Clinical tool for assessment of selective voluntary motor ... · Tools • Lower extremity – SCALE − Developed at UCLA (Fowler et al 2009) − Hip, knee, ankle, subtalar joint,

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?

ü üü

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






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”






Left Shoulder flexion/extension






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”






Left Elbow flexion/extension






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”






Left Forearm supination/pronation






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











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.”






Left Finger-thumb extension/flexion






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)











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)











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

Bibliography Aicardi J, Bax M. Diseases of the Nervous System in Childhood CDM Nos. 115/118. London: Mac Keith Press,

1992. Arnold, AS, MQ. Liu, et al. Do the hamstrings operate at increased muscle-tendon lengths and velocities after

surgical lengthening? J Biomech 2006; 39:1498-506. Balzer J, Marisco P, et al. Construct validity and reliability of the Selective Control Assessment of the Lower

Extremity in children with cerebral palsy. Dev Med Child Neurol 2016; 58:167-172. Baumann, JU, Ruetsch H, et al. Distal hamstring lengthening in cerebral palsy. An evaluation by gait analysis.

Int Orthop 1980; 3:305-9. Bax M, Tydeman C, Flodmark O. Clinical and MRI correlates of cerebral palsy: the European Cerebral Palsy

Study. JAMA 2006; 296:1602-1608. Berger W, Quintern J, Dietz V. Pathophysiology of gait in children with cerebral palsy. Electroencephalogr Clin

Neurophysiol 1982; 53:538-548 Bhattacharya A, Lahiri A. Mirror Movement in Clinical Practice. JIACM 2002; 3:177-181. Boyd RN, Graham HK. Objective measurement of clinical findings in the use of botulinum toxin type A for the

management of children with cerebral palsy. Eur J Neurol 1999; 6:S23-S25. Brown JK, Rodda J, Walsh EG, Wright GW. Neurophysiology of lower-limb function in hemiplegic children.

Dev Med Chld Neurol 1991; 33:1037-1047. 21. Brouwer B, Ashby P. Corticospinal projections to lower limb motoneurons in man. Exp Brain Res 1992;

89:649-654. Brunnstrom S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Phys Ther 1966;

46:357-375. Cahill-Rowley K, Rose J. Etiology of impaired selective motor control:Emerging evidence and its implications

for research and treatment in cerebral palsy. Dev Med Child Neurol 2014; 56:522-8. Carney, BT, Oeffinger D, et al. Sagittal knee kinematics after hamstring lengthening. J Pediatr Orthop B 2006;

15:348-50. Chicoine M, Park TS, et al. Predictors of ability to walk after selective dorsal rhizotomy in children with

cerebral palsy. Neurosurgery 1996; 38: 711-714. Cincotta M, Ziemann U. Neurophysiology of unimanual motor control and mirror movements. Clinical

Neurophysiology 2008; 119(4): 744-62. Davids JR, Holland WC, Sutherland DH. Significance of the confusion test in cerebral palsy. J Pediatr Orthop

1993; 13:717-721. . Engsberg JR, Ross SA, Collins DR, Park TS. Predicting functional change from preintervention measures in

selective dorsal rhizotomy. J Neurosurg 2007; 106:282-287. Evarts EV. Relation of pyramidal tract activity to force exerted during voluntary movement. J Neurophysiol

1968; 31:14-27. Eyre JA. Corticospinal tract development and its plasticity after perinatal injury. Neuroscience and

Biobehavioral Reviews 2007; 31:1136-1149. Fetters L, Chen YP, Jonsdottir J, Tronick EZ. Kicking coordination captures differences between full-term and

premature infants with white matter disorder. Hum Mov Sci 2004; 22:729-748. Fowler EG, Goldberg EJ. The effect of lower extremity selective voluntary motor control on interjoint

coordination during gait in children with spastic diplegic cerebral palsy. Gait Posture 2009; 29:102-7. Fowler EG, Knutson LM, DeMuth SK, Sugi M, Siebert K, Simms V, et al. Pediatric endurance and limb

strengthening for children with cerebral palsy (PEDALS) - a randomized controlled trial protocol for a stationary cycling intervention. BMC Pediatr 2007; 7:14.

Fowler EG, Staudt LA, Greenberg MB, Oppenheim WL. Selective Control Assessment of the Lower Extremity (SCALE): Development, validation and interrater reliability of a clinical tool for patients with cerebral palsy. Dev Med Child Neurol 2009; 51:607-614.

Fowler EG, Staudt LA, Greenberg MB. Lower extremity selective voluntary motor control in patients with spastic cerebral palsy: increased distal motor impairment. Dev Med Child Neurol 2010; 52:264-9.

Fowler E, Staudt L. Are we being too 'selective' about motor control? Dev Med Child Neurol 2014; 56:509–510.

Friel K, Williams PTJA,et al. Activity-based therapies for repair of the corticospinal system injured during development. Front Neurol 2014;5:229.

Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient: a method for evaluation of physical performance. Scand J Rehabil Med 1975;7:13-31.

Glenn OA, Ludeman NA, Berman JI, Wu YW, Lu Y, Bartha AI, et al. Diffusion tensor MR imaging tractography of the pyramidal tracts correlates with clinical motor function in children with congenital hemiparesis. Am J Neuroradiol 2007; 28:1796-1802.

Goldberg, EJ, Requejo PS, Fowler EG. Joint moment contributions to swing knee extension acceleration during gait in individuals with spastic diplegic cerebral palsy. Gait Posture 2011; 33: 66-70.

Heathcock JC, Galloway JC. Exploring objects with feet advances movement in infants born preterm: A randomized controlled trial.Phys Ther; 2009; 89:1027-1038.

Holodny AI, Watts R, Korneinko VN, Pronin IN, Zhukovskiy ME, Gor DM, et al. Diffusion tensor tractography of the motor white matter tracts in man. Ann. N.Y. Acad. Sci. 2005; 1064:88-97

Ino T, Nakai R, Azuma T, Yamamoto T, Tsutsumi S, Fukuyama H. Somatotopy of corticospinal tract in the internal capsule shown by functional MRI and diffusion tensor images. NeuroReport 2007; 18:665-668.

Löwing K, Carlberg EB. Reliability of the selective motor control scale in children with cerebral palsy. Advances in Physiotherapy 2008; 11: 58-63.

Martin JG. The corticospinal system: from development to motor control. Neuroscientist 2005; 11:161-173. Olree KS, Engsberg JR, Ross SA, Park TS. Changes in synergistic movement patterns after selective dorsal

rhizotomy. Dev Med Child Neurol 2000; 42:297-303. Ostensjo S, Carlberg EB, Vollestad NK. Motor impairments in young children with cerebral palsy: relationship

to gross motor function and everyday activities. Dev Med Child Neurol 2004; 46:580-589. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to

classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 1997; 39:214-223. Palisano R, Rosenbaum P, Bartlett D, Livingston M. GMFCS-E&R, Gross Motor Function Classification

System, Expanded and Revised. In: CanChild Centre for Childhood Disability Research, McMaster University http://www.canchild.ca/Portals/0/outcomes/pdf/GMFCS-ER.pdf; 2007.Accessed June 2, 2008.

Penfield W, Boldrey E. Somatic motor and sensory representation in the cerebral cortex of man as studied by electrical stimulation. Brain 1937; LX:389-443.

Penfield W, Rasmussen T. The cerebral cortex of man. New York: MacMillan, 1950. Perry J. Determinants of muscle function in the spastic lower extremity. Clin Orthop Relat Res 1993; 288:10-26. Rose J, Martin JG, Torburn L, Rinsky LA, Gamble JG. Electromyographic differentiation of diplegic cerebral

palsy from idiopathic toe walking: involuntary coactivation of the quadriceps and gastrocnemius. J Pediatr Orthop1999; 19:677-682.

Rose J. Mirmiran M et al.Neonatal microstructural development of the internal capsule on diffusion tensor imaging correlates with severity of gait and motor deficits. Dev Med Child Neuro. 2007; 49:745-50.

Ross S, Engsberg JR. Relation between spasticity and strength in individuals with spastic diplegic cerebral palsy. Dev Med Child Neurol 2002; 44:148-157.

Sanger TD, Chen D, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW. Definition and classification of negative motor signs in childhood. Pediatrics 2006; 118:2159-2167.

Schieber MH. Comparative anatomy and physiology of the corticospinal system, Chapter 2. . Handb Clin Neurol. 2007;82:15-37.

Schwartz MH, Rozumalski A, Steele KM. Dynamic motor control is associated with treatment outcomes for children with cerebral palsy. Dev Med Child Neurol 2016; doi: 10.1111/dmcn.13126. [Epub ahead of print]

Shumway-Cook A, Woollacott MH. Motor Control, Theory and Practical Applications. 2nd ed. Philadelphia: Lippincott Williams and Wilkins, 2001.

Sim J, Arnell P. Measurement validity in physical therapy research. Physical Therapy 1993; 73:102-110. Staudt M, Pavlova M, Bohm S, Grodd W, Krageloh-Mann I. Pyramidal tract damage correlates with motor

dysfunction in bilateral periventricular leukomalacia (PVL). Neuropediatrics 2003; 34:182-188. Staudt LA, Peacock W. Selective posterior rhizotomy for the treatment of spastic cerebral palsy. Pediatric

Physical Therapy 1989; 1:3-9.

Steele KM, Rozumalski A, Schwartz MH. Muscle synergies and complexity of neuromuscular control during gait in cerebral palsy. Dev Med Child Neurol 2015; 57:1176-1182.

Sukal-Moulton T, Krosschell KJ, Gaebler-Spira DJ, Dewald JPA. Motor impairments related to brain injury timing in early hemiparesis.part II: Abnormal upper extremity joint torque synergies Neurorehabilitation and Neural Repair 2014; 28: 24 –35

Sukal-Moulton T,Clancy T, Zhang, L, Gaebler-Spira D. Clinical application of a robotic ankle training program for cerebral palsy compared to the research laboratory application: Does it translate to practice? Arch Phys Med Rehabil

Tedroff K, Knutson LM, Soderberg GL. Synergistic muscle activation during maximum voluntary contractions in children with and without spastic cerebral palsy. Dev Med Child Neurol 2006; 48:789-796.

Thelen DD, Riewald SA, Asakawa DS, Sanger TD, Delp SL. Abnormal coupling of knee and hip moments during maximal exertions in persons with cerebral palsy. Muscle Nerve 2003; 27:486-493.

Thometz, J, Simon S, et al. The effect on gait of lengthening of the medial hamstrings in cerebral palsy. J Bone Joint Surg Am 1989; 71: 345-53.

Trost J. Physical assessment and observational gait analysis. In: Gage JR, editor. The Treatment of Gait Problems in Cerebral Palsy. London: Mac Keith Press. p. 71-89, 2004.

van der Linden, ML, Aitchison, AM, et al. Effects of surgical lengthening of the hamstrings without a concomitant distal rectus femoris transfer in ambulant patients with cerebral palsy. J Pediatr Orthop 2003; 23: 308-13.

Voorman JM, Dallmeijer AJ, Knol DL, Lankhorst GJ, Becher JG. Prospective longitudinal study of gross motor function in children with cerebral palsy. Arch Phys Med Rehabil 2007; 88:871-876.

Vos RC, Becher JG et al. Longitudinal association between gross motor capacity and neuromusculoskeletal function in children and youth with cerebral palsy. Arch Phys Med Rehabil 2016; 97:1329-1337.

Wakeling J, Delaney R, Dudkiewicz I. A method for quantifying dynamic muscle dysfunction in children and young adults with cerebral palsy. Gait Posture 2006. 25: 580-9.

Wiley ME, Damiano DL. Lower-extremity strength profiles in spastic cerebral palsy. Dev Med Child Neurol 1998; 40:100-107.

Documents

Clinical tool for assessment of selective voluntary motor ... · Tools • Lower extremity – SCALE − Developed at UCLA (Fowler et al 2009) − Hip, knee, ankle, subtalar joint,