SEGMENTAL ASSESSMENT OF TRUNK CONTROL (SATco)
A NEW TOOL TO ASSESS TRUNK CONTROL FOR
CEREBRAL PALSY CHILDREN IN BANGALORE:
A DESCRIPTIVE STUDY
A
Protocol submitted to
HOSMAT HOSPITAL EDUCATIONAL INSTITUTE
Bangalore
DESSERTATION RESEARCH
By
NILESH TELAIYA
M.P.T. (Pediatrics)
Guide Dr. Sherin George (PT)
Co- guide -Dr. Devika Rani (PT)
RESEARCH APPROVAL
SEGMENTAL ASSESSMENT OF TRUNK CONTROL (SATco)
A NEW TOOL TO ASSESS TRUNK CONTROL FOR
CEREBRAL PALSY CHILDREN IN BANGALORE:
A DESCRIPTIVE STUDY
Research proposal approved by Institutional ethics Committee on 19 /11/ 2010
INSTITUTIONAL ETHICS COMMITTEE
HOSMAT hospital educational institute.
BANGALORE - 25.
CONTENT
Page No.
1
INTRODUCTION
04
1.1
Background of the study
04
1.2
Statement of the problem
05
1.3
Objective of the study
05
1.4
Clinical Significance
05
REVIEW OF LITERATURE
06
METHODOLOGY
08
3.1
Study Design
08
3.2
Study Setting
08
3.3
Inclusion Criteria
08
3.4
Exclusion Criteria
08
3.5
Materials
08
3.6
Sampling
08
3.7
Sample size
08
3.8
Procedure
09
3.9
Outcome Measure
10
3.10 Data Analysis
10
REFERENCES
11
APPENDIX
13
Appendix I
13
Appendix II
14
Appendix III
16
INTRODUCTION
1.1
Background of the study
Cerebral palsy is defined as a non progressive disorder of posture and movements
which is caused by damage to the motor control centres of the developing brain and
can occur pre-, peri-, and postnatally.(14)
The ability to control sitting balance gradually emerges in children with typical
development (TD) during the period from 2-9 months of age, with head control
developing first followed by progressive development of trunk control (3). In children
with neuromotor disability, developments of sitting is delayed and depend on type of
cerebral palsy, children may continue to show constrains on sitting balance throughout
their lives, with some never gaining independent control of head and trunk (4, 5).
In cerebral palsy children impaired head and neck control is substituted by elevation
of shoulder girdle which prevents developing shoulder girdle control. Muscles of
trunk and abdomen are weak and inactive so there is impaired thoraco-lumbar control
which represents as kyphotic posture.16 Due to delay in phasic burst of muscles
activities, static, active and reactive postural control is impaired in sitting. Due to lack
of proximal stability of shoulder girdle and trunk, CP children show constrains in
developing manipulatory and mobility skills1
To assess trunk control various clinical movement assessments have been created.
Gold standard method is centre of pressure (COP) using force plates data which
examines (1) static balance (2) active or anticipatory balance adjustment and (3)
reactive balance of trunk control.(14)
Other scale to measure trunk control is gross motor function measure (GMFM) and
chailey levels of ability include items for quiet sitting which comprises measures of
trunk control(13). Alberta infant motor scale( by Piper et al ) measures sequential
development of postural control relative to supine, prone, sitting and standing for 0-18
months of age for full term baby. Peabody developmental motor scale is another tool
which assesses stationary balance that includes 30 items as one of its subtests(18). A
recent assessment tool for evaluating trunk control is` the spinal alignment and Rom
measures evaluate the childs ability to actively or passively to achieve alignment of
cervical, thoracic and lumbar spine.(11)
Although these tools are helpful in assessing balance control as a broadly defined
ability, they have limitation in the assessment of sitting balance; they tend to model
the entire trunk as a single unit(12). This approach ignores the facts that development of
trunk control in sitting may occur in progressive manner, with initial development of
4
head control followed by gradual incorporation of thoracic, lumbar and sacral
segments. Most of the above mention tests do not measure reactive control
To overcome above mention problem, a more recent clinical evaluation tool for
assessing the degree of trunk control was designed by P B Butler et al. Called `The
segmental assessment of trunk control`. It provides systemic method of assessing
discrete level of trunk control in children with motor disabilities. It assesses all 3
aspects of trunk control 1) static, 2) active control. 3) Reactive control. (10)
1.2 Statement of problem
SATco has been successfully used to assess trunk control in children with motor
disabilities in foreign population; cerebral palsy children in Indian population also
show constrain in development of segmental sitting trunk control and there is need to
evaluate it.
1.3 Objective of study
Objective of study is to apply SATco for cerebral palsy children among Bangalore
population and thereby to report the static, active and reactive postural control at
different segmental level in sitting.
1.4 Clinical significance
By assessing SATco in cerebral palsy children, it enables to comment at what level
trunk control is impaired and thereby one can direct rehabilitation at that segmental
trunk level and leads to level by level treatment approach to trunk control.
Review of literature
Development of trunk control in typically developing children
5
A study by Heiga Hirschfield and Hans Forssberg in 1992 concluded that
development in infant follows an epigenetic process. It supports the view that postural
adjustment develop in predetermined way before child practice independent sitting.
Shin ichi Hirabayashi, Yuuji Iwasaki. 1995 concluded that multimodal sensory
system including visual, somatosensory, and vestibular ones are involved in
maintaining postural control and balance.
Illingworth 1975 showed that the emergence of independent sitting balance is a
milestone in the motor development of child, normally occurring between 7 to 9
months of age.
Brothner and Jenson, 2001; Henry et al 1998a, Runge et al 1999. Studies evaluating
the maintenance of upright posture and balance have modelled the trunk as a single
rigid segment
Trunk control in cerebral palsy children:
Kathleen Washington et al (2004) examined spatial and temporal organization of
muscles activities in response to seated forward platform perturbation in infants with
high risk (HR), found that frequency of directionally appropriate phasic muscle were
significantly reduced in HR children
Hadders Algra et al (1994) have suggested infants who consistency lack
directionally inappropriate responses are unlikely to develop independent sitting
balance.
Brogren et al (1996) studied show that in response to seated platform perturbation,
children with spastic diplegia showed a caudalcephalo activation patterns as well as
increased antagonistic co activation of neck and hip muscles.
Hadders- Algra et al (1999a) suggest that the ability to modulate postural responses
altered in children born pre term compared with children born term.
Shumway Cook et al (2003) reported that training reactive balance control in children
with CP resulted in less COP displacement and shorter time taken for balance
recovery. Improvements in directional specificity of responses and other spatial and
temporal organisation.
A study by Anastasia Kyvelidu et al (2010) documented that linear and non linear
description of COP data is a reliable method for assessing sitting trunk control in
children with or at risk of CP with ICCs values 0.19 to 0.75 and 0.16 to 0.78
respectively.
Clinical research by Seeger et al 1984, Mc Clenghan et al 1992 has shown that
children with CP improve in manipulatory skills when given postural control in sitting
or standing.
Eva Brogren, Hans Forssberg , Mijna Hadders- Algra (2001) study showed marked
dysfunctions in the precise tuning of the postural adjustments to task specific
conditions in CP children although basic level of control was present
Doreen Bartlett (2005) in a study showed that Spinal Alignment and Range of Motion
Measure (SAROMM) for trunk control has ICC value above 0.80 and validity 0.44.
P Butler 2010-11-17 in a studied showed that SATco is a reliable and valid clinical
measures of trunk control in infants with TD as well as children with neuromotor
disability with overall score for reliability more than 0.80 and validity p value < 0.01.
Lesley Wiart, Johanna Darrah (2001) in a systemic review of four test of gross motor
development showed that PDMS having r value 0.96(item by item) and r = 0.99(total
score). Test retest ICC = 0.95.
3. Methodology
3.1 Study design: Observational study
Descriptive study
3.2 Study setting:
Hosmat Hospital, Bangalore
Special schools in and around Bangalore
3.3 Inclusion criteria:
subjects with diagnosed cases of cerebral palsy
subjects with developmental delay at risk of CP
Age group: 1 year to 10 years.
7
Subjects residing in and around Bangalore.
3.4 Exclusion criteria:
Subjects with hip/knee flexion contracture
Subjects with cognitive impairment
Uncooperative subjects with reduced attention span.
Subjects with hearing impairment
3.5 Materials:
A bench or stool of appropriate height
A camera with a tripod stand
straps with three D rings
3.6 Sampling:
Convenience sampling
Purposive sampling
Snowball sampling
3.7 Sample size
Sample size : 50 subjects.
3.8 Procedure
Subjects who will be reporting to OPD physiotherapy department of Hosmat Hospital
will be recruited for the study.
Subjects will also be recruited through word of mouth by parents/ guardian of
participating subjects.
Special schools, clinics and hospital network in Bangalore will be searched by the
researcher through internet and yellow pages. Researcher will personally visit the special
school, clinics and hospital network with bonafide certificate and will request for permission
to conduct study from the respective incharge of special schools, clinics etc.
Subjects will be scrutinised for the inclusion and exclusion criteria and those who
meet the inclusion criteria will be explained the purpose of study to the participant`s parents.
Written consent (Appendix-1) will be obtained from the parents of participants. Before
application of SATco, researcher will assess all the subjects with reference to Appendix-II and
will be documented.
Application of SATco as follows:
The assessment procedure and the scores form are detailed in Appendix III.
Subject will be made to sit on the bench with feet supported on ground or on stable
surface. Pelvis/thigh will be positioned by strapping system according to instruction part of
appendix III. Pelvis will be oriented in neutral position. Subject will be supported in upright
posture, hands and arms of the subject should be free from all external contacts, like on his
own trunk, thighs, bench or tester`s arms/hands throughout the test.
A camera will be fixed on a tripod stand and placed at 45 degree angle to the subject.
This will enable the researcher to detect the movement strategies from the front and side
views.
With reference to appendix-III, researcher will position himself behind the subject
usually in kneeling, depending on the size of subject or height of bench. Tester 2 will position
himself ideally out of the subject`s vision. After that researcher will give firm manual support
horizontally around the trunk at each designated level and static, active trunk control will be
assessed.
To assess reactive trunk control, tester 2 will give nudges sufficient to disturb balance
anteriorly at sternum/manubrium, posteriorly at c-7, right and left lateral direction at
acromian, while researcher will be maintaining the trunk of the subject in vertical alignment
at each designated level. This whole procedure of SATCO will be video recorded.
After completion of procedure, researcher will analyse the recorded video through
laptop, according to the scoring guidelines (appendix-III) to document presence or absence
of static, active and reactive trunk control at each designated level. The data coding shall
represent presence and absence of trunk control as 1 and 0 respectively. These numbers will
be taken for data analysis.
3.9 Outcome Measure
Segmental assessment of trunk control (SATco) appendix III
3.10 Data analysis:
Data will be described by using median and range for static, active and reactive trunk
control at each designated level.
4 REFERENCE
1. Sheila Schneiberg, Patrica A Kinley, Heidi Sveistrup, Erika Gisel,Nancy Mayo,Mindy
F Levin. The effectiveness of task oriented intervention and trunk restrain on upper
limb movement quality in children with cerebral palsy. Dev med child neurol.
2010;52:245-53
2. Harbouurne RT, Stergiou N. Non linear analysis of the development of sitting postural
control. Dev psychobiol. 2003; 43: 368-37.
3. Hirschfeld H, Forssberg H. Epigenetic development of postural responses for sitting
during infancy. Exp brain res. 1994; 97: 528-40.
4. Brogren E, Haddders Algra M, Forssberg H. Postural control in children with spastic
diplegia; muscles activities during perturbation in sitting. Dev med child neurol. 1996;
38: 379 88.
10
5. Asa Hedberg, Eva Brogren Hans Forsseberg,Mijna Hadders-Algra. Development of
postural adjustment in sitting position during first half year of life. Dev med child
neurol. 2005; 47:312- 20.
6. Eva Brogren, Hans Forssberg, Hadders Algra M. Influence of two different sitting
positions on postural adjustment in children with spastic diplegia. Dev med child
neurol. 2001; 43:534-46.
7. Kathleen Washington, Anne Shumway Cook, Robert Price, Marcia Ciol. Muscles
responses to seated perturbations for typically developing infants and those at risk of
motor delay. Dev med child neurol.2004; 46:681-88.
8. Shin Ichi Hirabayashi, Yuvji Iwasaki. Development of sensory organisation of
postural control. Brain and development. 1995; 17:111-3.
9. Majorie Woollacotsst, Anne Shumway-cook,Susan Hutchinson,Martia Ciol, Robert
Price, Deborah Kartin. Effects of training on muscles activity used in recovery of
stability in children with cerebral palsy. Dev med child neurol. 2005; 47:455-461.
10. P Butler ,Sandy Saavendra, Madeline Sofranc, Sarah E Jevis,Marjorie H Woollacott.
Refinement, reliability, and validity of the segmental assessment of trunk control.
Paediatric physical therapy.2010; 22:246-57.
11. Doreen Bartlett, Barbara Purdie. Testing of SAROM. Dev med child neurol. 2005;
47:739 -43.
12. Rechard Preuss,, Joyce Fung. Musculature and biomechanics of trunk in the
maintenance of upright posture. J electromyo and kinesiol.2008; 18:815-28.
13. Robert Palisana,Peter R, Stephen Walller, Dianne Russell, Ellin Wood,Barbara G.
Development and reliability of system to classify gross motor function in children with
cerebral palsy. Dev med child neurol. 1997; 39:214-23.
14. Anastaia Kyvelidou, Regina T Harbourne,Valerie K Shostron. Reliability of a centre of
pressures measures for assessing the development of sitting postural control in infants
with or at risk of cerebral palsy. Arch phys med rehabil. 2010; 91:1593-1601.
15. P Butler. A preliminary report on the effectiveness of trunk targeting in achieving
independent sitting balance in children with cerebral palsy. Clinical
rehabilitation.1998; 12:281-93.
16. Marcia Stamer. Posture and movements of the child with cerebral palsy. Academic
press; 2000. p.22, 26, 34, 65-66.
11
17. Kennea Martina Almedida, Martia Varginia, Rosane de Mello, Ana B, Priscila Martin.
Concurrent validity and reliability of the Alberta infant motor scale in premature
infants. Journal de pediatria. 2008; 84(5):442-48.
18. PDMS 2 Peabody developmental motor scale, second edition. Available from URL:
http/ [Link]/custemer/[Link]?Id=1783.
19. Lesely Wiart, Johanna Darrah. Systemic review of four tests of gross motor
development. Dev med child neurol.2001, 43:279-85.
APPENDIX I
HOSMAT College of Physiotherapy
Rajiv Gandhi University
Consent Form
I ________________________________ agree to take part in the research study conducted
by NILESH TELAIYA, Postgraduate student (M.P.T. Pediatrics), HOSMAT College of
Physiotherapy, Rajiv Gandhi University, entitled Segmental assessment of trunk
control(SATco) a new tool to assess trunk control for cerebral palsy children in Bangalore:
a descriptive study.
I acknowledge that the research study has been explained to me and I understand that
agreeing to participate my child in the research means that I am willing to
Provide information about his/ her health status to the researcher
Allow the researcher to have access to his/her medical records, pertaining to purpose
of the study
Participate in evaluator program
Make my child available for further follow up
12
I have been informed about the purpose; procedures, measurements and risks involved in
the research and my queries towards the research have been clarified.
I provide consent to the researcher to use the information, video or audio recordings, for
research and educational purpose only.
I understand that my child`s participation is voluntary and can withdraw at any stage of
the research project.
I understand that no monetary benefit will be given for participation in this research
study.
Name of the applicant
Signature of parents -
signature of researcher
Date:
APPENDIX- II
Assessment form
Name:
Age:
Gender:
Chief complain by subject/ guardian:
History:
Pre-natal history:
Peri-natal history:
13
Post-natal history:
Associated problem:
Convulsion: Y/N
If YES medicine:
Hearing impairment: Y/N
dose:
time:
If YES use of hearing aid: Y/N
Visual impairment: Y/N If YES use of corrective glasses: Y/N
Behaviour problem:
History of gross motor developmental milestone:
Sl. No.
Milestone
Head holding
Turning to prone
Prone on forearm
Prone on hands
Sitting independently
Crawling
Standing with support
Standing independently
14
Age at which
attained (months)
Cruising
10
Walking with support
11
Walking independently
12
Climbing steps with support
13
Climbing steps independently
Tightness / contracture/ deformity:
Upper limb:
Lower limb:
Tone (MAS): lower limb
Appendix 2
Assessment of trunk
control
APPENDIX- III
15
16
17
18
Table 1:
Demographic data:
A hemiplegic , B spastic diplegia, C spastic quadriplegia, D double diplegia
E ataxic, F athetoid , G hypotonia , H - spastic
19
Table2: SATco scores
Age
Head
group Control
Years
S
A R
Upper
thoracic
control
S
Middle
thoracic
control
A R
A R
Lower
thoracic
control
S
12
23
34
45
56
67
78
89
9 - 10
S static
A active
R reactive
20
A R
Upper
lumbar
control
S
A R
Lower
lumbar
control
S
Full trunk
control
S
