Northland Community and Technical College

Occupational Therapy Assistant Program

Critically Appraised Topic Assignment
Focused Question:

How can Occupational Therapy improve the health and wellness in Adolescents
diagnosed with Prader-Willi Syndrome who are obese?

Clinical Scenario: Prader-Willi Syndrome is a rare disorder caused by a genetic

abnormality. This syndrome affects approximately 1 in 16,000 people (Delparigi et.
al, n.d.). It is characterized by excessive hunger, low muscle tone, poor growth, and
a developmental delay (Prader-Willi syndrome, n.d.). Due to the symptom of
excessive hunger, otherwise known as hyperphagia, obesity is a major problem in
adolescents with Prader-Willi syndrome. Obesity can then lead to diabetes, heart
complications, and lung problems.
Children with Prader-Willi syndrome who are obese can generate many physical and
mental problems such as: stiff or weak joints, high blood pressure, or certain
cancers (Why Obesity Is a Health Problem, n.d.). These problems may lead to many
different medications that need to be taken which can then lead to many other
problems due to medication side effects.

Summary of Key Findings:

Level III
A Reduced Energy Intake, Well-Balanced Diet Improves Weight Control in
Children with Prader-Willi Syndrome; Miller, Lynn, Shuster, and Driscoll
(2013)
In this study, a total of 63 children with Prader-Willi Syndrome between 2 and
10 years were measured for body composition and energy expenditure. They
participated in a 3-day diet analysis before and after the implemented reduced
energy diet. The purpose of the study was to see the effectiveness of weight control
when using a well-balanced diet containing fat, carbohydrates, protein, and fiber. Of
the total 63 children, 33 reduced their energy intake as asked. The other children
reduced their energy intake as well, but failed to meet dietary standards. This
ultimately made a difference in results, as those who adhered to the energy intake
amount were able to eat more and still maintain a lower body fat percentage than
those who did not follow the standards. Overall, a reduced energy, well-balanced,
nutritious diet showed an overall positive effect in weight-management in those
with Prader-Willi Syndrome.
Specific Treatment of Prader-Willi Syndrome through Cyclical
Rehabilitation Programmes; Grolla, Andrighetto, Parmigiani, Hladnik,

Ferrari, Bernardelle, Dal Lago, Albarello, Baschirotto, Filippi, Lovato, and

Dolcetta (2011)
This study looked at the effectiveness of a rehabilitation program. A total of 49
patients were observed, with approximately half female and half male participants
in their late teens. Four times a year, these patients would attend a 4-week
rehabilitation program, consisting of a specific caloric diet, physical exercise, and
different activities to evaluate overall independence and abilities. This program
included music therapy, psychomotor therapy, education, and entertainment
activities. After these 4-week interventions, results showed that the participants
overall body mass index (BMI) decreased. This program was shown to be effective
for individuals with Prader-Willi Syndrome; furthermore leading to a significant
weight loss, thus creating an overall healthier well-being. In conclusion, a strict diet
and activity program can benefit individuals with Prader-Willi Syndrome.
Level IV
Childhood Obesity as an Emerging Area of Practice for Occupational
Therapists: A Case Report; Pizzi and Orloff (2015)
This article highlights a case study of a family of obese individuals. The study
focuses on two daughters, aged seven and five, their occupational therapy services
they receive, and their new plan of intervention. Both have been receiving services
for motor and learning disabilities, but the occupational therapist decided to
incorporate an obesity intervention in their overall plan of care. The purpose of
adding this new intervention was to recognize the affects obesity has on ones
overall cognitive capabilities. To start the new intervention, the care team educated
the teachers on the effects obesity has on learning in order to help meet the two
daughters mental, physical, and social needs. The next part they focused on was
the parents lifestyle and participation with the intervention, which proved to impact
the childrens lifestyles. The occupational therapist then developed a home program
to help focus on school, exercise, and family routines. With this program, they
incorporated nutritional guides and developed ways around family routines that
were affecting their performance. After the program, the family had varied
responses to the intervention. Responses included support, defensiveness, and
overwhelmed feelings. Overall, the program positively impacted the family and
helped the family develop a more structured lifestyle to help with participation in
the occupational therapy intervention.
Level V
Obesity and Occupational Therapy (Position Paper); Salles-Jordan, Katie
(2007)
Obesity is a major issue that results in a significant decrease in participation
of activities of daily living. Occupational Therapy plays a role in helping people who
are obese by regaining the ability to complete their activities of daily living such as:
play, work, and self-care. Occupational Therapy professionals help develop a plan
for people who are obese, which helps motivate the client to participate in daily life
routines. Not only can occupational therapy be helpful in the clinical setting, but in
many community settings as well. Many education programs are implemented

throughout the community and provide many opportunities for change to the
environment with the addition of adaptive equipment such as cupboard locks. Also
included are wellness programs such as nutrition and fitness management, along
with developing eating routines with use of visual schedules. Occupational Therapy
is very beneficial to individuals who struggle with obesity because it allows them to
become more independent and motivated to participate in daily living activities.
Genetically determined obesity in Prader-Willi syndrome: The ethics and
legality of treatment; Holland, Anthony J., and Wong, Josephine (1999)
Prader-Willi Syndrome is a disease that is characterized by a non-satisfiable
appetite, which leads to overeating and can ultimately result in obesity. Many
people who are diagnosed with Prader-Willi Syndrome do not get the correct type of
care that they need to be successful and independent in daily living. Many
caregivers take away a clients independence by not allowing them to make
decisions on their own. For example, some caregivers dont allow those diagnosed
with Prader-Willi Syndrome to determine their own eating schedule and eating
habits due to poor health results. This takes away the clients independence, which
is a huge concern for ones lifestyle. It is argued as to whether caregivers should be
able to make final decisions for the individual with Prader-Willi Syndrome. In the
article, it concludes that there is no definite rule stating what the caregiver can and
cannot do when it comes to decision-making. The final results depend on each
clients specific situation, the clients mental capacity, and their overall health and
wellbeing. In conclusion, it is vital to the clients health to implement a wellness
program to allow the individual to manage and control their symptoms that overall
lead to obesity.
Qualitative
Identifying Strategies Early Intervention Occupational Therapists Use to
Teach Caregivers; Colyvas, Sawyer, and Campbell (2010)
In this study, a random sample of occupational therapy early intervention
videotapes were selected to review and analyze different techniques and strategies
used throughout therapy sessions. The overall purpose of this study was to compare
traditional service approaches versus client-based service approaches for
caregivers. These videotapes were reviewed and then used to compare the different
techniques. Overall, the results showed that for caregiving, a participation-based
approach was more beneficial to the patients because of the overall involved
concept of the caregivers.
Obesity, Stigma and Occupational Therapy; Leemhuis, Karen, and
Cozzolino, Melinda (2010)
Research shows that obesity is a prevailing issue throughout the world and
can not only lead to physical problems, but mental problems as well such as
depression. Occupational Therapy for people who are obese is very significant.
Occupational Therapy allows for the ability to engage in daily living activities and
regain independence. Many Occupational Therapy goals for people who are obese
are to establish and maintain certain skills such as: self-care, self-esteem, leisure

activities, the use of adaptive equipment for overall energy conservation, range of
motion limitations, and looking at overall functional mobility. In this article, a survey
was given to people at least 18 years of age and to some Occupational Therapy
professionals. It looked at different clinical experiences with obesity, overall attitude
towards obese people, and what they believed were clinical barriers. The survey
found that most Occupational Therapy professionals do not have enough
background knowledge regarding obesity. Results did show that many Occupational
Therapy practitioners were familiar with transferring, specific equipment, proper
work environment, and different staffing that is needed when working with clients
who are obese; however, they are not well educated on how to promote
independence and decrease obesity. Overall, the results of these questionnaires and
surveys showed that there is a lack of education in prevention of obesity, but with
experience over time with clients who are obese, treatment becomes more
beneficial.
Autonomy and Intellectual Disability: the Case of Prevention of Obesity in
Prader-Willi Syndrome; van Hooren, Widdershoven, van den Borne, and
Curfs (2002)
In this study, qualitative interviews were conducted to determine what
individuals with Prader-Willi Syndrome have for decision-making; in other words,
determining whether the individual themselves are allowed to make their decisions
regarding eating habits or whether the caregivers determine the decision for them.
These interviews found that Prader-Willi caregivers seek many options including
visual schedules and cupboard locks to create the clients eating routine. Many
caregivers do not allow the individual to make choices for themselves, thus reducing
their independence. Another interview was conducted to determine the individuals
with Prader-Willi Syndromes history of eating habits and past behaviors. From these
interviews, they concluded that caregivers base their decisions on past behaviors
and habits, but do not base their overall choice on the individuals character. The
lack of individual freedom and making choices is an argument based on morals. This
article concludes that by developing different concepts of autonomy, or making
individual choices, it will be easier to develop a framework to allow individuals with
Prader-Willi Syndrome to determine their wants and needs independently.

Bottom Line for Occupational Therapy Practice:

Occupational Therapy Practitioners can provide a variety of different programs and treatments to
improve functionality for children with Prader-Willi Syndrome (PWS) who are obese. Evidencebased research has provided many strategies which include education, dieting, exercise,
functional mobility, and participation in activities of daily living. Occupational Therapy for
children with Prader-Willi Syndrome who are obese would be a wonderful opportunity because it
can help with education of the disease, a decrease in obesity, and an improvement in the childs
overall health and well-being. The goal of this research is determine the need for Occupational
Therapy in children with PWS. Research shows that Occupational Therapy can benefit children
in many ways that ultimately result in the same goals. These goals include a decrease in obesity,
an improvement in participation of daily living, and increasing the clients health and well-being.

According to Colyvas, Sawyer, and Campbell (2010), Occupational Therapy can focus on
implementing treatments that are client-based rather than providing traditional treatment. This
benefits the client by including their specific needs and goals to motivate them to participate in
therapy. Not only does a client-centered treatment motivate the client, but it also teaches
caregivers that independence and meeting needs and wants of the client makes a huge difference
in their overall well-being. Salles-Jordan (2007) states that creating a client-centered,
individualized plan increases the clients interest and motivation as well. Research shows that
including a client-centered, individualized plan during treatment implementation overall benefits
the client and their health.
Another strategy that has been shown to increase independence and improve the well-being of
clients with Prader-Willi Syndrome who are obese is to educate on freedom with decisionmaking and to educate on character and attitude towards obese individuals (Leemhuis and
Cozzolino, 2010). According to Holland & Wong (1999) and van Hooren and van den Borne
(2002), giving an individual with PWS the freedom to make their own decisions about eating and
feeding teaches them self-discipline and teaches symptom maintenance in the long run.
Occupational Therapy plays a huge role in education for people with PWS. Not only do OT
professionals educate the clients, but they educate the family and caregivers as well to develop a
care plan that will give the most benefit to the client. Freedom of decision-making results in
improved health and increases functional independence. When it comes to education on attitude
towards obese patients, it is important for Occupational Therapy professionals to keep the Code
of Ethics in mind, specifically treating all patients equally to the best of your knowledge. This
decreases clinical barriers, which then leads to an increase in improved health and wellbeing of
adolescents with PWS (Leemhuis and Cozzolino, 2010).
According to Miller, Shuster, and Driscoll (2013) and Grolla et. al (2011), developing a strict diet
plan and physical exercise program that included riding a stationary bike and completing
exercises on an exercise mat significantly decreases obesity in children with PWS. During this
study, the participants showed an average daily body weight loss of 0.22 kg, or approximately
0.5 pounds. Research shows that a diet not only decreases obesity, but it improves the clients
management of symptoms which ultimately leads to increased independence. Teaching diet and
physical exercise strategies at a young age will help develop a habit that will likely be continued
throughout life.
Education on creating a structured lifestyle has also been shown to benefit adolescents with PWS
(Pizzi & Orloff, 2015). Developing a specific lifestyle helps give children with PWS structure,
which ultimately leads to independence and increasing their overall well-being. Managing and
decreasing obesity by creating a structure for these children has been shown through research.
Changing a childs unhealthy lifestyle early will benefit the child as they grow older.
Occupational Therapy is a wonderful opportunity for children with PWS who are obese. OT
professionals can provide many home programs for families, can educate individuals as well as
the community on ways to manage the symptoms, and can also provide structured plans to
improve the clients independence leading to improvement in the childs occupations. To answer
the research question of How can Occupational Therapy improve the overall health and
wellbeing for children with PWS who are obese?, Occupational Therapy offers a variety of ways

to enable the child to become independent and to improve their health through education, home
programming, and structured plans.
Review Process:
Inclusion Criteria: People who are obese, Occupational Therapy, Prader-Willi
Syndrome, within 20 years, peer-reviewed, full text, adolescents
Exclusion Criteria: Past 20 years when research was found
Search Strategy:
Categories
Patient/Client Population
Intervention
Comparison
Outcome

Key Search Terms

Children, obesity, Prader Willi Syndrome
Occupational Therapy, Therapy, Treatment
N/A
Improved health and wellbeing

Databases and Sites Searched:

Databases: ProQuest Nursing and Allied Health Source, EBSCOHost
Sites: http://ghr.nlm.nih.gov/condition/prader-willi-syndrome
http://www.nhlbi.nih.gov/health/educational/wecan/healthy-weight-basics/obesity.htm

Quality Control/Peer Review Process:

The topic for this research question was formed as a personal interest and for an educational
purpose. First, a PICO worksheet was used to determine the specific research question. The
purpose for this topic was to determine how the profession of Occupational Therapy can benefit
adolescents with Prader-Willi Syndrome. Peer-reviewed journal articles were then gathered
regarding the research question through the NCTC library database. Once gathered, the articles
were then reviewed and summarized for information regarding the topic. A total of 8 peerreviewed articles were gathered to answer the research question. Once all information was
gathered and placed into appropriate sections, an OTAS peer-reviewed the critically appraised
topic for further editing.
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of Evidence Study Design/Methodology of Selected
Number of Articles Selected
Articles
Level I
Systematic reviews, meta-analysis,

Level II
Level III
Level IV
Level V

randomized controlled trials

Two groups, nonrandomized studies (e.g.,
cohort, case-control)
One group, nonrandomized (e.g., before
and after, pretest, and posttest)
Descriptive studies that include analysis
of outcomes (single subject design, case
series)
Case reports and expert opinion, which
include narrative literature reviews and
consensus statements

Qualitative

2
1
2
3

Limitations of the Studies Appraised:

Level III
Specific Treatment of Prader-Willi Syndrome through Cyclical
Rehabilitation Programmes; Grolla, Andrighetto, Parmigiani, Hladnik,
Ferrari, Bernardelle, Dal Lago, Albarello, Baschirotto, Filippi, Lovato, and
Dolcetta (2011)
Sample size consisted of only 49 patients
Only done once- if done more than once, would have shown more
validity
A Reduced-Energy Intake, Well-Balanced Diet Improves Weight Control in
Children with Prader-Willi Syndrome; Miller, Lynn, Shuster, and Driscoll
(2013)
Didnt consider medication side effects of individuals with PWS
Only 63 subjects used
Level IV
Childhood Obesity as an Emerging Area of Practice for Occupational
Therapists: A Case Report; Pizzi and Orloff (2015)
There wasnt any statistical data on the results
This study was from New Zealand
Family routine and lifestyle impacted results
Only 1 family involved
Not specifically on a child with PWS
Level V
Obesity and Occupational Therapy (Position Paper); Salles-Jordan, Katie
(2007)
Information was based on opinion, not factual, statistical data
Focused on just obesity, not specifically obesity in patients with PraderWilli Syndrome
Genetically determined obesity in Prader-Willi syndrome: The ethics and
legality of treatment; Holland, Anthony J., and Wong, Josephine (1999)
Information was not focused on treatment implementation
Information was expert opinion, no statistical data
Qualitative

Identifying Strategies Early Intervention Occupational Therapists Use to

Teach Caregivers; Colyvas, Sawyer, and Campbell (2010)
Small sample size
Comparisons of the two strategies are based on opinions of OT
professionals
Outcomes of therapy vary from person to person, not depending on
the intervention used
Obesity, Stigma and Occupational Therapy; Leemhuis, Karen, and
Cozzolino, Melinda (2010)
The results of the survey were not specific and individualized
Couldnt determine how attitudes affected Occupational Therapy
treatment
No comparison of attitudes towards obesity compared to other
conditions
Autonomy and Intellectual Disability: the Case of Prevention of Obesity in
Prader-Willi Syndrome; van Hooren, Widdershoven, van den Borne, and
Curfs (2002)
Study involved individuals with Prader-Willi Syndrome and Individuals
with Intellectual Disabilities, not just specifically individuals with
Prader-Willi Syndrome
Interview didnt allow caregivers to state reasoning for their actions

Articles Selected for Appraisal:

Colyvas, J. L., Sawyer, B., Campbell, P. H. (2010). Identifying strategies early
intervention occupational therapists use to teach caregivers. American
Journal of Occupational Therapy, 64, 776-785. DOI: 10.5014/ajot2010.09044
Grolla, E., Andrighetto, G., Parmigiani, P., Hladnik, U., Ferrari, G., Bernardelle, R., &
Dolcetta, D. (2011). Specific treatment of Prader-Willi Syndrome through
cyclical rehabilitation programmes. Disability & Rehabilitation, 22(19/20),
1837-1847 11p. doi: 10.3109/09638288.2010.549288
Holland, A. J., & Wong, J. (1999). Genetically determined obesity in prader-willi
syndrome: The ethics and legality of treatment. Journal of Medical
Ethics, 25(3), 230. Retrieved from
http://search.proquest.com/docview/216350616?accountid=40780
Leemhuis, Karen, M.S., O.T.R./L., & Cozzolino, Melinda, OTD, OTR/L,M.S., C.R.C.
(2010). Obesity, stigma, and occupational therapy. Physical Disabilities
Special Interest Section Quarterly / American Occupational Therapy
Association, 33(1), 1-3. Retrieved from
http://search.proquest.com/docview/236176144?accountid=40780

Miller, J. L., Lynn, C. H., Shuster, J., & Driscoll, D. J. (2013). A reduced-energy intake,
well-balanced diet improves weight control in children with Prader-Willi
syndrome. Journal of Human Nutrition & Dietetics, 26(1), 2-9 8p. doi:
10.1111/j.1365-277X.2012.01275.x
Pizzi, M., & Orloff, S. (2015). Childhood obesity as an emerging area of practice for
occupational therapists: A case report. New Zealand Journal of Occupational
Therapy, 62(1), 29-38. Retrieved from
http://search.proquest.com/docview/1718110894?accountid=40780
Salles-Jordan, K. (2007). Obesity and occupational therapy (position paper). The
American Journal of Occupational Therapy, 61(6), 701-3. Retrieved from
http://search.proquest.com/docview/231970072?accountid=40780
van Hooren, R. H., Widdershoven, G. A. M., van den Borne, H. W., and Curfs, L. M. G.
(2002). Autonomy and intellectual disability: the Case of prevention of obesity
in Prader-Willi Syndrome. Journal of Intellectual Disability Research, 46(7),
560-568 9p.

Other Resources Utilized:

Prader-Willi Syndrome. (n.d.). Retrieved September 11, 2015.
Delparigi, A., Tschop, M., Heiman, M., Salbe, A., Vozarova, B., Sell, S., Tataranni, P.
(n.d.). High Circulating Ghrelin: A Potential Cause for Hyperphagia and
Obesity in Prader-Willi Syndrome. The Journal of Clinical Endocrinology &
Metabolism, 5461-5464.
Why Obesity Is a Health Problem. (n.d.). Retrieved September 11, 2015.