Versão brasileira da Segmental Assessment of Trunk Control ( SATCo ) Brazilian version of the Segmental Assessment of Trunk Control ( SATCo ) La versión brasileña de la Segmental Assessment of Trunk Control ( SATCo )

Traduziu-se e adaptou-se para o portugues do Brasil o teste Segmental Assessment of Trunk Control (SATCo). Dois profissionais proficientes na lingua inglesa traduziram, independentemente, a escala original para o portugues do Brasil (T1 e T2). Em seguida, gerou-se a versao traduzida de consenso (TU). Dois tradutores realizaram duas versoes em ingles (RT1 e RT2) da versao TU. Um novo processo de consenso entre tradutores e pesquisadores resultou em uma versao em ingles (RTfinal), que foi comparada com a versao original, com vistas a possiveis diferencas semânticas. A versao do instrumento em portugues do Brasil (TU), denominada “Avaliacao Segmentar do Controle de Tronco”, foi revisada pela comissao de especialistas, composta por tres fisioterapeutas, para verificacao do conteudo e gerou a segunda versao de concordância (Tfinal). Tfinal foi encaminhada a uma das autoras da escala original para verificar o entendimento da versao em portugues do Brasil. Apos essa etapa, 20 fisioterapeutas aplicaram a escala em criancas com paralisia cerebral. Parte dos fisioterapeutas indica a necessidade de complementacao de informacao na descricao das instrucoes e na descricao da pontuacao.


INTRODUCTION
Postural control involves control of the body's position in space for the dual purpose of stability and guidance, which reflects the ability of postural control and is fundamental for the correct execution of everyday tasks 1 .During the execution of these tasks, the trunk has the main function of stabilizing the posture.In order to have this postural adjustment, it is necessary to balance essential components (EC) such as range of motion, maintenance of strength and coordination of trunk muscles.
In the case of an external disturbance, postural misalignment usually occurs and can be quickly corrected by EC, structuring the adequate trunk control during manual activities and in gross motor activities 1 .Postural control is the main component for individuals to keep their body in a state of balance in situations of rest and in the performance of functional activities 2 .
The ability to maintain balance in sitting posture gradually emerges in children with typical development at around six months of age.It begins with the development of the head control, followed by the progressive development of trunk control 3,4 .In children with neuromotor disabilities, motor control may be altered and, depending on the severity of the disorder, it can present restrictions of balance in sitting posture throughout life, without ever acquiring the independent control of the trunk movement 5 .
Evaluating the balance in sitting posture is essential to direct the intervention of children with motor disabilities.It is noted that the development of instruments to evaluate the trunk control in research and clinical practice is increasing..Researchers and clinicians from other countries who wish to use such instruments need to translate them to their language and validate them for using it in different cultural contexts 10 .
Butler 11 created the SATCo in 1998.In 2010, she refined and validated the instrument to assess the level of trunk control, considering many subunits that must be coordinated to achieve sitting posture control 11,12 .Unlike other instruments that evaluate the trunk as a single unit, SATCo allows more detailed analysis and the narrow definition of the level where trunk control difficulties are presented, which leads to the new perspective in the treatment of trunk control deficiencies 9 .
In Brazilian Portuguese language there is still no rating scales that can measure the level of trunk control.Therefore, the translation and cultural adaptation of SATCo will provide a new instrument to professionals in the rehabilitation areas 13 .
This study aimed to translate SATCo scale to Brazilian Portuguese and adapt it to the Brazilian culture.

METHODOLOGY
This study performed the translation to Brazilian Portuguese and the cultural adaptation of the instrument for measuring the level of trunk control, SATCo.The methodological procedure followed the internationally recommended steps: translation, translation synthesis, back-translation, analysis in expert committee, pre-test and final version 10,14 .Documentation describing all steps for the translation and cultural adaptation was sent to the author of the original questionnaire to ensure adequacy of the translation process.This study was preceded by a formal authorization of authors of the original version of SATCo for translation and validation of the instrument to the Brazilian Portuguese language.
The scale and instructions related to its application, which are presented in the original English language version, were translated to the Brazilian Portuguese language, according to international recommendations.Translations were performed by two independent translators, and only one of them knew the purpose of the study, but did not know the scale.These two translations for Brazilian Portuguese (T1 and T2) were merged into a single version (TU), after the consensus between the two translators and the researchers.
After translating the scale and its instructions, TU was back-translated (BT) to the original language, by hiring two other translators who did not know the study purposes, following the same rules of the initial translation.These two versions in English (BT1 and BT2) went through a new process of consensus among translators and researchers, resulting in an English version (BTfinal), which was compared with the original version, aiming to detect possible semantic differences.
The version of the instrument in Brazilian Portuguese (TU) was revised by an experts' committee composed of three physical therapists, all with over 10 years of clinical experience in the area of neurofunctional physical therapy and with knowledge of the two languages, for verifying the content validity.For this review, the commission compared item by item the version in Brazilian Portuguese (TU) with the original English version to confront their agreement and suggest changes that could improve translation.Each item was also assessed regarding relevance in the content evaluation of the instrument, checking the equivalence.After this review, a second version for agreement was prepared, which was forwarded to one of the original scale authors, who is Brazilian, to check the understanding of the Portuguese version of the scale, reaching a final version in Brazilian Portuguese (Tfinal).After this step, Tfinal version was delivered to 20 physical therapists, with at least two years of experience in the field of neurofunctional physical therapy in children, to test the translated and adapted instrument.These physical therapists tested the instrument in children with cerebral palsy (CP) to check the interpretation about the task to be performed (instruction) and the child's response, and yet for record of the response of each item evaluated by the scale.

INSTRUMENT
SATCo was developed and validated by Butler et al. 9 ; it is a systematic method of assessing the levels of trunk control in children with motor impairment.For the purposes of SATCo, children must be sitting on the seat, in standing posture, hands and arms free from any external contact, including their own body, seat or the evaluator's arms, feet on the ground and hip stabilized by the straps system described in the scale.
The evaluator must be positioned behind the child and offer a firm manual support, horizontally, around the trunk, in each one of the levels assigned to each condition.The support given must be sufficient to ensure that the log is in neutral posture.
The assistant, preferably positioned outside the child's line of sight, generates a horizontal imbalance, with the fingertips in the manubrium of sternum, at the level of vertebra C7 and in the left and right acromia.
For each level of support, the following are tested: static control, in which the child must remain static, fixing the look forward; active control, in which the child is requested to rotate the head more than 45º to either side, slowly, and reactive control, in which an imbalance is generated by the assistant in the fixed points, with enough intensity to upset the balance momentarily.
The child's ability to maintain or quickly recover the vertical position of the trunk without support at all levels is evaluated during the static, active and reactive test and noted on the SATCo file.In each level of support, we marked the presence or absence of control using the symbols "" (present), "-" (absent) and "NT" (not tested).
The presence of control is considered when the child has a slight disturbance of balance, i.e., reacts by swinging, but is able to come back to the starting position.Absence of control is indicated when the balance disorder is moderate to severe and the child loses balance and the range of motion reaches its limits.The test continues with the reduction in the level of support offered until the child is no longer able to keep or return quickly to the starting position.

Participants
To test the translated instrument, 20 children with CP participated in the study (four with GMFCS I, one with GMFCS II, five with GMFCS III, six with GMFCS IV, four with GMFCS V ), of both genders, aged 6.1 years old (±4.8).Children with CP who presented visual and/or auditory deficit and could not understand simple verbal commands were excluded.

Test procedures and data analysis
Each physical therapist asked to test the SATCo scale assessed each item of the instrument tested for the description of instructions; illustrations; description of the score and form for evaluation and classified them in various aspects of the instrument in suitable as it is; need for inclusion of any question/information; need for exclusion of any question/information; or need for modification of any question/information.From the information received, a database was organized to systematize the review of the Brazilian version of SATCo, taking care not to modify the content of the instrument.

Translation of SATCo
After translation, the instrument was called "Avaliação Segmentar do Controle de Tronco" (Segmental Assessment of Trunk control), but we opted for using the acronym in English, SATCo, associated with the abbreviation of "Brazil", BR (SATCo-BR).In the comparison between the translated and the original version, performed by the experts' committee, a few incorrect items were found, which hindered the understanding and interpretation of information.These items were changed (Table 1).

Administration of the translated version of SATCo
In relation to the description of instructions of SATCo Portuguese version, 14 physical therapists (70%) revealed that the instructions were adequate and six (30%) suggested the inclusion of some kind of information.When it came to the illustrations, all physical therapists (100%) revealed that the illustrations were appropriate.Regarding the description of score, 10 physical therapists (50%) indicated that the description was adequate and 10 (50%) had questions about score and used the terms "present" or "absent" to register the level of trunk control.Based on this result, we found the need for inclusion of extra information in relation to the score.Regarding the evaluation form, only one physical therapist suggested the inclusion of information.Table 2 presents the adaptations in the instructions, according to suggestions given by physical therapists.-It was inserted in the description of the stimulus to be applied in the reactive component: "with light pressure" -Support of the evaluator, as indicated in the registration form for each level.
-It was emphasized that the symbol () must be used when the control component is present and the symbol (-) when the control is absent.
In the first level of control, it was inserted that the arm is supported in previous apparatus.

DISCUSSION
This study translated and adapted for Brazilian Portuguese the segmental assessment of trunk control, an instrument to assess the level of control of the trunk on sitting posture.
A suitable instrument to assess the level of trunk control of individuals with movement disorder is crucial both for use in clinical practice and in research.A good evaluation instrument must address what is desired to investigate, be trustful to the investigated population, present validity, be of easy applicability and sensitive to changes 10 .SATCo showed high correlation with Alberta Infant Motor Scale (r=0.86),Bayley Scales of Infant and Toddler Development Test (r=0.83) and age (r=0.90) 4 .However, there are studies that confirm the instrument validity.
SATCo was originally written in English with adaptations relevant to the American culture, especially in the context of language and grammatical constructions.The translated version of the instrument, without adapting the cultural context, may fail in terms of meaning for anyone who applies it and receives the application, because some words in different languages may not have the same meaning 15,16 .Administration of the translated test to a group of professionals with experience in the field is necessary in order to ensure adaptation of the instrument.Aiming at applying the instrument to the Brazilian population, in addition to the translation, the instrument was tested in terms of cultural equivalence, in such a way that it could be understood and interpreted by the evaluators (Appendix I).
During the initial translation steps and evaluation of the initial translation (back-translation) there were no important differences between the translators and the experts committee.Some items, although not incorrect, hindered the understanding and interpretation of information, thus they were adapted to the Brazilian culture.In two of those, terms were changed to maintain the structure and to ensure understanding of the item.One of them is the term "lower scapula" whose translation was modified to "inferior angle of the scapula", to make the anatomical reference more precise and understandable.The other was "no support given and straps in pelvis/thighs removed", which was changed to "without support of the evaluator and without straps around the pelvis/thighs".
After preparing the final version in Portuguese (Tfinal), 20 physical therapists tested this release in children with CP.In this step, four aspects for interpretation were assessed: description of instructions, illustration, description of score and form for evaluation.
In the instruction about the placement of strap on the patient and the sitting support surface, the step-by-step shown in the figure was discriminated in the text in order to facilitate the procedure of placing the strap.In the description of the stimulus to be applied in the reactive component, the term "with light pressure" was inserted, indicating the stimulus intensity.It was included that the support of the evaluator to each level must be followed as indicated in the evaluation form of SATCo.Such modifications, made after suggestions of 20 physical therapists, facilitated the instrument interpretation.
Regarding illustrations of the instrument, 100% of the physical therapists agreed these were adequate for instrument use.Whereas for the score criterion, 50% of the physiotherapists did not use the correct symbol employed by the instrument and used the terms "present" or "absent".Thus, there was the need to highlight the symbol (), which indicates presence, and the symbol (-) which indicates absence.The bold was used for that.
Finally, the evaluation form, which was reinforced in the first level of control indicating head control, the arms of the evaluated must be previously supported in the table placed in front.
Use of SATCo enables to identify the trunk area with reduced postural control, essential information to plan an appropriate intervention to each patient with the movement alteration.Studies using SATCo show the accurate assessment of the level of trunk control in children with CP allow better targeting of therapy to improve the postural control or compensate for the absence of control with the use of assistive technology, aiming at achieving greater functional performance of the individual 1,17 .
In summary, the translation and adaptation of the segmental scale of trunk control -SATCO will help clinicians and researchers to identify the level of trunk control of individuals with movement disorder, aiming at directing interventions and monitoring the evolution of this control in a precise, reliable and easy way to apply.

Figure 1 .
Figure 1.Flowchart of the translation process of SATCo.

Table 1 .
Changes made after back-translation of the Portuguese version and of the changes proposed by the experts' committee for the SATCo-BR version