1. CLINICAL PROBLEM SOLVING MCCAUL BENSON NOVEMBER 5 Trunk Control as a prognostic factor for functional outcome of CVA Patients

2. 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

3. Prior Level of Function Independent Works part time at family business Lives alone in private residence

4. Complications Complex medical case Current breast cancer diagnosis Suspected stroke Saturday-found Monday Suspected bone mets: Left clavicle and scapula

5. Examination Alert, no verbalizations Decreased attention and concentration Severe cognitive deficits Able to follow simple commands Responses not accurate

6. 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

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

8. 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???

9. 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

10. 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

11. 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

12. Results VariablesAdmissionDischarge Grooming.44.57 Dressing:upper body.64.60 Toileting.48.71 Transfer bed/chair/wheelc hair.87.81 Toilet transfer.72.85 Walk, 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:

13. Conclusion Positive sensitivity to change Intrinsic 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

14. 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

15. Methods Prospective design TCT and FIM administered < 72 hours Outcome measures:  LOS  FIM (motor, cognitive, efficiency)  Gait velocity/distance  Static and dynamic walking balance  Berg balance

16. Results VariablesR Length of stayr = -0.722 Discharge FIMr = 0.738 Discharge motor FIMr = 0.723 Gait velocityr = 0.654 Walking distancep = 0.003 COG symmetryr = 0.601 Berg Balancer = 0.755 TCT was significantly correlated with the following…

17. 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

18. Limitations Small sample sizes Bias because patients were pre-selected further research is needed particularly the prediction tool of length of stay Differences between acute care timeframe and inpatient rehab Correlation coefficients Minimal methods Need for future research

19. 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

20. Up Next TCT=appropriate “predictive” tool Quick, easy, objective tool Not the only tool to use  limitations with TCT and research Drawing assumptions to outcomes with my patient Intervention-focus on trunk control, limit dependent positions, challenging treatments, facilitate core muscles

21. 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

22. QUESTIONS???