Brazilian version of the Segmental Assessment of Trunk Control (SATCo)

ABSTRACT

The Segmental Assessment of Trunk Control (SATCo) test was translated and adapted to Brazilian Portuguese. Two English language proficient professionals independently translated the original scale for the Brazilian Portuguese (T1 and T2). Following, the translated version of consensus was generated (TU). Two translators performed two versions in English (BT1 and BT2) of the TU version. A new process of consensus between translators and researchers resulted in an English version (BTfinal) that was compared with the original version, aiming to detect possible semantic differences. The version of the instrument in Brazilian Portuguese (TU), called Segmental Assessment of Trunk Control, was revised by the experts’ committee, composed of three physical therapists for content checking and the second version of agreement was generated (Tfinal). Tfinal was submitted to one of the original scale authors to check the understanding of the Brazilian Portuguese version. After this step, 20 physical therapists applied the scale in children with Cerebral Palsy. Part of the physical therapists indicates the need for complementary information in the description of instructions and score.

Keywords:
Trunk; Scales; Measurement; Child; Evaluation

RESUMO

Traduziu-se e adaptou-se para o português do Brasil o teste Segmental Assessment of Trunk Control (SATCo). Dois profissionais proficientes na língua inglesa traduziram, independentemente, a escala original para o português do Brasil (T1 e T2). Em seguida, gerou-se a versão traduzida de consenso (TU). Dois tradutores realizaram duas versões em inglês (RT1 e RT2) da versão TU. Um novo processo de consenso entre tradutores e pesquisadores resultou em uma versão em inglês (RTfinal), que foi comparada com a versão original, com vistas a possíveis diferenças semânticas. A versão do instrumento em português do Brasil (TU), denominada “Avaliação Segmentar do Controle de Tronco”, foi revisada pela comissão de especialistas, composta por três fisioterapeutas, para verificação do conteúdo e gerou a segunda versão de concordância (Tfinal). Tfinal foi encaminhada a uma das autoras da escala original para verificar o entendimento da versão em português do Brasil. Após essa etapa, 20 fisioterapeutas aplicaram a escala em crianças com paralisia cerebral. Parte dos fisioterapeutas indica a necessidade de complementação de informação na descrição das instruções e na descrição da pontuação.

Descritores:
Tronco; Escalas; Medidas; Criança; Avaliação

RESUMEN

Se tradujo y se adaptó al portugués de Brasil la prueba Segmental Assessment of Trunk Control (SATCo). La escala original fue traducida de forma independiente por dos expertos en lengua inglesa al portugués de Brasil (T1 y T2). Después se produjo una versión traducida en acuerdo (TU). De esta versión, fueron realizadas dos versiones en lengua inglesa por dos traductores (RT1 y RT2). Se formó un nuevo consenso entre traductores e investigadores del cual generó una versión en lengua inglesa (RTfinal), en que se comparó al original para encontrar diferencias semánticas. La versión del instrumento en portugués brasileño (TU) se llamó Avaliação Segmentar do Controle de Tronco (Evaluación Segmentaria de Control del Tronco) y fue corregida por un conjunto de expertos, constituido de tres fisioterapeutas, para chequear el contenido, siendo que al final generó una segunda versión por consenso (Tfinal). Esta segunda versión la mandaron a una de las autoras de la escala original para chequear la comprensión de la versión en portugués de Brasil. Tras esta etapa, veinte fisioterapeutas aplicaron esta escala a niños con parálisis cerebral. Una parte de los fisioterapeutas señalan que es necesario complementar informaciones sobre la descripción de las instrucciones y de los puntajes.

Palabras clave:
Torso; Escalas; Medidas; Niño; Evaluación

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 tasks¹. 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 activities¹. 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 activities².

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 movement⁵.

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. Without the appropriate measurement of that control, it is not possible to provide valid information about the effectiveness of a given therapeutic approach.

The development and validation of new instruments that aim to evaluate trunk control occurred mostly in English-speaking countries. Examples of evaluation instruments of trunk control are: Sitting Assessment of Children with Neuromotor Disability⁶, Trunk Control Measurement Scale⁷, Trunk Impairment Scale⁸ and Segmental Assessment of Trunk Control (SATCo)⁹. 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 contexts¹⁰.

Butler¹¹ 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 deficiencies⁹.

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 areas¹³.

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).

Figure 1
Flowchart of the translation process of SATCo.

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.

RESULTS

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).

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

Back-translation terms Brazilian Portuguese version	Amendments proposed by the experts’ committee
Examiner	Evaluator
Lower scapula	Inferior angle of the scapula
No support given and straps in pelvis/thighs removed	Without support of the evaluator and without straps around the pelvis/thighs
IMC (kg/m2)	21,7 (2,96)

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.

Table 2
Changes in the Brazilian Portuguese version of SATCo after being tested by physical therapists

Description of instructions	Illustrations	Score description	Form for evaluation
- The figure was detailed on the strap placement instruction (strapping).	-	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.
- 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.

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 changes¹⁰. 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.

REFERÊNCIAS

• ¹
  Curtis DJ, Butler P, Saavedra S, Bencke J, Kallemose T, Sonne-Holm S, et al. The central role of trunk control in the gross motor function of children with cerebral palsy: a retrospective cross-sectional study. Dev Med Child Neurol. 2015;57(4):351-7. doi: 10.1111/dmcn.12641.
  » https://doi.org/10.1111/dmcn.12641
• ²
  Karthikbabu S, Rao BK , Manikandan N, Solomon JM , Chakrapani M, Nayak A. Role of trunk rehabilitation on trunk control, balance and gait in patients with chronic stroke: a pre-post design. Neurosci Med. 2011;2(2):61-7. doi: 10.4236/nm.2011.22009.
  » https://doi.org/10.4236/nm.2011.22009
• ³
  Saavedra SL, van Donkelaar P, Woollacott MH. Learning about gravity: segmental assessment of upright control as infants develop independent sitting. J Neurophysiol. 2012;108(8):2215-29. doi: 10.1152/jn.01193.2011.
  » https://doi.org/10.1152/jn.01193.2011
• ⁴
  Rachwani J, Santamaria V, Saavedra SL, Woollacott MH. The development of trunk control and its relation to reaching in infancy: a longitudinal study. Front Hum Neurosci. 2015;9:94. doi: 10.3389/fnhum.2015.00094.
  » https://doi.org/10.3389/fnhum.2015.00094
• ⁵
  Pavão SL, Santos AN, Woollacott MH, Rocha NA. Assessment of postural control in children with cerebral palsy: a review. Res Dev Disabil. 2013;34(5):1367-75. doi: 10.1016/j.ridd.2013.01.034.
  » https://doi.org/10.1016/j.ridd.2013.01.034
• ⁶
  Reid DT. Development and preliminary validation of an instrument to assess quality of sitting of children with neuromotor dysfunction. Phys Occup Ther Pediatr. 1995;15(1):53-82. doi: 10.1080/J006v15n01_04.
  » https://doi.org/10.1080/J006v15n01_04
• ⁷
  Heyrman L, Molenaers G, Desloovere K, Verheyden G, De Cat J, Monbaliu E, et al. A clinical tool to measure trunk control in children with cerebral palsy: the trunk control measurement scale. Res Dev Disabil. 2011;32(6):2624-35. doi: 10.1016/j.ridd.2011.06.012.
  » https://doi.org/10.1016/j.ridd.2011.06.012
• ⁸
  Saether R, Helbostad JL, Adde L, Jørgensen L, Vik T. Reliability and validity of the Trunk Impairment Scale in children and adolescents with cerebral palsy. Res Dev Disabil. 2013;34(7):2075-84. doi: 10.1016/j.ridd.2013.03.029.
  » https://doi.org/10.1016/j.ridd.2013.03.029
• ⁹
  Butler PB, Saavedra S, Sofranac M, Jarvis SE, Woollacott MH. Refinement, reliability, and validity of the Segmental Assessment of Trunk Control (SATCo). Pediatr Phys Ther. 2010;22(3):246-57. doi: 10.1097/PEP.0b013e3181e69490.
  » https://doi.org/10.1097/PEP.0b013e3181e69490
• ¹⁰
  Coster WJ, Mancini MC. Recomendações para a tradução e adaptação transcultural de instrumentos para a pesquisa e a prática em Terapia Ocupacional. Rev Ter Ocup. 2015;26(1):50-7. doi: 10.11606/issn.2238-6149.v26i1p50-57.
  » https://doi.org/10.11606/issn.2238-6149.v26i1p50-57
• ¹¹
  Butler PB. A preliminary report on the effectiveness of trunk targeting in achieving independent sitting balance in children with cerebral palsy. Clin Rehabil. 1998;12(4):281-93.
• ¹²
  Major RE, Johnson GR, Butler PB. Learning motor control in the upright position: a mechanical engineering approach. Proc Inst Mech Eng H. 2001;215(3):315-23. doi: 10.1243/0954411011535911.
  » https://doi.org/10.1243/0954411011535911
• ¹³
  Saether R, Helbostad JL, Riphagen II, Vik T. Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review. Dev Med Child Neurol. 2013;55(11):988-99. doi: 10.1111/dmcn.12162.
  » https://doi.org/10.1111/dmcn.12162
• ¹⁴
  Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-91.
• ¹⁵
  Pedroso RS, Oliveira MS, Araujo RB, Moraes JFD. Tradução, equivalência semântica e adaptação cultural do Marijuana Expectancy Questionnaire (MEQ). Psico-USF. 2004;9(2):129-36. doi: 10.1590/S1413-82712004000200003.
  » https://doi.org/10.1590/S1413-82712004000200003
• ¹⁶
  Helmstadter GC. Principles of psychological measurement. New York: Appleton-Century-Crofts; 1964. (Century Psychology Series).
• ¹⁷
  Heyrman L, Desloovere K, Molenaers G, Verheyden G, Klingels K, Monbaliu E, et al. Clinical characteristics of impaired trunk control in children with spastic cerebral palsy. Res Dev Disabil. 2013;34(1):327-34. doi: 10.1016/j.ridd.2012.08.015.
  » https://doi.org/10.1016/j.ridd.2012.08.015

• Funding Source: Nothing to declare
• 6
  This study was approved by the Research Ethics Committee of the Federal University of São Paulo under Opinion No. 209.239

APPENDIX 1: BRAZILIAN PORTUGUESE VERSION OF SATCO - SCALE OF SEGMENTAL ASSESSMENT OF TRUNK

Nome do paciente: Nível de apoio manual Nível funcional Estático Ativo Reativo Comentários Nº. ref.: Avaliador: Data: Enfaixamento em pelve/coxas usado como indicado Braços e mãos elevados como indicado Manter posição neutra vertical da cabeça e do tronco acima do nível de suporte manual Mínimo de cinco segundos Enquanto vira a cabeça com os braços elevados Manter/recuperar rapidamente após breve desequilíbrio Cintura escapular. Posição da mão do avaliador pode variar a partir da horizontal Controle de cabeça. Os braços devem ser apoiados em aparato anterior ao longo do teste Não testado para controle de cabeça Axilas Controle torácico superior Ângulo inferior da escápula Controle torácico médio Acima das costelas inferiores Controle torácico inferior Abaixo das costelas Controle lombar superior Pelve Controle lombar inferior Nenhum suporte dado e faixas em pelve/coxas removidas Controle completo de tronco Deformidade fixa de coluna? Sim _________ Não _________ Comentários_________________ Limitação da rotação cervical: Direita _________ Esquerda__________ Comentários ______________

Nome do paciente:	Nível de apoio manual	Nível funcional	Estático	Ativo	Reativo	Comentários
Nº. ref.:
Avaliador:
Data:
	Enfaixamento em pelve/coxas usado como indicado	Braços e mãos elevados como indicado	Manter posição neutra vertical da cabeça e do tronco acima do nível de suporte manual
			Mínimo de cinco segundos	Enquanto vira a cabeça com os braços elevados	Manter/recuperar rapidamente após breve desequilíbrio
	Cintura escapular. Posição da mão do avaliador pode variar a partir da horizontal	Controle de cabeça. Os braços devem ser apoiados em aparato anterior ao longo do teste			Não testado para controle de cabeça
	Axilas	Controle torácico superior
	Ângulo inferior da escápula	Controle torácico médio
	Acima das costelas inferiores	Controle torácico inferior
	Abaixo das costelas	Controle lombar superior
	Pelve	Controle lombar inferior
	Nenhum suporte dado e faixas em pelve/coxas removidas	Controle completo de tronco
Deformidade fixa de coluna? Sim _________ Não _________ Comentários_________________
Limitação da rotação cervical: Direita _________ Esquerda__________ Comentários ______________

Instruções

Sujeito

O sujeito deve estar sentado em um banco, com os pés apoiados no chão ou em uma superfície estável e a posição da pelve e das coxas controlada por um sistema de enfaixamento (Figura 2). A pelve permanece em posição neutra, com relação ao eixo vertical. O sujeito permanece em postura ereta (“sentado reto”) com a presença das curvaturas cervical, torácica e lombar normais. A cabeça permanece ereta. Os braços e mãos não devem estar em contato com o tronco, coxas, banco ou qualquer outro contato externo, exceto como indicado. As mãos do sujeito não devem estar unidas.

Avaliador

O avaliador aplica suporte manual firme horizontalmente ao redor do tronco em cada um dos níveis designados em cada item. O apoio dado deve ser suficiente para assegurar que o tronco permaneça em uma postura vertical neutra e que qualquer instabilidade do tronco seja eliminada. As mãos e braços do sujeito devem ser elevados para que não haja contato com o corpo e com as pernas do mesmo, ou com o banco, ou com as mãos do avaliador. Brinquedos podem ser usados para motivar crianças, assegurando inclinação para pegá-los, mas não apreensão.

Em cada nível de suporte o avaliador deve encorajar o sujeito a sentar-se ereto e elevar as mãos e os braços durante o teste de a) controle estático, b) controle ativo, virando a cabeça lentamente para cada lado (>45 graus, ou até a amplitude que for possível) e c) controle reativo, permanecendo estável durante desequilíbrios dados por outro avaliador. Essa fase requer um assistente para aplicar um único desequilíbrio leve, suficiente para perturbar o equilíbrio brevemente, pela frente (manúbrio/esterno), por trás (C7) e pelos lados (acrômio), usando as pontas dos dedos com uma leve pressão. Se o sujeito apresentar problemas mínimos de equilíbrio, haverá oscilação excessiva, porém, poderá retornar para a vertical. Se, entretanto, houver problemas moderados ou graves de equilíbrio, o sujeito perderá o equilíbrio e chegará ao limite da amplitude de movimento.

O teste continua com rebaixamento do nível de suporte (apoio do examinador, conforme indicado para cada nível) até que o sujeito claramente não consiga manter ou rapidamente volte para a postura inicial. O avaliador deve estar atrás do sujeito, usualmente ajoelhado, dependendo do tamanho do sujeito e da altura do banco. É recomendado que o assistente fique fora da linha de visão do sujeito.

Figura 1
Indicação da forma do posicionamento das mãos do avaliador no suporte ao paciente: () (posicionamento correto) e (X) (posicionamento incorreto).

Pontuação

Em cada nível de suporte, a presença de controle é registrada utilizando o símbolo (), e a ausência de controle é registrada utilizando o símbolo (-). “NT” indica que o controle não foi testado naquele nível de suporte - “não testado”. A presença de controle é mostrada por:

Estático: manter uma postura de tronco vertical e neutra nos planos sagital e frontal por cinco segundos. Se a atenção do sujeito for brevemente perdida, acompanhada pela rotação da cabeça, mas a posição vertical for mantida, ainda deve ser pontuado como presença de controle.

Ativo: pode apresentar leve desalinhamento com relação à posição neutra (menor que 20 graus), mas ocorre realinhamento imediatamente, pela trajetória mais direta. Exemplo: a flexão de tronco é corrigida com extensão, indo em direção à postura neutra do tronco, sem realizar flexão lateral (inclinação) de tronco.

Reativo: o sujeito se move saindo da posição neutra vertical, mas rapidamente retorna para o alinhamento pela trajetória mais curta.

Instruções de filmagem opcional

Se um sistema de filmagem estiver disponível, recomenda-se que a avaliação seja gravada. Isso assegura a documentação visual para referências futuras e também permite a revisão do teste no caso de pontuações ambíguas. Se a filmagem for usada, a câmera fixada a 45 graus do sujeito irá permitir o julgamento do movimento nos planos frontal e lateral para a detecção de estratégias de movimento.

Instruções de enfaixamento

Três faixas e três anéis em forma de D devem ser firmemente presos à parte inferior da lateral do banco, para permitir que o sujeito fique fixo ao banco, como representado nas figuras a seguir.

Figura 2
Demonstração da colocação do enfaixamento para posicionamento do paciente.

Puxe as faixas das coxas para frente, cruzando o banco (Figura 2.1). O sujeito deve sentar-se no banco com as faixas ao redor das coxas (Figura 2.2). Puxe cada faixa para cima, passando entre as pernas do sujeito, passando por cima de cada coxa e pelos anéis em forma de D. Volte para baixo do banco e fixe (Figura 2.3). Em seguida, puxe a faixa pélvica para cima, partindo da frente do banco, circunde a pelve do sujeito e retorne pelo anel em forma de D para chegar à frente do banco (Figura 2.4). Mantenha a faixa baixa o suficiente para apoiá-la no sacro e não permitir que ela escorregue para a região lombar (Figura 2.5). Ajuste a compressão da faixa até que a pelve fique alinhada verticalmente (Figura 2.6). A proposta dessa faixa é apenas atuar como “outro par de mãos” para garantir que a pelve fique vertical (Figura 2.7).

APPENDIX 2: GUIDELINES FOR THE SCORE

Definição de controle

Alinhamento vertical neutro estável, com breves desvios de até 20 graus nos planos frontal e sagital (nível dos olhos). Manutenção das curvaturas cervical, torácica e lombar normais.

Você pontua só o que vê

Se o controle não for demonstrado, pontue como ausência de controle (-), ou não testado (NT). Se você acredita que a criança tenha controle, mas o desempenho correto não é demonstrado e surgem estratégias compensatórias durante o teste, pode ser pontuado como NT.

Da mesma forma, se o avaliador cometer algum erro de alinhamento que impeça a avaliação do controle vertical real, deve ser pontuado como NT. Sempre que o registro NT for realizado, deve ser feito um comentário sobre a natureza do erro ocorrido para referência futura.

Observe estratégias compensatórias que possam indicar falta de controle normal

• • Apoio manual

• - No banco;

• - Na boca;

• - No corpo (próprio ou do avaliador);

• - Conjunto (segurando um brinquedo, objeto, ou mãos juntas);

• - Num brinquedo/objeto segurado pelo avaliador.

• • Alinhamento de tronco

• - Inclinação anterior;

• - Curvatura para trás ou apoio no suporte manual;

• - Curvaturas maiores ou menores do que as normais.

• • Estratégias de movimento

• - Enrijecimento (rigidez) com falta de movimentos de tronco além do nível de suporte;

• - Movimento rápido ao invés de um movimento lento e controlado. Exemplo: da cabeça.

Erros críticos de realização do teste

• • Apoio manual

• - Não horizontal;

• - Não estável.

• • Alinhamento de tronco

• - Tronco abaixo do suporte não mantido na vertical e/ou não eliminação das inclinações de tronco.

• • Movimento

• - Posicionamento errado e/ou magnitude de desequilíbrio insuficiente;

• - Desequilíbrios quando o tronco não está na vertical (alinhado).

Erros críticos de pontuação, levando à determinação incorreta do nível de controle

• • Imaturidade do sistema esquelético (costelas ainda não alongadas);

• • Dificuldades por excesso de tecido adiposo;

• • Diferenciar perda de controle de cabeça de postura habitual;

• • Diferenciar perda de controle cervical relacionada à postura de movimentos cervicais relacionados à perda visual cortical.

Nível de especificação de controle

• • O foco é determinar o nível mais alto no qual o sujeito demonstra perda de controle, sendo esse nível registrado como tendo controle ausente;

• • Não testado (NT) em um nível acima de outro no qual o controle está presente é considerado como presença de controle;

• • Não testado (NT) em um nível abaixo de outro no qual o controle está presente é considerado como ausência de controle;

• • Se o equilíbrio estático apresentar escore NT, mas o sujeito mantiver o alinhamento durante o reativo ou ativo, então o estático deverá ser considerado com controle normal.

Publication Dates

• Publication in this collection
  Mar 2017

History

• Received
  Nov 2016
• Accepted
  Mar 2017