Lost without translation: Selective Control Assessment of the Lower Extremity (SCALE) in German EILEEN FOWLER UCLA Center for Cerebral Palsy, Department of Orthopaedic Surgery/Orthopaedic Institute for Children, Geffen School of Medicine, University of California, Los Angeles, CA, USA. doi: 10.1111/dmcn.12827 This commentary is on the original article by Balzer et al. on pages 167–172 of this issue.
As clinicians and scientists, translation is an important concept. We translate the meaning of words to students, patients, and families. We have been challenged to translate scientific evidence into practice. When publishing consensus definitions, classifications, evaluations, and outcomes, English language nuances across countries and continents must be considered. During meetings of the Taskforce on Childhood Motor Disorders,1 we spent hours deliberating the optimal words to define various motor impairments, including reduced selective motor control and obtaining consensus among a diverse group of clinicians and researchers – not an easy task. In developing content validity for Selective Control Assessment of the Lower Extremity (SCALE),2 we learned that facilitating plantar flexion by coaching a child to move as if they were pushing on a ‘gas pedal’ was not logical in a country that uses ‘petrol’.
Balzer et al.3 translated the English version of SCALE into German for use in the clinical environment. Although, I cannot directly evaluate this translation, the methods used instill confidence in their findings. International guidelines for translation of clinical measures were followed.4 The authors assessed the validity and reliability of the translated version for children with spastic cerebral palsy for which SCALE was designed. The original published SCALE validation results were supported and expanded. Additional validation was performed using the Fugl-Meyer Assessment, which includes evaluation of isolated joint motion. Some limitations were noted. The concentration of participants in Gross Motor Function Classification System level I limits the generalization of their results to children with lower mobility levels. Additionally, this study demonstrated the reliability of scoring but did not address the reliability of administration as all tests were scored from videotaped assessments. Hopefully, the German version of SCALE will fully translate into the clinical environment. As the American Academy for Cerebral Palsy and Developmental Medicine, European Academy of Childhood Disability, and the Australasian Academy of Cerebral Palsy and Developmental Medicine move toward an international alliance that supports clinicians in developing countries, translation must consider not only the meaning of the words but also the values present in diverse cultures.
REFERENCES 1. Sanger TD, Chen D, Delgado MR, Gaebler-Spira D,
terrater reliability of a clinical tool for patients with
Hallett M, Mink JW, Taskforce on Childhood Motor
cerebral palsy. Dev Med Child Neurol 2009; 51:
Disorders. Definition and classification of negative
607–14.
Lower Extremity: in children with cerebral palsy. Dev Med Child Neurol 2016; 58: 167–72. 4. Beaton DE, Bombardier C, Guillemin F, Ferraz MB.
motor signs in childhood. Pediatrics 2006; 118: 2159–67.
3. Balzer B, Marisco P, Mitteregger E, van Linden M,
2. Fowler EG, Staudt LA, Greenberg MB, Oppenheim
Mercer TH, van Hedel HJA. Construct validity and
WL. Selective Control Assessment of the Lower
reliability of the Selective Control Assessment of the
Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000; 25: 3186–91.
Extremity (SCALE): development, validation, and in-
The straight leg raise test for hamstring contractures: what is the contribution of sciatic nerve irritation? HENRY G CHAMBERS Department of Orthopedic Surgery, Rady Children’s Hospital, University of California, San Diego, CA, USA. doi: 10.1111/dmcn.12818 This commentary is on the original article by Marsico et al. on pages 173–179 of this issue. 116 Developmental Medicine & Child Neurology 2016, 58: 110–122
One of the most common problems in all children with cerebral palsy (CP) is hamstring contractures. Whether they are ambulant or particularly when they are sitting, constant spasticity or dystonia combined with bone growth leads to progressive relative shortening of the semitendinous, gracilis, semitendinosus, and biceps femoris muscles. The gait of ambulant children with CP can be
altered by this contracture with ensuing crouch gait and posterior pelvic tilt. In nonambulatory patients, the hamstring contractures can become obstacles to standing and transfer activities and, in some severe cases, can even lead to problems sitting in wheelchairs. The criterion standard for assessing hamstring contractures has been the popliteal angle. In this test, the hip is flexed to ninety degrees, the knee is extended to its maximum extension, and the angle that results is measured. This has served as a reproducible pre- and post-treatment assessment of hamstring contractures for years. In my practice, the straight leg raise (SLR) test was reserved for evaluating patients who might have back pain and a possible radiculopathy secondary to a ruptured nucleus pulposis. One of my partners has always used the SLR to assess hamstring contractures, but I have always discounted its utility. Marisco et al.1 have posited that the SLR may be the best test for the assessment of hamstring contractures, not only because it could reproducibly assess the degree of contracture, but also because they surmised that there might be irritation of the sciatic nerve caused by shortening of all of the structures behind the knee. Many patients who have had either serial casting or hamstring lengthening complain (if they are able) that they have tingling in their feet or even peroneal nerve injury with loss of motor strength in the ankle extensors and evertors. Karol et al.2 reported an almost 10% incidence of sciatic nerve irritation after casting post-surgery for hamstring contractures. The authors of this current study measured the SLR test along with performing a surface electromyography evaluation of the activation of the biceps femoris muscle. They noted that when a SLR test was performed, there was activation of the biceps femoris in over 50% of their patients,
leading the authors to surmise that there is a neural irritation component to the hamstring contracture in children with CP. There were several limitations of this study as they mainly studied ambulant patients. In order to standardize their test, they had to strap the patient down to perform the measurements which may limit the clinical usefulness of this test. When the SLR test is performed, it is very difficult to control the pelvis, so when the limb is lifted, often the pelvis rises as well. This is one of the reasons that the popliteal angle is used more often in the clinical setting. There are many who still use the SLR test as their sole assessment of hamstring contractures. However, based on this study I don’t believe that this test will supplant the popliteal angle measurement as the criterion standard. It does provide some insight into the contribution of possible sciatic nerve irritation as a contributor to what is called a ‘hamstring contracture’. Although there is no data to support this, it may be a predictor of those who have postoperative or post-casting nerve palsies. The authors admit that they have small numbers and did not evaluate the most severely involved patients, so these numbers may be skewed. They also did not have a control group of children with typical development, so it is unclear what happens with nerve activation in a normal situation either. I believe that this paper raises some interesting questions for future research and will encourage clinicians to go beyond thinking simplistically about the cause of hamstring contractures. Certainly there are peripheral nerve contributions combined with central nervous involvement that contribute to the development of hamstring contractures. It should give the treating clinician another tool to evaluate the musculoskeletal system of children with CP.
REFERENCES 1. Marsico P, Tal-Akabi A, van Hedel HJA. Reliability
2. Karol LA, Chambers C, Popejoy D, Birch JG. Nerve
and practicability of the straight leg raise test in children
palsy after hamstring lengthening in patients with cere-
with cerebral palsy. Dev Med Child Neurol 2016; 58:
bral palsy. J Pediatr Orthop 2008; 28: 773–76.
173–79.
Classifying communication ability in cerebral palsy HELEN COCKERILL Evelina Children’s Hospital - Paediatric Neurosciences, St. Thomas Hospital, London, UK. doi: 10.1111/dmcn.12863 This commentary is on the original article by Vander Zwart et al. on pages 180–188 of this issue.
We live in an age of burgeoning functional classification systems for individuals with cerebral palsy (CP). Systems are
now available that describe gross motor function, manual ability, communication, and eating/drinking ability.1 The purpose of these systems is to capture a child’s usual, everyday functioning in a way that diagnostic labels cannot. This has clear benefits for clinical practice and research. The Communication Function Classification System (CFCS) is a relative newcomer to the field.2 A key aspect of communication is that it involves two or more people working together to construct meaning. It also encompasses motor, cognitive, linguistic, and social dimensions. Commentaries
117
As clinicians and scientists, translation is an important concept. We translate the meaning of words to students, patients, and families. We have been challenged to translate scientific evidence into practice. When publishing consensus definitions, classifications, evaluations, and outcomes, English language nuances across countries and continents must be considered. During meetings of the Taskforce on Childhood Motor Disorders,1 we spent hours deliberating the optimal words to define various motor impairments, including reduced selective motor control and obtaining consensus among a diverse group of clinicians and researchers – not an easy task. In developing content validity for Selective Control Assessment of the Lower Extremity (SCALE),2 we learned that facilitating plantar flexion by coaching a child to move as if they were pushing on a ‘gas pedal’ was not logical in a country that uses ‘petrol’.
Balzer et al.3 translated the English version of SCALE into German for use in the clinical environment. Although, I cannot directly evaluate this translation, the methods used instill confidence in their findings. International guidelines for translation of clinical measures were followed.4 The authors assessed the validity and reliability of the translated version for children with spastic cerebral palsy for which SCALE was designed. The original published SCALE validation results were supported and expanded. Additional validation was performed using the Fugl-Meyer Assessment, which includes evaluation of isolated joint motion. Some limitations were noted. The concentration of participants in Gross Motor Function Classification System level I limits the generalization of their results to children with lower mobility levels. Additionally, this study demonstrated the reliability of scoring but did not address the reliability of administration as all tests were scored from videotaped assessments. Hopefully, the German version of SCALE will fully translate into the clinical environment. As the American Academy for Cerebral Palsy and Developmental Medicine, European Academy of Childhood Disability, and the Australasian Academy of Cerebral Palsy and Developmental Medicine move toward an international alliance that supports clinicians in developing countries, translation must consider not only the meaning of the words but also the values present in diverse cultures.
REFERENCES 1. Sanger TD, Chen D, Delgado MR, Gaebler-Spira D,
terrater reliability of a clinical tool for patients with
Hallett M, Mink JW, Taskforce on Childhood Motor
cerebral palsy. Dev Med Child Neurol 2009; 51:
Disorders. Definition and classification of negative
607–14.
Lower Extremity: in children with cerebral palsy. Dev Med Child Neurol 2016; 58: 167–72. 4. Beaton DE, Bombardier C, Guillemin F, Ferraz MB.
motor signs in childhood. Pediatrics 2006; 118: 2159–67.
3. Balzer B, Marisco P, Mitteregger E, van Linden M,
2. Fowler EG, Staudt LA, Greenberg MB, Oppenheim
Mercer TH, van Hedel HJA. Construct validity and
WL. Selective Control Assessment of the Lower
reliability of the Selective Control Assessment of the
Guidelines for the process of cross-cultural adaptation of self-report measures. Spine 2000; 25: 3186–91.
Extremity (SCALE): development, validation, and in-
The straight leg raise test for hamstring contractures: what is the contribution of sciatic nerve irritation? HENRY G CHAMBERS Department of Orthopedic Surgery, Rady Children’s Hospital, University of California, San Diego, CA, USA. doi: 10.1111/dmcn.12818 This commentary is on the original article by Marsico et al. on pages 173–179 of this issue. 116 Developmental Medicine & Child Neurology 2016, 58: 110–122
One of the most common problems in all children with cerebral palsy (CP) is hamstring contractures. Whether they are ambulant or particularly when they are sitting, constant spasticity or dystonia combined with bone growth leads to progressive relative shortening of the semitendinous, gracilis, semitendinosus, and biceps femoris muscles. The gait of ambulant children with CP can be
altered by this contracture with ensuing crouch gait and posterior pelvic tilt. In nonambulatory patients, the hamstring contractures can become obstacles to standing and transfer activities and, in some severe cases, can even lead to problems sitting in wheelchairs. The criterion standard for assessing hamstring contractures has been the popliteal angle. In this test, the hip is flexed to ninety degrees, the knee is extended to its maximum extension, and the angle that results is measured. This has served as a reproducible pre- and post-treatment assessment of hamstring contractures for years. In my practice, the straight leg raise (SLR) test was reserved for evaluating patients who might have back pain and a possible radiculopathy secondary to a ruptured nucleus pulposis. One of my partners has always used the SLR to assess hamstring contractures, but I have always discounted its utility. Marisco et al.1 have posited that the SLR may be the best test for the assessment of hamstring contractures, not only because it could reproducibly assess the degree of contracture, but also because they surmised that there might be irritation of the sciatic nerve caused by shortening of all of the structures behind the knee. Many patients who have had either serial casting or hamstring lengthening complain (if they are able) that they have tingling in their feet or even peroneal nerve injury with loss of motor strength in the ankle extensors and evertors. Karol et al.2 reported an almost 10% incidence of sciatic nerve irritation after casting post-surgery for hamstring contractures. The authors of this current study measured the SLR test along with performing a surface electromyography evaluation of the activation of the biceps femoris muscle. They noted that when a SLR test was performed, there was activation of the biceps femoris in over 50% of their patients,
leading the authors to surmise that there is a neural irritation component to the hamstring contracture in children with CP. There were several limitations of this study as they mainly studied ambulant patients. In order to standardize their test, they had to strap the patient down to perform the measurements which may limit the clinical usefulness of this test. When the SLR test is performed, it is very difficult to control the pelvis, so when the limb is lifted, often the pelvis rises as well. This is one of the reasons that the popliteal angle is used more often in the clinical setting. There are many who still use the SLR test as their sole assessment of hamstring contractures. However, based on this study I don’t believe that this test will supplant the popliteal angle measurement as the criterion standard. It does provide some insight into the contribution of possible sciatic nerve irritation as a contributor to what is called a ‘hamstring contracture’. Although there is no data to support this, it may be a predictor of those who have postoperative or post-casting nerve palsies. The authors admit that they have small numbers and did not evaluate the most severely involved patients, so these numbers may be skewed. They also did not have a control group of children with typical development, so it is unclear what happens with nerve activation in a normal situation either. I believe that this paper raises some interesting questions for future research and will encourage clinicians to go beyond thinking simplistically about the cause of hamstring contractures. Certainly there are peripheral nerve contributions combined with central nervous involvement that contribute to the development of hamstring contractures. It should give the treating clinician another tool to evaluate the musculoskeletal system of children with CP.
REFERENCES 1. Marsico P, Tal-Akabi A, van Hedel HJA. Reliability
2. Karol LA, Chambers C, Popejoy D, Birch JG. Nerve
and practicability of the straight leg raise test in children
palsy after hamstring lengthening in patients with cere-
with cerebral palsy. Dev Med Child Neurol 2016; 58:
bral palsy. J Pediatr Orthop 2008; 28: 773–76.
173–79.
Classifying communication ability in cerebral palsy HELEN COCKERILL Evelina Children’s Hospital - Paediatric Neurosciences, St. Thomas Hospital, London, UK. doi: 10.1111/dmcn.12863 This commentary is on the original article by Vander Zwart et al. on pages 180–188 of this issue.
We live in an age of burgeoning functional classification systems for individuals with cerebral palsy (CP). Systems are
now available that describe gross motor function, manual ability, communication, and eating/drinking ability.1 The purpose of these systems is to capture a child’s usual, everyday functioning in a way that diagnostic labels cannot. This has clear benefits for clinical practice and research. The Communication Function Classification System (CFCS) is a relative newcomer to the field.2 A key aspect of communication is that it involves two or more people working together to construct meaning. It also encompasses motor, cognitive, linguistic, and social dimensions. Commentaries
117
