Assessment

 Procedures  for  Postural  

Control  for  Children  with  Cerebral  
Palsy  
Sarah  (Sally)  Westco;  McCoy,  PT,  PhD  
Department  of  RehabilitaBon  Medicine  
University  of  Washington,  Sea;le,  WA,  
USA  
  University  of  Washington  
 Overview  of  PresentaBon  

•  Overall  Measurement  Model  for  Children  with  

CP  
•  Postural  Control  System  Model  
•  Postural  Control  Motor  ExaminaBon  
–  Movement  strategies  
–  Control  of  Dynamics    
Measurement  Model  from  Move  &  
PLAY  study  
•  Movement  and  ParBcipaBon  in  Life  AcBviBes  in  Young  Children  
with  CP  (Bartle;  et  al.  2010)  
•  Child  (Body  Structure/FuncBon  Impairments)  
–  Primary  
–  Secondary  
–  Associated  Health  CondiBons/Co-­‐MorbidiBes  
–  AdapBve  behavior  
•  Family  Ecology  
–  Family  environment  
–  Family  Support  to  Child  
–  Family  ExpectaBons  of  Child  
•  Outcomes  (AcBvity  &  ParBcipaBon)  
–  Motor,  self-­‐care,  parBcipaBon  in  play  &  work  
Postural  Control  Model  
(Westco;  &  Burtner,  2004)  
 Postural  Control  Model  
(Horak,  2006)  

•  Musculoskeletal!
•  Cogni-ve  
–  Biomechanical
Constraints! –  Cogni-ve  Processing  

•  Motor! •  Memory  
–  Reten-on  of  Learning  
–  Movement
Strategies! •  Perceptual  
–  Control of –  Orienta-on  in  Space  
Dynamics!
–  Sensory  Strategies  
 Movement  Strategies  
•  Components  of  PC  movement  strategies  
–  Postural  PreparaBons  
–  ReacBve  Postural  Adjustments  
–  AnBcipatory  Postural  Adjustments  
•  Control  of  dynamics  within  all  movements  
Postural  Movement  Strategies  (Liu,  
2001)  
 ExaminaBon  of  Postural  Control  

•  Purpose  of  tes-ng:   •  Quali-es  of  tests:  

•  DiscriminaBon   •  ReflecBve  of  funcBonal  
–  IdenBfy  if  a  balance   capabiliBes  &  quality  of  
problem  exists   postural  strategies  
•  EBology   •  SensiBve  &  selecBve  for  
–  Determine  underlying   postural  control  problems  
cause  
•  Reliable  &  valid  
•  PracBcal-­‐easy  to  use  &  
inexpensive.  
•  Mancini  &  Horak,  2010  
 Movement  Strategies  
•  Motor  RPA:    
–  Ordinal  schemes:  Movement  Assessment  of  Infants  –  AutomaBc  
ReacBons  SecBon  (MAI-­‐AR)  (Chandler  et  al.  1980)  
 Movement  Strategies  
•  Motor  APA:    
–  Interval  schemes:  Lab  tests  (COP;  EMG);  FuncBonal  reach  test  (FRT);  Pediatric  
Reach  Test  (PRT)  (Liu,  Zaino  &  Westco;  McCoy  2007;  Zaino  &  Westco;  McCoy  2008;  Donahue  et  
al.  1994;  Volkman  et  al.  2007;  Bartle;  &  Burmingham  2003)  
 Movement  Strategies  
•  Sifng  reach  tests  
•  FuncBonal  reach  
•  Reach  area  
•  Bilateral  reach    
–  (Sprigle  et  al.  2007)  

•  Standing  Push-­‐pull  tests  

–  In-­‐place  response  
–  Compensatory  stepping  
–  Needs  to  be  developed  
 Movement  Strategies  

•  CombinaBon  of  Postural  PreparaBon,  RPA,  APA  

•  Pediatric  Balance  Scale  (PBS)  
–  (Franjoine,  Gunther,  &  Taylor,  1999,  2003;  Ko;  &  Held,  2002;  Gan  et  al.  2008)  
•  Rated  on  ordinal  scale  as  to  Bme  &  quality  
–  14  funcBonal  movement  items  
•  StaBc  &  dynamic  tasks  
•  Sifng,  standing,  transfers  
•  Reaching  &  turning  
–  Reliability:  Inter-­‐rater  &  test-­‐retest  high  
–  Concurrent  validity:  high  with  funcBonal  mobility  tasks  
 Movement  Strategies  
•  Pediatric  Balance  Scale  
–  14  funcBonal  movement  items:  
•  Sit  to  stand  &  Stand  to  sit  (combine  with  TUG)  
•  Sit  unsupported  
•  Transfers  
•  Stand  unsupported,  with  eyes  closed,  with  feet  together,  heel-­‐to-­‐toe  
•  Stand  on  one  foot  (TOLS)  
•  Turn  360  degrees  
•  Turn  to  look  behind  
•  Retrieve  object  from  floor  
•  Place  alternate  feet  on  stool  
•  Reach  forward  with  outstretched  arm  (FRT)  
 Movement  Strategies  

•  Early  Clinical  Assessment  of  Balance  

–  430  Children  with  CP:  Move  &  PLAY  study  
•  Gross  Motor  FuncBon  ClassificaBon  System  Levels  I-­‐V  
•  Age  1.5  to  5  years  
•  Children  at  GMFCS  I-­‐III  tested  on  the  Pediatric  Balance  Scale  
(PBS)  (Franjoine,  Gunther,  &  Taylor,  1999)  
•  Children  at  GMFCS  IV-­‐V  tested  on  the  Movement  Assessment  
of  Infants  –  AutomaBc  ReacBons  secBon  (MAI-­‐AR)  (Chandler  
et  al.  1980)  
–  Head  control  RPA  to  Standing  APA  and  Control  of  
dynamics  
 Movement  Strategies  

•  Early  Clinical  Assessment  of  Balance  

–  DeterminaBon  of  selecBon  and  combinaBon  of  items  
from  full  MAI  AutomaBc  ReacBons  SecBon  and  full  PBS  
•  MAI  –  all  items  except  forward  protecBon  as  difficult  to  test  
•  PBS  –  Reduced  number  of  items  from  14  to  6  
–  Started  with  ‘Sit  on  Bench’  as  next  higher  item  from  sit  on  floor  
within  MAI  
–  Eliminated  items  that  were  difficult  to  test  in  1.5-­‐5  year-­‐olds  
–  Chose  2  items  for  each  of  relaBvely  easy,  moderate,  and  difficult  
skills  across  the  construct  of  postural  control  
•  Total  ECAB  items  13  
•  Adjusted  scoring  so  scores  from  0-­‐100    
 Movement  Strategies  

•  Early  Clinical  Assessment  of  Balance  –  Construct  

Validity  
 Movement  Strategies  

•  Early  Clinical  Assessment  of  Balance  

–  MAI  7  Items  –  AutomaBc  ReacBons  SecBon    
•  Lateral  head  righ-ng  (len  &  right)  
–  Tested  in  supported  sifng    
•  Head  righ-ng  in  extension  
–  Tested  prone    
•  Head  righ-ng  in  flexion  
–  Tested  in  pull  to  sit    
•  Rota-on  in  the  trunk  (len  &  right)  
–  Tested  in  rolling  
•  Equilibrium  reac-ons  in  siMng  (len  &  right)  
•  Protec-ve  extension  to  the  side  &  backwards  (len  &  right)  
–  Tested  in  sit  
 Movement  Strategies  

•  Early  Clinical  Assessment  of  Balance  

–  MAI  Items  re-­‐scaled  form  original  MAI    
•  Rated  as:  
•  0  (no  response)  
•  1  (slight  response)  
•  2  (moderate  response)  
•  3  (complete  &  consistent  response)  
–  Specific  criteria  for  each  item  on  score  sheet  
 Movement  Strategies  

•  Early  Clinical  Assessment  of  Balance  

–  PBS  Items  
•  SiMng  with  back  unsupported  but  feet  supported  
•  Moving  from  siMng  to  standing  
•  Standing  unsupported  with  eyes  closed  
•  Standing  unsupported  with  feet  together  
•  Turning  360  degrees  in  standing  unsupported  
•  Placing  alternate  foot  on  the  step  while  standing  
unsupported  
 Movement  Strategies  

•  Early  Clinical  Assessment  of  Balance  

–  PBS  Items  rated  as:  
•  0  (cannot  do)  
•  1  (slight  ability  to  complete)  
•  2  (some  ability  to  complete)  
•  3  (almost  completes)  
•  4  (fully  completes)      
 Movement  Strategies  
•  Early  Clinical  Assessment  of  Balance  
•  Administer  and  score  items  on  the  scales  
•  Total  score  calculated  as  follows:  
–  7  items  from  MAI  are  summed  
•  If  child’s  postural  control  is  beyond  an  item  you  do  not  have  
to  test  and  credit  them  for  the  item  
–  6  items  scores  from  PBS  are  reweighted  to  account  for  
increased  difficulty  of  execuBon  and  summed    
•  items  8  and  9  mulBplied  by  1.5    
•  Items  10  and  11  mulBplied  by  2.5  
•  Items  12  and  13  mulBplied  by  4  
–  MAI  and  PBS  item  scores  are  then  summed  for  total  
score  between  0  and  100.  
 Movement  Strategies  
•  Early  Clinical  Assessment  of  Balance  –  Video  
Prac-ce  
 Control  of  Dynamics  
•  Timed  Up  and  Go  (TUG)  
–  (Williams  et  al.  2005)  

•  Timed  Up  and  Down  Stairs  (TUDS)    

–  (Zaino  et  al  2004)  
•  Standardized  Walking  Obstacle  Course  (SWOC)    
–  (Held  &  Ko;,  2006)  
•  Timed  Obstacle  AmbulaBon  Test  (TOAT)      
–  (Torseth  et  al.  2007;  Barnes  et  al.  2009)  
•  Dynamic  Gait  Index  (DGI)    
–  (Jonsdofr  &  Ca;aneo,  2007;  Hall  &  Herdman,  2006)  
 Control  of  Dynamics  
•  Standardized  Walking  
Obstacle  Course  (SWOC)  
–  12.2  m  X  0.9m  path  
–  Tested  with:    
•  arms  at  side;    
•  age-­‐appropriate  carrying  task;    
•  dimly  lit  environment  
–  Time,  steps,  stumbles,  step-­‐offs  
recorded  
–   High  intra-­‐  &  inter-­‐rater  reliability    
 Control  of  Dynamics  
•  Timed  Obstacle  Ambula-on  Test  (TOAT)  
–  Community  obstacles  
–  Time  &  balance  
–  Reliability  
•  Time  score  high  
•  Balance  score  moderate  
 Control  of  Dynamics  
•  Dynamic  Gait  Index  
–  Quality  of  gait  rated  on  4-­‐point  scale  
•  Gait  Level  Surface    
•  Change  in  gait  speed    
•  Gait  with  horizontal  head  turns    
•  Gait  with  verBcal  head  turns    
•  Gait  and  pivot  turn    
•  Step  over  obstacle    
•  Step  around  obstacles    
•  Stairs  
–  Reliability  and  validity  high  in  adults;  needs  tesBng  in  
children    
 ExaminaBon  Summary  
•  Consider  Postural  control  a  complex  
movement  
•  Examine  the  components  with  appropriate  
tests  
•  Try  to  maintain  standardized  procedures  
•  Let  you  examinaBon  results  guide  your  
intervenBon  and  measurement  of  outcomes  
Thank-­‐You  and  QuesBons?