Trunk control. Outline 13/09/2014. Hilde Feys. Disclosure of Relevant Financial Relationships

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Berenice Price
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Disclosure Information AACPDM 6 th Annual

trunk in children with cerebral palsy: The Trunk

Dr. Hilde FEYS Speaker Name: Lieve Heyrman Hilde

Relationships I have no financial relationships

Disclosure of Off-Label and/or investigative

investigational use in my presentation Faculty

Department of Rehabilitation Sciences, Leuven,

clinical assessment of trunk Trunk Introduction

1 Disclosure Information AACPDM 6 th Annual Meeting September 10-13, 2014 Evaluation of trunk in children with cerebral palsy: The Trunk Control Measurement Scale Dr. Lieve HEYRMAN Prof. Dr. Hilde FEYS Speaker Name: Lieve Heyrman Hilde Feys Disclosure of Relevant Financial Relationships I have no financial relationships to disclose. Disclosure of Off-Label and/or investigative uses: I will not discuss off label use and/or investigational use in my presentation Faculty of Kinesiology and Rehabilitation Sciences, Department of Rehabilitation Sciences, Leuven, Belgium Outline Introduction State-of-the-art of clinical assessment of trunk Trunk Introduction Trunk Control Measurement Scale Content and psychometric properties Administration of TCMS and scoring criteria 1

2 Trunk in CP Introduction Trunk in CP Introduction CLINICAL FINDINGS Increased trunk motion during functional activities Romkeset al Heyrman et al Increased/decreased tone Muscle weakness Decreased selectivity of muscle recruitment Prosseret al Spinal deformities Morrell et al Persson-Bunkeet al Trunk in CP Introduction Part 1: Clinical assessment of trunk Scientific evidence? CLINICAL FINDINGS Increased trunk motion during functional activities Romkeset al Increased/decreased tone Evaluation tools for trunk? Muscle weakness Trunk interventional research Methodological/descriptive studies Decreased selectivity of muscle recruitment Spinal deformities Prosseret al Morrell et al Persson-Bunkeet al systematic review 2

3 Part 1: Clinical assessment of trunk Trunk interventional research Review of databases Pub, Embase, Medline, Web of Science, The Cochrane Library, Psychinfo Trunk interventional research systematic review Methodological/descriptive studies In- exclusion criteria: Population: children with CP between 0 1 yrs Intervention: focus on trunk Intervention study Full-text, in English Physical therapy/conceptual treatments Three types of interventions Physical therapy/conceptual treatment Other therapy Equipment-supported therapy Taping Electrical stimulation, biofeedback, saddle riding, Hippotherapy Study N Intervention Trunk assessments Batra M et al Choi M et al Jonsdottir J et al Neurofacilitation of Developmental reaction vs NDT Other assessments GMFM Dim scores GMFM total scores Postural reactions 1/3 studies: Trunk-specific assessment(pas) 10 Task Oriented Training vs Trunk EMG GMFM Dim B NDT 2/3 studies: General assessment(gmfm Dim B) Practice of reaching task vs NDT Posture Assessment Scale (PAS) Head & trunk kinematics 3

4 Other therapy Equipment-supported therapy (1) Study N Intervention Trunkassessments Other assessments Bertoti DB et al. 19 Butler PB et al. 199 Footer CB et al Herrero P et al Karabay I et al Kuczynski M et al Park ES et al Biofeedback seat insert ti upright position of trunk 6 Targeted Training Segmental Assessment of Trunk Control(SATCo) 1 Therapeutic taping paraspinal muscles GMFMDim B GMFM total score 3 Hippotherapy simulator Sitting Assessment Scale GMFM Dim B GMFM total score 55 Functional electrical stimulation trunk muscles 25 Saddle riding COP 26 Electrical stimulation trunk muscles GMFM Dim B RX spinal angles GMFM Dim B RX spinal angles Other therapy Equipment-supported therapy (2) Study N Intervention Trunkassessments Other assessments Quint C et al Saddle riding Passive ROM pelvic tilt 4/12 Silva e studies: Borges MB Trunk-specific 40 Hippotherapy assessments(sas, SATCo, SACND) COP et al simulator 6/12 Simsek studies: TT et al. General 30 Kinesiotaping assessments(gmfm Sitting Assessment Dim B, ChaileyLevelsof Scale GMFM Dim B 2011 GMFM total score Ability) Unger M et al Wade W et al Vibration trunk muscles 13 Balance board gaming Position pelvic tilt Forward trunk sway Muscle thickness Sit-ups in 1 minute SittingAssessmentfor children with Neuromotor dysfunction ChaileyLevelsof Ability(box sitting) Other therapy Hippotherapy (1) Study N Intervention Trunkassessments Other assessments Other therapy Hippotherapy (2) Study N Intervention Trunkassessments Other assessments Bertoti DB et al. 19 Cherng RJ et al Haehl V et al Hamill D et al Hyungkyu K et al Kwon JY et al Hippotherapy Postureassessment scale 14 Hippotherapy GMFM Dim E Tone hip adductors 2 Hippotherapy Trunk kinematics 1 Hippotherapy Sitting Assessment Scale GMFM Dim B 45 Hippotherapy COP 32 Hippotherapy PediatricBalance Scale GMFM Dim D & E GMFM total score Gait parameters McGibbon NH et al. 199 MacKinnon JR et al Shurtleff TL et al Shurtleff TL et al Hippotherapy GMFM Dim E Gait parameters 19 Hippotherapy Postureassessment GMFM total score 3/10 studies: scale Trunk-specific assessment(pas, SAS) Peabody DMS Bruininks-Oseretsky Scale (fine motor) 1/10 studies: General assessments(gmfm Dim B) 19 Hippotherapy Barrel test (head & trunk kinematics) Functional reaching test 12 Hippotherapy Barrel test (head & trunk kinematics) 4

5 Summary Clinical assessmenttool Posture assessmentscale 3 Sitting assessmentscale 3 Sitting Assessmentfor children with Neuromotor dysfunction 1 SATCo 1 Chailey Levels of Ability 1 GMFM Dim B Numberof studies (25 in total) Summary Clinical assessmenttool Posture assessmentscale 3 Sitting assessmentscale 3 Sitting Assessmentfor children with Neuromotor dysfunction 1 SATCo - Limited detail on trunk 1 - Limited evaluation of psychometric properties Chailey Levels of Ability 1 GMFM Dim B Numberof studies (25 in total) Summary Clinical assessmenttool Posture assessmentscale 3 Sitting assessmentscale 3 Sitting Assessmentfor children with Neuromotor dysfunction 1 SATCo 1 Chailey Levels of Ability 1 GMFM Dim B Numberof studies (25 in total) Segmental Assessment of Trunk Control Assessment of static trunk during upright sitting, during head movements and during external perturbation Scoring 0-1 (present/absent) at 7 segmental levels of trunk Excellent intra- and interrater reliabilityand concurrent validity (Butler et al. 2010) Measures static aspects of trunk only Highly valuable in children with limited functional abilities (GMFCS IV & V) Butler PB

6 Sitting Assessment for children with Neuromotor Dysfunction Part 1: Clinical assessment of trunk Assessment of sitting abilities in two subsections In rest During reaching tasks Evaluation of four key features: postural tone, proximal stability, postural alignment and balance Qualitative scoring (1-4) for each key feature in each subsection Trunk interventional research Methodological/descriptive studies Excellent interrater and test-retest reliability, content validity (Reid D et al. 1995, 1996) Reid D 1995 Part 1: Clinical assessment of trunk Trunk interventional research Methodological/descriptive studies Spinal Alignment and Range of Motion Measure (SAROMM) Spinal alignment in upright sitting Sagittal, frontal and transverse plane Range of motion Mainly lower limbs Seated Postural Control Measure (SPCM) Static postural alignment & postural performance during functional activities in sitting Evaluation of static trunk only Bartlett & Purdie 2005 Fife

7 Trunk Impairment Scale Assessment of trunk in sitting in stroke patients Three subscales Static sitting balance Dynamic sitting balance Coordination Scoring on 2 to 4-point ordinal scale Total score = 23 Trunk Impairment Scale Evaluation of reliability and validity of TIS in children with CP Results: excellent intra- and interrater reliability (Saether et al. 2011, 2013) evidence for construct validity (Saether et al. 2013) High correlations with GMFM and GMFCS levels Assesses static and dynamic aspects of trunk Verheyden G et al Limitations of TIS Unilateral involvement of stroke <-> uni- and bilateral involvement in CP Not all movements planes were included Movements beyond the BOS were not included Part 2: Trunk Control Measurement Scale Content of the scale Evaluation of psychometric properties Trunk Control Adapted Measurement versionscale of TIS (TCMS) 7

8 Scale requirements Trunk Control Measurement Scale Isolated trunk Only sitting Feet unsupported Static and dynamic trunk Active trunk movements in three planes ~ Insights multidimensional into strengths and aspectsof weaknesses functionalmovements of child s trunk in ADL -> targeted intervention Detailed scoring system Information on performance TCMS Static sitting balance Selective movement Dynamic reaching Maintaining stable trunk during upper and lower limb movements Item 1-5 Selective trunk movements in three planes within base of support Item 6-12 Reaching tasks: active trunk movementsbeyond base of support Item Heyrman L, Molenaers G, Desloovere K, Verheyden G, De Cat J, Monbaliu E, Feys H. A clinicaltoolto measuretrunkin children withcerebralpalsy: the TrunkControl MeasurementScale. Research in Developmental Disabilities 2011; 32: Psychometric properties of TCMS Inter-rater & test-retest reliability Construct validity Discriminative ability CP vs TD children Subgroupsof CP ~ topography ~ functional abilities (GMFCS-levels) STUDY 1 STUDY 2 STUDY 1 A clinical tool to measure trunk in children with cerebral palsy: the Trunk Control Measurement Scale Heyrman et al. Res Dev Disabil 2011; 32;

9 Study 1 Results reliability Participants N= 26 spasticcp GMFCS level I-III TCMS total Static sitting balance Selective movement Dynamic reaching ICC interrater ICC test-retest Age 15yrs (11.2 ± 2 yrs) N= 30 TD children Age-matched SEM Interrater 1.6 (2.9%) Test-retest 1.97 (9.43%) SDD 4.66 (%) 5.47 (9.4%) Results reliability Results construct validity TCMS total Static sitting balance Selective movement Dynamic reaching ICC interrater Excellent interrater and test-retest reliability ICC test-retest TCMS Total GMFM Dim A lying Dim B sitting GMFM Dim C crawling Dim D standing Dim E walking/ jumping Total TCMS SEM Interrater 1.6 (2.9%) Small measurement errors Test-retest 1.97 (9.43%) SDD 4.66 (%) 5.47 (9.4%) Static sitting balance Selective movement Dynamic reaching

10 Results construct validity Results discriminative ability TCMS Total GMFM Dim A lying Dim B sitting GMFM Dim C crawling Dim D standing Dim E walking/ jumping Total TCMS Static sitting balance Selective movement Dynamic reaching Evidence for construct validity Total TCMS Static sitting balance Selective movement CP Median 33.5 (25-42) 17 (16-1) 13 (10-16) TD Median 53.5 (51-57) 20 (20-20) 24 (22-27) p-value < < Highly discriminative between CP and TD children Dynamic reaching 4 (1-9) 10 (10-10) < < Aim Study 2 TOPOGRAPHY STUDY 2 Clinical characteristics of impaired trunk in children with spastic cerebral palsy Differences in trunk deficits? HEMI DI QUADRI GMFCS levels Heyrman et al. Res DevDisabil2013; 34; Differences in trunk deficits? I II III IV 10

11 Methods Study 3 Spastic CP N= ± 2.1 yrs N=3 N=46 N=16 N=47 N=2 N=16 N=9 Results topography Study 3 TCMS (range) Total TCMS (0 5) Static sitting balance (0 20) Selective movement (0 2) Dynamic reaching (0 10) Hemiplegia 44.5 (37-50) 1 (1-20) 1.5 (14-22) (6-10) Diplegia 40 > (30-46) >> 1 (16-20) 16.5 (10-19) 5 (2-) Quadriplegia 13.5 (-21.5) (5-11.5) 5 (2-) 1 (0-1.5) Results topography Study 2 Results topography Study 2 TCMS (range) Total TCMS (0 5) Hemiplegia 44.5 (37-50) Diplegia 40 (30-46) Quadriplegia 13.5 (-21.5) TCMS (range) Total TCMS (0 5) Hemiplegia 44.5 (37-50) Diplegia 40 (30-46) Quadriplegia 13.5 (-21.5) Static sitting balance (0 20) Selective movement (0 2) Dynamic reaching (0 10) 1 (1-20) 1.5 (14-22) (6-10) 1 (16-20) 16.5 (10-19) 5 (2-) (5-11.5) 5 (2-) 1 (0-1.5) Static sitting balance (0 20) Selective movement (0 2) Dynamic reaching (0 10) 1 (1-20) 1.5 (14-22) (6-10) 1 (16-20) 16.5 (10-19) 5 (2-) (5-11.5) 5 (2-) 1 (0-1.5) 11

12 Results GMFCS levels Study 2 TCMS (range) Total TCMS (0 5) Static sitting balance (0 20) Selective movement (0 2) Dynamic reaching (0 10) Level I 45 (43 51) 19 (1 20) 20 (16 22) (6 10) > Level II 3 ( ) 17.5 (16 1.5) 16 (13 1.5) 5.5 (2.5 ) > LevelIII 24 ( ) 14 (9 16).5 (7.5 10) 1 (0.5 2) > Level IV ( 12) 6 (5 9) 2 (2 4) 1 (0 1) Psychometric properties of TCMS Inter-rater & test-retest reliability Construct validity Discriminative ability Responsiveness to change? Part 3: Assessment of TCMS General starting position Sitting without back, arm or feet support Thighs in full contact with table Hands rest on the legs, close to the body No shoes, orthoses, or braces Light handbraces are allowed 12

13 General instructions Upright sitting at the start + during performance Each item is perfor three times BEST performance counts Bilateral / left & right scores Indicate compensations on score scheet Static sitting balance Testing procedure Verbal explanation Demonstration if needed (items 2, 4 and 5) keep your trunk as stable as possible Dynamic sitting balance Selective movement Dynamic reaching Dynamic sitting balance Selective movement Dynamic reaching 13

14 Selective movement Testing procedure 1. Verbal explanation& demonstration of tester 2. Demonstration on patient with manual guidance 3. Patient performs under (manual) guidance of tester 4. ACTUAL PERFORMANCE three attempts BEST performance counts After each attempt: feedback on performance Selective movement Starting position Items 6, 7, 10, 11, 12: arms crossed Items, 9: arms onlegs Demand SELECTIVE movements of the trunk! Non-assessedbody regionsshouldbekeptas stableas possible Dynamic sitting balance Selective movement Dynamic reaching Dynamic reaching Reaching distance Forearm length (olecranon -> proc styloideus) Left & right Testing procedure Verbal explanation Three attempts (each side for items 14 and 15) Arms as straight as possible to determine reaching distance 14

15 Thank you for your attention 15

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