Trunkus kontrol hos børn med CP hvordan kan det måles og hvorfor er det vigtigt? CPOP dag 2015 Derek Curtis, FT PhD Hvidovre Hospital

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1 Trunkus kontrol hos børn med CP hvordan kan det måles og hvorfor er det vigtigt? CPOP dag 2015 Derek Curtis, FT PhD Hvidovre Hospital

2 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).

3 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)

4 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.

5 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

6 Method A two-tiered search in August 2012 using nine peer-reviewed electronic databases Nine articles with relevant information on seven clinical measures.

7 Bañas and Gorgon 2014

8 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)

10 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.

11 Example items from TCMS

12 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

13 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 Ingen correlation med dim A lying and rolling. (Heyrman et al 2011)

14 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)

15 The Segmental Assessment of Trunk Control (SATCo) test Static Head Control Reactive Active Upper Thoracic Control Mid Thoracic Control Lower Thoracic Control Upper Lumbar Control Lower Lumbar Control Full Spinal Control 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

16 SATCo test of 3 aspects of upper thoracic control in an 8 year old with CP 1. STATIC 2. ACTIVE 3. REACTIVE

17 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 >.

18 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.

19 The reliability of the Segmental Assessment of Trunk Control (SATCo) in children with cerebral palsy Authors: Lisbeth Hansen, PT MSc 1,2, Katrine Thingholm Erhardsen, PT MSc 3, Stig Peter Magnusson, PT, DMSci 4, Jesper Bencke, Msc Phd. 2, Derek John Curtis, PT Msc, PhD 1,2 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.

20 Pediatric Reach test Pediatric Physical Therapy (2)pp Sitting and standing assessment

21 Test procedure for sitting

22 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

24 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 r s (p<.001) Inter-rater sitting section ICC 0.84 Interday not reported (Bartlett and Birmingham 2003)

25 Sitting Assessment for Children with Neuromotor Dysfunction (SACND) Reid DT, Schuller R, Billson N Phys Occup Ther Pediatr 1996; 16: 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.

26 Reach test

27 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.

29 Evidence Inter-rater agreement 67-92% ICC>.99 Test retest ICC>.99 (Reid et al 1996)

30 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)

31 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)

32 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.

33 Thank you for listening

Putting the Rehabilitation into Complex Rehab Technology

Chapters Putting the Rehabilitation into Complex Rehab Technology THE INTEGRATION OF TARGETED THERAPY IN A DYNAMIC STANDING PROGRAM How normal motor control development and skill acquisition is dependent