Clinicaltoolforassessmentofselectivevoluntarymotorcontrolinpatientswithspasticcerebralpalsy
AmericanAcademyofCerebralPalsyandDevelopmentalMedicineMontreal,September2017
DisclosureInformationAACPDM71stAnnualMeeting|September13-16,2017
SpeakerNames:MarciaGreenberg,KristinKrosschell,LorettaStaudt,TheresaMoulton
DisclosureofRelevantFinancialRelationshipsIhavenofinancialrelationshipstodisclose.
DisclosureofOff-Labeland/orinvestigativeuses:Iwillnotdiscussofflabeluseand/orinvestigationaluseinmypresentation
Clinical Tools For Assessment of Selective Voluntary Motor Control In Patients with Spastic Cerebral Palsy
SCALE: Selective Control Assessment of the Lower Extremity
&
TASC: Test of Arm Selective Control
Presenters
TASCKristin J. Krosschell, PT, DPT, MA, PCSTheresa Sukal-Moulton, PT, DPT, PhDNorthwestern University
SCALEMarcia B. Greenberg MS, PT, KEMGLoretta A. Staudt MS, PTCenter for Cerebral Palsy at UCLA
spasticity
impaired selective voluntarymotor control
sensorydisturbance
weakness
Spastic Cerebral Palsy Multiple Impairments
Selective Voluntary Motor Control (SVMC)
The ability to perform isolated joint movements
upon request, without using mass
flexor/extensor patterns and without undesired
movement at other joints, such as mirroring
Overview of SVMC
• Results from damage to the corticospinal tracts – pathwaysfor voluntary movement responsible for fine control
• Important for treatment planning and surgical decisionmaking
• While only assessed in patient’s with spastic CP, it has aseparate mechanism from spasticity
• Used as screening for selective posterior rhizotomy
Corticospinal Tracts
• Commonly injured in CP
• White matter damage of prematurity (e.g. PVL)
• Responsible for voluntary movement− Force
− Speed
− Timing
− Patternface
armhip foot and ankle
Tools
• Lower extremity – SCALE − Developed at UCLA (Fowler et al 2009)
− Hip, knee, ankle, subtalar joint, toes
• Upper extremity – TASC− Developed at Northwestern University
− Shoulder, elbow, forearm, wrist, fingers, thumb
• Both ask patient to perform selective movementtask
• Similar administration and scoring
Scoring
• SVMC at each joint is graded as:
− Normal = 2 points
− Unable/Absent = 0 points
− Impaired = anything else = 1 point
• SCALE 5 joints for a maximum of 10 points per limb
• TASC 8 movement patterns for a maximum of 16 points per limb
SCALE Validity and Reliability
• Content validity
• 14 expert clinicians
• Rated content, administration and grading
• Mean agreement 91.9%
• Recommendations incorporated into final tool
• Construct validity
• Interrater reliability
SCALE: Construct Validity
n = 51
rs= -0.83
p<0.001
n = 51
rs= -0.83
p<0.001
SCALE Interrater Reliability
SCALE Validity and Reliability
Balzer et al (Dev Med Child Neurol 2016)
• German translation of SCALE
• 38 participants
• Validity• Similar results to UCLA using GMFCS
• Inter-rater reliability• ICC >.9; p <.001
• Intra-rater reliability (video)• ICC >.9; p <.001
Overview of SCALE
• Patient is able to follow directions
• Minimum age typically 4 years
• Hip, knee, ankle, subtalar and toe motion
• Non-synergistic movement task
• Check available passive ROM
• Move within 3 second verbal count
• Move ONLY the joint being tested
• Grade best performance
Example of scores for a child with spastic diplegic CP
Maximum score per each lower limb = 10
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3 6
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Scoring System
3 6
Grading
• Normal− Completes isolated movement within 3 seconds
• Unable− Does not move requested joint or
− Cannot perform movement out of synergy
• Impaired− Less than 50% available motion
− Slower than 3 second verbal count
− Mirror movements of contralateral limb
− Motion at other joints
− Movement occurs only in one direction
Grading Guidelines
• Only grade what you observe – no assumptions
• If contracture is present
− Grade movement that you see, not palpate
− Note contracture in descriptor section
− Area for comments
Hip
“flex”” “extend”
Starting position
““flex””
Knee
“extend” “flex” “extend”
Starting position
Ankle
“move foot up” “down” “up”
“Starting position”
Subtalar Joint
“in” “out” “in”
Starting position
Toes
“flex”
Starting position
“extend” “flex”
Administration and Grading Guidelines
• Hip− Tight hamstrings restricted ROM
− Can use hip extension with knee flexed
• Knee− Allowed to lean back on hands
− Watch for trunk movement
• Ankle − Can flex knee to 20o
− Must observe at least 15o arc of motion
• Subtalar − Need active eversion
• Toes− Motion at all five toes
Resisted Extensor Synergy
Resisted Flexor Synergy(“Confusion Test”)
Descriptors for Impaired Grade
• Mirrors motion on opposite limb
• Motion slower than 3 sec verbal count
• Moves one direction only
• Movement of other joints
• Motion less than 50% of range
• Contractures/spasticity interfere , knee, ankle)
• Ankle: inverts/everts, not pure dorsiflexion
• Ankle: primarily moves toes
Clinical Examples: Videos
• Each joint
• Each grade
• Patient example
SCALE: Research and Clinical Decision MakingLoretta Staudt, MS, PT
• Research
− Proximal to distal impairment
− SVMC and gait
− Force production
− Mirror movements
• Clinical decision making
− Selective posterior rhizotomy
− Hamstring lengthening
− Exercise design
Test of Arm Selective Control (TASC)Clinical tool for assessment of selective voluntary motor control in patients with spastic cerebral palsy
Clinical use of the TASC
KristinJ.Krosschell,PT,DPT,MA,PCSAmericanAcademyofCerebralPalsyandDevelopmentalMedicineMontreal,September2017
Test of Arm Selective Control• Designed to differentiate and describe selective
voluntary movement control in the upper limb ofthose with cerebral palsy
• Background» NIH Task Force on Childhood Motor Disorders» No scales to specifically examine UE selective
control» Modeled after Selective Control Assessment
of Lower Extremity (SCALE)
TASC
TASC General DirectionsLocation: Minimize distractions, document setting (location, others present, time of day, etc)Seating: Choose appropriately (90/90, no arms)
Must be able to follow simple motor commands.
1.Proximal to distal, less impaired side 1st
2.Check PROM3.Demonstrate the task4.Ask the patient to perform
a. Within 3 sec cadenceb. Without moving other joints/limbsc. Up to 3 attempts allowed.
5.Instructions/verbal cues may be modifiedto maximize performance
TASC test items
1.Shoulder abd/add2.Shoulder flex/ext3.Elbow flex/ext (concentric/eccentric)4.Forearm supination/pronation5.Wrist ext/flex6.Finger/thumb ext/flex7.Thumb opposition (‘neat’ or tip to tip pincer)8.Thumb ext/flex (key grip)
Scoring
2 • Performs completely (>50% of available range) without movement at other joints
• Within a 3 second cadence• Without mirror movement
1 • Completes ≤ 50% of available ROM• Performs slower than 3 second cadence• Movement occurs only in 1 direction, or motion
at another joint (including mirror movements) occurs.
0 • Does not complete the task, or only does so with other joint movement
Reduced ROM
• Consider:» Contractures» Non-standard start positions» Available ROM
Movement properties and descriptors
• Spastic catch• Muscle tightness• ↓ ROM• Motion slow• Extra movement• Mirror movements• No palpable contraction• Movement in only one direction
• Flexion and/or extension synergy influence
TASC Scoresheet
Starting position 1(Items 1-3)
Correct alignment
Poor alignment
wristneutral
shoulderneutral
elbowextended
Fingersextendedasrequiredbytask
Starting position 2(Items 4-8)
wristneutral
shoulderneutral
elbow90◦ examinermaylightlysupportelbowifneeded
Fingersflexedorextendedasrequiredbytask
Meet our patient
• 7 year old• R hemi
• What might you hypothesize as primaryissues based on the next few videos?
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Shoulder ABD/ADD
Start position 1
“UP, DOWN, UP”
“Raise your arm to the side as high as you can (with the palm of your hand facing down), bring it down, and then raise it again. Try to keep your elbow, wrist and fingers straight while you do this.”
Left Shoulder Abduction/Adduction
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Right Shoulder Abduction/Adduction
Shoulder flexion/extensionStart position 1
“UP, DOWN, UP”“Raise your arm to the front as high as you can, with your thumb pointing to the ceiling, bring it down, and then raise it again. Try to keep your elbow, wrist and fingers straight while you do this”
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Left Shoulder flexion/extension
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Right Shoulder flexion/extension
Elbow flexion/extension
Start position 1
“UP, DOWN, UP”
“Bend your elbow up as far as you can while your thumb points towards the ceiling, straighten your elbow and then bend it again”
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Left Elbow flexion/extension
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Right Elbow flexion/extension
Forearm supination/pronationStart position 2
"Turn your hand so that I can see the inside of your hand, the back of your hand and then the inside of your hand again."
“UP, DOWN, UP”
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Left Forearm supination/pronation
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Right Forearm supination/pronation
Wrist extension/flexionStart position 2
“OUT, IN, OUT”
“Move your wrist so you hand comes out, in, and then out again.”
Left Wrist extension/flexion
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Right Wrist extension/flexion
Finger and thumb flexion/extension
“OPEN, CLOSE, OPEN”
Start position 2“Open your hand wide, make your hand into a fist, and then open it wide again.”
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Left Finger-thumb extension/flexion
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Right Finger-thumb extension/flexion
Thumb opposition (thumb to 1st finger tip to tip)
Start position 2
“Move your thumb and index finger together to make a circle like this (demo). Straighten your thumb and finger out. Make a circle again.”
“CLOSE, OPEN, CLOSE”
Left Thumb opposition (pincer)
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Right Thumb opposition (pincer)
Thumb extension (key grip)
“UP, DOWN, UP”
Start position 2
“Keep your fingers flexed and your thumb straight. Lift your thumb up, down and up.”
Left Thumb extension (key grip)
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
2 q > 50% available ROMq within a 3 second countq without mirror movement
1 q ≤ 50% available ROMq slower than 3 second countq movement occurs only in one
directionq motion at another jointq mirror movements
0 q No AROMq Immediate or obligatory
motion at another joint
Left Thumb extension (key grip)
TASC Scoresheet
TASC team membersNIH Task Force members
Kristin J Krosschell, PT, DPT, MA, PCSTheresa Sukal Moulton, PT, DPT, PhDDeborah Gaebler Spira, MDDarcy Fehlings, MDEileen Fowler, PT, PhD
PTHMS Synthesis studentsKat Block, PT, DPTAlexi Block, PT, DPTErin Salzman, PT, DPTJessica Barnum, PT, DPTKatie Warner, SPTElizabeth Byrne, SPTAndrew Robertson, SPTErin Cameron, SPTShannon Murphy, SPT
Acknowledgements:NIH Task Force on Childhood Movement DisordersSanger FundsLocal clinics for hosting and recruiting
Clinical tools for assessment of selective voluntary motor control in patients with spastic cerebral palsy
Research in UE SVMC and Relationship to TASC
AmericanAcademyofCerebralPalsyandDevelopmentalMedicineAnnualMeeting,September2016TheresaSukal-Moulton,PT,DPT,PhD
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