CLINICAL PROBLEM SOLVINGMCCAUL BENSON

NOVEMBER 5

Trunk Control as a prognostic factor for functional outcome of

CVA Patients

Patient History: Patient “X”

63 year old female

Status post acute ischemic stroke, left MCA

R side hemiplegia

PMH: breast cancer with previous left mastectomy, HTN

Large family support

Prior Level of Function

IndependentWorks part time at family businessLives alone in private residence

Complications

Complex medical case

Current breast cancer diagnosis

Suspected stroke Saturday-found Monday

Suspected bone mets: Left clavicle and scapula

Examination

Alert, no verbalizations

Decreased attention and concentration

Severe cognitive deficits

Able to follow simple commands

Responses not accurate

Objective Measures

  Strength: L UE/LE WFL; R UE/LE 0/5 except 1/5 R hip adduction  Coordination: R UE/LE grossly decreased, non functional   Tone: abnormal, flaccid R side except during R shoulder flexion PROM  Sensation: unable to assess at this time  ROM: Pt with + L gaze preference but able to turn head and eyes to R/past midline with cues. At one point, pt

observed to use L UE to lift R UE vs. another time when asked to touch her R hand, pt unable to use L UE to demonstrate knowledge of R UE

  AROM: no AROM R side, L side WFL PROM: L UE/LE grossly decreased, non functional  Bed mobility: Rolling-mod assistance, additional time, verbal cues to R vs. Max assistance to left , multiple trials for re-positioning Supine to sit: deferred due to pt fatigue and frustration 

Note: minimal assistance: patient performs over 75% of work Moderate assistance: patient performs 50% Maximal assistance: patient performs 25% of work

Prognosis

Fair Good family support + Severe hemiplegia - Severely impaired - Cancer dx - Young + Determination/interest +

Question of interest

What we know: Trunk control=an important predecessor to other higher level motions, especially balance and gait, both important functions of ADLs and functional independence.

What we do not know…

The predictive value of core strength and the relationship to functional outcome

Treatment: bed mobility, transfer training, balance Core stability/trunk strengthening???

Question of Interest

For my 63 year old female status post acute ischemic stroke, does the trunk control test predict functional outcome?

Importance of trunk control Importance of prognosis and discharge planning Implications for future treatment

Trunk control test as an early predictor of stroke rehabilitation outcome.

Purpose: To investigate the construct and predictive validity of the Trunk Control Test (TCT)

Compared TCT scores at admission and discharge with the Functional Independence scores (FIM)

Subjects: 49 patients Inpatient rehabilitation Majority hemiparetic patients

Trunk Control Test (TCT) and FIM

FIM: 13-item motor subscale and a 5-item cognitive subscale

TCT: examines four axial movements: rolling from supine position to weak side (T1), rolling to the strong side (T2), supine to sit (T3), sitting in balanced position on the edge of the bed with feet off the ground for 30 seconds (T4)

Scoring: 0=unable to perform without assistance 12=able to perform movement but in an abnormal manner 25=able to complete movement normally

total obtained on all 4 tests=100 total possible

Results

Variables Admission DischargeGrooming .44 .57Dressing:upper body

.64 .60

Toileting .48 .71Transfer bed/chair/wheelchair

.87 .81

Toilet transfer .72 .85Walk, wheelchair

.65 .79

TCT at admission correlated with the total FIM and motor FIM Tct-adm correlation to total Fim: .707 (adm) and .79 (dis) (P<.0001)TCT correlated with the motFim: .819 (adm) and .856 (dis) (P<.0001)

AS well as various motor items specifically:

Conclusion

Positive sensitivity to changeIntrinsic stability the authors conclude that the trunk mobility

test can actually predict motor FIM at discharge better than the motor FIM at admission alone

high correlations between the TCT and motor FIM and total FIM scores

concluding the construct validity of the TCT in severely impaired stroke patients

TRUNK CONTROL TEST AS A FUNCTIONAL PREDICTOR IN STROKE PATIENTS

Purpose: to evaluate prospectively the trunk control test correlation at admission to rehab with length of stay, functional independence measure, gait velocity, walking distance and balance measured at discharge

Subjects: 28 patients hemiplegia secondary to CVA in the 4 weeks

preceding admission to inpatient rehab mean age=64.5 15 days was average time from onset of stroke

Methods

Prospective designTCT and FIM administered < 72 hoursOutcome measures:

LOS FIM (motor, cognitive, efficiency) Gait velocity/distance Static and dynamic walking balance Berg balance

Results

Variables R Length of stay r = -0.722 Discharge FIM r = 0.738 Discharge motor FIM r = 0.723 Gait velocity r = 0.654 Walking distance p = 0.003 COG symmetry r = 0.601Berg Balance r = 0.755

TCT was significantly correlated with the following…

Conclusion

Trunk balance in the acute stage of stroke is a functional outcome prediction tool

TCT is a short and simple tool to predict functional outcome in stroke patients

TCT correlated well with some specific motor results such as walking speed, distance, and balance

Limitations

Small sample sizesBias because patients were pre-selectedfurther research is needed particularly the

prediction tool of length of stay Differences between acute care timeframe

and inpatient rehab Correlation coefficients Minimal methodsNeed for future research

Back to Patient X

The TCT was not appropriate for my patient in the acute care setting at initial evaluation due to severity of impairments

After multiple PT sessions, patient X would have theoretically scored 24/100 on the TCT, and as evidence would suggest, this indicates potential for poor functional outcomes

Up Next

TCT=appropriate “predictive” toolQuick, easy, objective toolNot the only tool to use limitations with

TCT and researchDrawing assumptions to outcomes with my

patientIntervention-focus on trunk control, limit

dependent positions, challenging treatments, facilitate core muscles

References

Duarte, E. (2002) Trunk control test as a functional predictor in stroke patients. Journal of Rehabilitation Medicine. Doi: 10.1080/165019702760390356

 

Franchignon, F.P. (1997) Trunk Control Test as an Early Predictor of Stroke Rehabilitation Outcome. Stroke Journal. Doi: 10.1161/01.STR.28.7.1382

QUESTIONS???