Trunkus kontrol hos børn med CP – hvordan kan det måles og hvorfor er det vigtigt?

CPOP dag 2015

Derek Curtis, FT PhD Hvidovre Hospital

Postural control in CP

Static postural control has been shown to be linked to gross motor function in children with CP (Pavão et al 2014, van der Heide et al 2005, Curtis et al 2015)

A stable posture requires interaction between sensory systems, the central nervous system and the musculoskeletal system. In CP, these systems and the interactions between systems are affected causing postural control deficits (Woollacott and Shumway-Cook 2005).

Importance of trunk and head postural control to function

Head control

• Respiration - Optimal respiration requires neutral or extended neck (Paal et al 2010)

• Communication – verbal and non-verbal

• Eating and drinking - Correct postural alignment is important in the normal feeding/swallowing process (Redstone 2004)

• Stabilising sensory systems- vision and vestibular

• Comfort

• Cosmetic

Trunk control

Independent sitting (Saavedra et al 2012)

Reaching (Rachwani et al 2015)

Gait (Ledebt 1995)

Gross Motor Function (Curtis et al 2015)

Is trunk control affected in CP?

Method

• 100 children with CP

• Trunk control Measurement Scale (TCMS), GMFCS and impairment topography (hemi-, di-, quadriplegi)

Results

Median TCMS score 38.5 out of 58 (66%)

• Median subscale scores were

- 18 out of 20 (90%) for the subscale static sitting balance,

- 16 out of 28 (57%) for the subscale selective movement control and

- 6 out of 10 (60%) for the subscale dynamic reaching. • Total TCMS and subscale scores differed between topographies and

GMFCS.

Conclusion

Children with:

• Hemiplegia and diplegia:

- static trunk control = limited difficulties .

- active trunk movements (within and beyond BoS) = impaired

• Quadriplegia:

- profound difficulties with both static and dynamic aspects of trunk control.

Trunk deficit increases with GMFCS level

Method

• A two-tiered search in August 2012 using nine peer-reviewed electronic databases

•Nine articles with relevant information on seven clinical measures.

Bañas and Gorgon 2014

Conclusion

Four of seven clinical measures recommended for use in practice:

1. Pediatric Reach Test (PRT),

2. Sitting Assessment for Children with Neuromotor Dysfunction (SACND),

3. Segmental Assessment of Trunk Control (SATCo), and

4. Trunk Control Measurement Scale (TCMS)

Test instructions

1. No orthoses, shoes and/or a trunk brace

2. Sitting on the edge of a treatment table without back, arm or feet support.

3. The thighs make full contact with the table.

4. The hands rest on the legs, close to the body.

5. The patient is asked to sit upright at the start of each item and needs to be encouraged to maintain the upright position during the performance of the task.

6. Each item is performed three times. The best performance is taken into account for scoring.

7. If the child performs the tasks of subscale ‘static sitting balance’ with single arm support, only support with the hand flat on the table without grasping is allowed.

Example items from TCMS

Scoring

3 subscores

• Static sitting balance (20 points)

• Dynamic sitting balance (28 points)

• Dynamic reaching (equilibrium reactions) (10 points)

Total TCMS score max 58 points

Evidence

Method

• 26 children with spastic CP

• GMFCS I-III

• 30 TD children

• Tested on two occasions by two therapists

Results

• Inter-rater repeatability: ICC 0.98 (excellent repeatability)

• Test-retest repeatability: ICC 0.97 (excellent repeatability)

• Construct validity: Spearmans rank coefficient TCMS and GMFM 0.88. Ingen correlation med dim A lying and rolling.

(Heyrman et al 2011)

Conclusion

• TCMS is suitable for children who can maintain a sitting position therefore focusing on GMFCS I-III.

• Children with lower functional levels might better be evaluated with an evaluation tool that does not require independent sitting, such as the SATCo.

(Heyrman 2011)

The Segmental Assessment of Trunk Control (SATCo) test

Head Control

Upper Thoracic Control

Mid Thoracic Control

Lower Thoracic Control

Upper Lumbar Control

Lower Lumbar Control

Full Spinal Control

Reactive Active

Static

Static (steady state)

Align and maintain 5 seconds

Active

Hold alignment while turning head

or reaching

Reactive

Maintain or quickly return to

upright when perturbed

SATCo test of 3 aspects of upper thoracic control in an 8

year old with CP

1. STATIC

2. ACTIVE

3. REACTIVE

Scoring the SATCo test

The test gives three scores; the levels at which postural control is poor: 1. static, 2. active and 3. reactive.

Evidence

Method

24 children with neuromotor disability mean age 10 yr 4 mo. Eight researchers independently scored recordings.

Results

ICC values for inter-rater and intra- reliability were > .84 and >.98 Concurrent validity with GMFM dimension B (resulted in Pearson correlation coefficients ranging from .73 to .83).

Conclusion

The SATCo is a reliable and valid measure allowing clinicians greater specificity in assessing trunk control.

The reliability of the Segmental Assessment of Trunk Control (SATCo) in children with cerebral palsy

Authors: Lisbeth Hansen, PT MSc1,2, Katrine Thingholm Erhardsen, PT MSc3, Stig Peter Magnusson, PT, DMSci4, Jesper Bencke, Msc Phd.2, Derek John Curtis, PT Msc, PhD1,2

Method

31 children tested twice by two testers

GMFCS I-V

Results

Relative reliability was excellent (ICC≥0.9) except for one analysis for which it was good. Complete agreement between scores was seen in 73% of cases. In 20% of cases the absolute difference in agreement was one level while 7% showed disagreement greater than one segmental level.

Conclusion

SATCo is a relevant assessment tool with potential for implementation in clinical practise. Relative reliability was excellent and absolute reliability varied with the SATCo score but was generally good.

Pediatric Reach test

Pediatric Physical Therapy 2003 15 (2)pp 84-92

Sitting and standing assessment

Test procedure for sitting

Testing protocol

Sitting dimension

• Sit on bench with no back or sides

• Feet on floor

• Hands in lap

• No external stabilisation with hands or legs

• 15 s quiet sitting

• Sit up tall

• Reach as far as possible with three second count at end of movement

Scoring

Reach length in cm

Evidence

Method

19 typically developing children

10 children with CP

Concurrent validity on standing and TD children only

Results

Construct validity: GMFCS and PRT Pearson correlation rs-0.88 (p<.001)

Inter-rater sitting section ICC 0.84

Interday not reported

(Bartlett and Birmingham 2003)

Sitting Assessment for Children with Neuromotor Dysfunction (SACND) Reid DT, Schuller R, Billson N

Measures sitting postural control in children with neuromotor disabilities:

• Aged 2 - 10 years,

• who can sit without constant hand support.

The test consists of 2 x 5 minute phases which are videoed:

1. Rest - sitting independently on a bench while listening to a story or watching a video.

2. Reach - sitting on a bench independently and reaching towards objects on a board - centrally, up, down, and to each side, with the favoured hand. Propping with hand(s) on the body or bench is acceptable, but the child resting their hands in their lap achieves optimum scoring.

Phys Occup Ther Pediatr 1996; 16: 23-32

Reach test

Test procedure

• The test is scored from the video.

• Criteria are given for ‘normal’ behaviour for each of the constructs, including three key features (score=1); and lower levels of behaviour, missing one or more of those features (scores = 2, 3, or 4).

• Lower scores therefore indicate higher ability

• A score of 4 indicates that independent sitting balance was not maintained.

Evidence

Inter-rater agreement 67-92% ICC>.99

Test retest ICC>.99

(Reid et al 1996)

Conclusion

“The results indicated the SACND to have good to excellent inter-rater and test-retest reliability when used by well trained raters” Reid et al (1996)

Testing trunk control – who, why, when and how?

Who: child where truncus control is/could be an issue, especially GMFCS 2+ (Heyrman et al 2013)

Why: to determine the child’s trunk control skills in order to plan an intervention or determine the effect of an intervention.

When: preparing a status on a child or assessing the effect of an intervention. Assessing a child’s support requirements in walking aids/adaptive seating.

How: using an instrument with known clinimetric properties that is

•Valid

•Repeatable

•Sensitive to change for the group of children that your subject belongs to (i.e the same GMFCS group and cognitive level the test was developed for)

1. There are a number of measurement instruments that can be used to measure sitting balance in children with CP

2. The trunk plays a key role in gross motor function in children with CP

3. Trunk control is worst in severe CP

4. Measuring trunk control allows us to determine where our training should be targeted and not least allows us to measure the effect of our training.

Thank you for listening