet prepared for distribution to external third parties? Comment on the factors that, over a period of several decades, resulted in the adoption ...Assume that the investors defrauded by Nay could have filed their lawsuit against Ernst & Ernst under the Securities Act of 1933. How, if at all, do you believe the outcome of their suit would have been affected?A key issue in the overtime lawsuits is whether audit staff below the position of audit senior requires close supervision and have the ability and authority to exercise "independent discretion and judgment." Do ...Acme, Inc., a multinational company based in the United States, has a large subsidiary located in Beijing, China. Acme is audited by an international accounting firm headquartered in the United States; its subsidiary is ...Should the SEC have the authority to highlight or bring special attention to certain disclosures made by SEC registrants? Why or why not?
Post your question


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A Louisiana police captain defied Obama's race-baiting agenda this week to send a very blunt message to a local street gang.
"You will be hunted. You will be tracked. And if you raise your weapon to a man like me, we'll return fire with superior power,' said Captain Clay Higgins in a video message as he stood with officers from over a dozen Louisiana law enforcement agencies.
According to Daily Mail, Higgins explained that a local gang known as the Gremlins had been terrorizing the community of St. Landry Parish, where he is from.
"Every one of these animals is most definitely armed and dangerous," Higgins said of the gang.
"You think men like these are afraid of an uneducated, 125 lbs punk like you? That's never won a fair fight in your life, and holds your gun sideways?" he asked, referring to a specific gang member. "I'll meet you on solid ground anytime, anywhere, light or heavy, makes no difference to me. You won't walk away."
"The Gremlin street gang is all bad. And the fact that they're so extremely violent, every day that they're lose is a danger to the community," Higgins told KATC. "I'm hopeful that the Acadiana community can make a strong stand, and by extension, perhaps the country, will hear this message and make a strong, unified stand."
Liberals are of course furious about this, but we love it. SHARE this story if you support Higgins and his message!


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Pretty simple, what do guys in high school usually look for in a girl. Physically and stuff
Most Helpful Guy
If I can talk to you like I do with the boys, you're in. Really as long as you take care of yourself and wear flattering, in style clothing you'll be good for looks. You don't need big breasts or a butt, they just need to not look like the back of an IPhone or fat and untoned. Try to show off what you have. Don't wear legging with no butt etc. I know many people that I don't find particularly attractive that are because of their personality. Honestly when it comes to looks there's a perfect look for every guy. Personality is so important though, and that's what you should focus on. Learn to flirt and to take care of yourself, and you'll be good.00|00|0


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Re: [json] JSON Query discussion group
Expand Messages
- Hi Kris! I think this is a good group to have. :)
One quick question: I was wondering about naming of the effort.
To me, "Path" and "Query" imply somewhat different (but overlapping)
feature sets:
* Path leaning towards traversal and selection of nodes, similar to
XPath, JsonPath
* Query seems more oriented towards aggregate operations (SQL, XQuery, Jaql)
Others may have different connotations with these terms.
But given the description of goals, it seems to me that the effort
would be more geared for defining a Path language, and not Query
Am I totally off here? I just wonder if naming might lead people to
read too much into the effort; even if actual goals are clearly
-+ Tatu +-
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text: Volunteers needed for state archaeological work By The Associated Press April 29, 2013 Story Share MORGANTOWN, W.Va. -- A team set to explore the Grave Creek Mound Archaeological Complex in Moundsville is looking for volunteers this summer.As many as 15 participants will help contribute to West Virginia's preservation and educational goals while also learning about the region's ancient history June 2-9.The West Virginia University Native American Studies Program, the Division of Culture and History and the Humanities Council are partners in the program. It includes free lodging in Moundsville and transportation between Morgantown and Moundsville, plus partial reimbursement for dining and mileage.Also planned are a nightly film series and an all-day archaeological symposium on June 8. The featured speaker is Rebecca Morehouse, curator of state collections at the Maryland Archaeological Conservation Laboratory. Story Share Story Share Trending Now 1 Bulletin Board: Aug. 16, 2017 2 Bulletin Board: Aug. 15, 2017 3 Bulletin Board: Aug. 18, 2017 4 Bulletin Board: Aug. 14, 2017 5 Bulletin Board: Aug. 17, 2017 Rockefeller, Toyota mark milestone at Buffalo plant Previous Story State cyclists raise funds to support 4-H campers Next Story


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Hall Console Tables with Storage
Hall Console Tables with Storage – Console tables are the right answer for desk house in either an entryway or behind a sofa. Console tables are either lengthy and rectangular or shorter and in the shape of a half circle.
Hall console tables with storage might be very functional when positioned in the dining room or dwelling room. This console desk might be the enticing house furnishings that draws the visitor vision. It can be true with some conditional. The decoration on the console desk may be considered as a result of the decoration represents the room profile.
Overall, this tables are amazing and very popular in the world. That's all about of Hall Console Tables with Storage.


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We have one twin and one single bedroom, both of which are very comfortable with lovely views. There is a bathroom and separate toilet near each room. Other facilities in bedrooms include; TV, radio, wash basin, razor point, hair dryer, tea and coffee making facilities and ironing facilities.
Train: London (Victoria Station) direct to Lewes (about 1 hour); Gatwick (35 minutes); Brighton (15 minutes).
Car: M23 from London, A23 then A27 to Lewes; from Brighton and Eastbourne, take the A27 to Lewes.
We can supply individual directions when we know which area you are coming from; we send visitors a detailed map when acknowledging deposits.
Peaceful caravan site in idyllic South Downs setting
From £8 per pitch per night
Elegant yurts in 150 acres of ancient woods river & wildlife
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Beachy Head lighthouse B&B with panoramic South Downs view
From £138 - £210 per room per night
Magical shepherds hut retreat in the Sussex countryside
From £100 - £120 per accommodation per night


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Uncaged 2016 Full Movie Online Watch in HD Quality Download free Hollywood movies 2016.
Stars: Gene Jones, Ben Getz, Kyle Kirkpatrick, Garrett Hendricks
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Released: 02 Feb 2016
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This is a list of individuals belonging to cyborg races and cultures.
- Individual characters with unknown species origin will be listed here. If a cyborg character's species is known, they should instead go in a subcategory.
"Cyborg is a term derived from the English language words "cybernetic organism", referring to a...Cyborg


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4 Ft Easter Bunny in Flower Pot Airblown Inflatable
- Sold for: Start Free Trial or Sign In to see what it's worth.
- Item Category: Entertainment
- Source: eBay
- Sold Date: Jan 25, 2008
- Channel: Auction House
*4 Foot Easter Bunny in Flower Pot Airblown Inflatable-New*Blows up in minutes with a built-in Heavy Duty Fan. Easy assembly! Made of lightweight durable nylon. This Gemmy Air Blown Inflatable Easter Decoration sets up easily and collapses into original box for easy storage. 4 feet tall Just Inflate and Celebrate !


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It's there a reason they make the kids seem evil and look like they are descendants of Damon's from the Omen lol? I mean, they are oranges, no kid should be that angry about an orange.
So, what's the point of making them look like this
I certainly wouldn't want to give a child an orange that makes them demonic lol. It's just I don't get what the point of this advertsing pitch is. Any thoughts?


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Put back what you take
Removal rates aren't the same across your field
As we wrap up another cropping season, I hope that your year has been a success. As I write this in late August, for publication in October, I am hopeful for a record corn and soybean harvest. With record yield potential comes some management decisions you need to make prior to planting next year's crop. Management decisions regarding soil fertility are critical to give your crop the potential for great yields again next year. In that sense, I believe MFA's Nutri-Track program has a fit on all acres across our trade territory.
Nutri-Track is is designed to manage, maintain and track fertility levels across operations by combining GPS-based soil testing and yield monitoring. Whether you raise corn, soybean, wheat or forage, your soil's nutrient levels are a critical factor in maximizing production. Nutri-Track has three unique stages that will fit any operations.
Stage 1: Intensive soil sampling
Nutri-Track's 2.5-acre grid-sampling program will provide a baseline for your field's nutrient levels and soil properties. This is essential to correct any underlying problems so that you can maximize yield. We also use this program for range and pasture ground to maximize forage production and grazing capacity.
Stage 2: Intensive soil sampling with yield monitor crop removal
MFA Nutri-Track techs combine the information they receive from the 2.5-acre grid samples with yield data to give you a tailored recommendation for your nutrient removal and build program. By using yield monitor data, you will no longer have to use a flat yield removal rate. Thus, in the future, you can apply the right amount of fertilizer to the right areas of your fields. You won't be over-applying in low-producing areas of the field. You will boost production in areas that can support additional yield goal.
Stage 3: Yield monitor crop removal
This is perfect for fields that already have optimum fertility. You maintain those levels by replacing exactly what you have removed. This program is also a good fit for rented ground.
The question that I most often get is, "Why should I enroll in this program?"
We all know that each field has areas that out-yield the rest of the field. By employing the data analysis along with precision application, you can apply fertilizer with true variable-rate technology. You will get your nutrients to right spots in the field. The practice has proven itself.
The next question that I get is, "Through this program I will spend less money on nutrients, correct?"
That is not always the case. When I look at composite data from our precision techs, I see that growers are under fertilizing areas of the field and sometimes over fertilizing other areas. Cost might be a wash, but putting the nutrients where they are most efficiently used has the potential to boost yield.
This year looks to be one of the best we have seen in several years across our trade territory as a whole. I understand that there are parts of our trade territory that won't see record yields. This program is still a fit for those acres. At MFA we support the 4 R's: The Right fertilizer source,
Right rate, Right time, and Right place. As an industry, this is an important concept. Regulators and environmentalists scrutinize agriculture more each year. We need to manage our inputs and be good stewards.
MFA can help you develop a plan for all of your acres and make sure we are using your nutrients to the best of their ability for maximized profit.
Contact your local MFA location to make a nutrient management plan. It's a good practice.


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Newcastle post stunning financial results
Newcastle United have announced record profits of £18.7m for last season, as the tight financial ship run by Mike Ashley continues to post strong financial results.
The club also saw revenues increase by 35 per cent from £95.9m to £129.7m, which is due in part increases in television income and new deals with sponsors.
More than half Newcastle's income - £78.3m - came from the new Premier League television rights deals, with commercial income also increasing.
A Newcastle statement said: "Most significantly, the club reported strong commercial revenue growth delivering £25.6m in 2014, up from £17.1m in 2013.
"This 49.7 per cent increase was largely the result of two lucrative new deals with the club's principal sponsors, Wonga and Puma."
Owner Ashley remains a hugely unpopular figure among Newcastle fans who accuse him of putting profit before the club's ambition, with these latest figures confirming his policy of spending within the club's means is reaping rewards off the pitch.
Newcastle's healthy financial position also makes them a hugely attractive prospect for any potential buyer to snap up if Ashley decides to walk away from the Premier League club any time soon.