USE OF VIDEO RECORDINGS FOR OBJECTIVE FUNCTIONAL ASSESSMENT AFTER POSTERIOR RHIZOTOMY c Lance Morton BSc Physiotherapy (Witwatersrandl Candice Wart BSc Physiotherapy (witvi@tersrand) M uriel Goodman PhD (Witwatersrand) OPSOMMING Die doel van hierdie studio is om vas te stel of dit moontlik is om die voor en na-operatiewe funksionele toestand van serebraal gestremde kinders w at Selektiewe Posterior Rhisotomie ondergaan het, objektief te bepaal en te vergelyk, deur die gebruik van video opnames. 'n Vraelys Is onder skole vir serebraal gestremde kinders versprei om fisioterapeute se opinies in verband m et die gebruik van video op­ nam es te bepaal. Elf video opnam es is deur twee van die skrywers en fisioterapeute m et ervaring in die behandeling van serebraal gestremde kinders, bestudeer. Die twee groepe het probeer om die funksionele toestand van die kinders objektief te bepaal deur gebruik te maak van 'n vorm w at vir hierdie doel opgestel is. Hulle het ook sekere eienskappe van die video opnam es getoets, soos onder andere die standarisering van toeruating, kamera hoeke, fisioterapeut se posisie en die opeenvol- ging van aktiwiteite. Daar is gevind dat m et die gebruik van bestaande video opnames, dit nie moontlik is om hierdie kinders objektief te toets nie. ’n Aan- bevole formaat w at gevolg behoort te word in die produksie van toekomstige video opnames, is saamgestel. KEY WORDS: Video recordings, Function, Cerebral Palsy INTRODUCTION T h e m ost recent a nd controversial breakthrough in the m anage­ m ent o f C erebral Palsy (C P ) has been developed by neurosurgeons using a technique known as Selective P o ste rio r R hizotom y (SP R ). D r W arwick Peacock pioneered th e technique in South Africa in 1980. T h e controversy surrounding th e p rocedure stem s from the inability, th u s far, to objectively assess th e effects it has had on the children on whom it has been perform ed. T h e successful outcom e o f SP R d e pends to a large extent on the c o rre c t choice o f candidates fo r this p ro c e d u re 1. In o rd e r to make co rre c t choices th e prim ary aim o f th e op eratio n which is to relieve spasticity, should always be b o m in mind. Secondary aim s d e p en d on th e functional ability o f the child p rio r to rhizotom y. Since 1980 S P R ’s have been perform ed on C P children. Peacock, 1989 2 n o ted that the two groups o f children who could benefit from this pro c ed u re were, am bulatory spastic diplegics and re ta rd e d non- am bulatory spastic quadriplegics. In studies o f th e p atien ts o p e rated o n in South Africa it was n o ted that the spastic diplegics experienced reduction o f spasticity post-operatively with im proved functional abilities, notably in term s o f gait.3,4 M ore involved p atien ts (spastic quadriplegics) also benefited, but in term s o f ease o f care, p o sition­ ing, sitting function a nd increased range o f m otion, ra th e r th an in individual functional activities o f daily living. T h e d a ta collected from this South A frican group form s th e basis for the selection criteria used in th e com bined neurosurgery a nd orth o p ae d ic rhizotom y clinic a t University o f C alifornia, L os Angeles2. Until recently follow-up studies have largely been subjective clini­ cal stu d ies1. An exception is th e gait analysis u n d ertaken on a m b u ­ latory children o p e rated on in C ape Town in 19855, and m ore objective m ethods o f evaluating S P R a re urgently needed. T his alternative p rocedure to trea tm e n t o f C P has aroused the in te rests o f patients, therapists and neurosurgeons alike. Few n e u ro ­ * Undergraduate project * * Department o f Physiotherapy, University o f the Witwatersrand surgeons have had experience o r form al training in th e evaluation a nd tre a tm e n t o f C P children. Som e concern h as been voiced t y th e m ore traditionally involved p ractitio n ers w ho c o n te n d th a t th e p ro ­ c ed u re is being utilised by a g ro u p w ith little form al training and experience w ith this diverse a nd difficult pa tie n t population. U n fo r­ tunately, very few o rth o p ae d ic surgeons, neurologists, n e u ro su r­ g e o n s o r p a e d i a t r i c i a n s a r e in a p o s i t i o n t o m o n i t o r a n d independently evaluate th e resu lts o f a neurosurgical p rocedure. A com prehensive co-operative a p p ro ac h is needed, in which th e pro- c ed u re is carefully em ployed and thoroughly studied . Physiotherapists a re essential in th e trea tm e n t a nd m anagem ent o f C P children a nd have gained extensive experience in th e assess­ m ent o f these ch ild ren 2, thus th e ir involvem ent in th e assessm ent o f th e S P R p rocedure is invaluable. T h e assessm ent o f CP has traditionally posed many problem s. T h e re is a g reat n eed fo r establishing assessm ent a nd recording system s which a re objective, valid a nd reproducible . T h e following p a ram ete rs m ust be considered fo r evaluation: r a n g e o f m o tio n , s t r e n g th , p o s t u r a l s ta b ility , a b ility to p e rfo rm g raded m uscle contraction, selective c o n tro l and en d u ran c e in v ari­ ous functional activities. T hese may include sitting, standing, tra n s ­ fers, locom otion, dressing, toileting, feeding a n d m obility for long 2 and sh o rt distances . 7 In 1988, R osenbaum expressed th e opinion th at th e use o f video recordings fo r the evaluation o f th e effects o f S P R was a good idea. T h e re is how ever a need to re d u ce th e d a ta o b tained significantly b efore this m ethod can b e efficiently a nd effectively utilised. Recently, em phasis has been placed on the use o f video recording in the assessm ent o f various functional activities. S taudt (1989) has used video recording for assessm ent o f c ertain developm ental po s­ tu res a n d transitional m ovem ents based on th e d egree o f th e child’s g independent function . T hese functional scales w ere developed as a m u lti - c e n tr e e f f o r t by p h y s io th e r a p is ts fro m five c e n tr e s in th e U nited S tates o f A m erica. M any o f th e S outh A frican C P schools a re using video recordings in an a tte m p t to assess th e functional abilities o f th e children. A fte r initial observation o f th e video recordings, th e a u th o rs felt th a t they lack an a d e q u a te standardised stru c tu re as well as a recognised professional ap p ro ac h regarding th eir production. T his re n d e rs them scientifically inad e q u ate fo r in depth objective analysis. F o r th e sam e reasons it was felt that it would be difficult to assess these video g recordings using S ta u d t’s Functional A ssessm ent . METHODS AND MATERIALS Sample Subjects w ere draw n from th re e C erebral Palsy schools in the PW V area. From these schools 15 cases w ere available, four o f which w ere discarded d u e to th e p o o r quality o f the video recordings. T he sam ple consisted o f five boys a nd six girls, whose ages ranged betw een two and ten years pre-operatively. A m ong the children th e re w ere five spastic quadriplegics and six spastic diplegics. All these children had u n dergone SP R a nd had been video taped both pre- and post-operatively. In all cases w ritten consent was obtained from the schools fo r the use o f th e video recordings in the study. Procedure In o rd e r to fulfil the aim s o f th e study, o n e form and two ques- Fisioterapie, Februarie 1992, dee148 no 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) tionnaires w ere compiled. Q u e stionnaire A, which aim ed to ascertain th e physiotherapist’s views on th e use o f video recordings fo r the objective evaluation o f these CP children, was sent to seven CP schools in th e PW V area. O nly physiotherapists w ho w ere involved in the trea tm e n t o f CP children w ho had undergone SPR com pleted the questionnaire. O ver a th ree week period th e a u th o rs assessed all eleven video tapes a nd each case was docum ented using a standardised form . The a u th o rs aim ed to • Objectively assess th e pre- and post-operative functional sta tu s o f the child using S taudt’s Functional A ssessm ent. • Assess th e standardisation o f th e video recordings • R eview the sequence o f developm ental functional activities in ­ cluded in each video recording. E ach case was th en viewed again. D uring this second viewing p a rticular a tte n tio n was paid to the following criteria: • Visual clarity o f th e video recordings • Lighting • Sound quality • Standardisation o f th e physiotherapist’s position • A ngle o f th e cam era T h e video recordings w ere then random ly allocated to physiother­ apists experienced in the trea tm e n t and m anagem ent o f CP children. However, c are was taken to e n su re th at in each case th e physiother­ a p is t h a d n o p r io r in v o lv e m e n t w ith th e t h e r a p y o f t h a t c hild. T o g eth er with th e tapes, each physiotherapist was given a second q uestio n n a ire and they followed the sam e protocol w hen evaluating th e tapes. By m eans o f this each physiotherapist was asked to: • Objectively assess the pre-and post-operative functional status of th e child using S taudt’s Functional A ssessm ent. • A ssess th e outcom e of the p rocedure in each case study. • Explain th e objective grounds on which they had based their conclusions. • C om m ent on the standardisation of the form at o f the video recordings enabling objective conclusions to be reached. RESULTS AND DISCUSSION Table I: The results obtained from questionnaire A USING VIDEO RECORDINGS FOR EVALUATION? YES 95% NO 5% PREFERRED METHODS OF EVALUATING THE SUCCESS OF SPR VIDEO RECORDINGS 57% COMPUTER ANALYSIS 19% FUNCTIONAL ASSESSMENT 90% RANGE OF MOVEMENT 57% MUSCLE TONE 33% SUBJECTIVE EVALUATION 57% BEST POST-OPERATIVE STAGE AT WHICH VIDEO SHOULD BE TAKEN 3 MONTHS 0% 6 MONTHS 48% 9 MONTHS 0% 12 MONTHS 95% IS A SPECIFIC SEQUENCE BIENG FOLLOWED? YES 100% NO 0% ABILITY TO QUAUTATE/QUANTIFY EFFECTS OF SPR FROM VIDEOS YES 40% POSSIBLY 20% NO 40% AVERAGE PRODUCTION TIME PER VIDEO 42 MINS AVERAGE PRODUCTION COST PER VIDEO R20 F rom T able I it can be seen that 95% of the physiotherapists are presently using video recordings for th e evaluation of Selective P o s­ te rio r Rhizotom y. However, only 57% suggested video recordings as a p re fe rre d m ethod o f evaluation. N inety percent felt th at functional assessm ent is necessary for evaluation. T h e re may be an inference th a t functional assessm ent o f th e children m ay be achieved using video recordings as 40% o f th e physiotherapists p referring th e use o f functional assessm ent a lso p ro p o se d th e use o f video recordings. It was interesting to n ote th a t in all th e cases viewed by the authors, not once was th e testing o f ranges o f m ovem ent o r m uscle to n e o m itted from the video recordings. T his was in spite o f th e fact th a t such little em phasis had been placed on th e use o f these two m easurem ents as p re fe rre d evaluation tools (57% a nd 33% resp ec­ tively). B oth ranges o f m ovem ent a nd m uscle tone can only be subjectively assessed from th e recordings, a nd they should th ere fo re be recorded on se p a ra te form s. It is n ot necessaiy to include them in th e video recordings. T he general consensus is th a t th e child should be video tap e d at six m onthly intervals u p to tw o years post-operatively a n d annually th e re a fte r in o rd e r to m o n ito r th e p rogress o f th e child. T h e a u th o rs feel th at it is beneficial to have an early assessm ent o f th e child, th ree m onths post-operatively, in o rd e r to allow th e child sufficient tim e fo r recovery, b ut it is also im portant to docum ent th e sta tu s o f the child b efore o th e r factors (such as m aturity a n d /o r th e effects o f physiotherapy) have had an influence. All the physiotherapists currently using video recordings a re a t ­ tem pting to follow a specific sequence. However, it is evident from fu rth e r results obtained by th e a u th o rs, th at they a re n ot being successful in this respect and th e re is a need to establish a sta n d ­ ardised sequence. From the c u rre n t average p ro duction tim e o f each video re c o r­ ding the a u th o rs e stim ate th at it would take 3 h ours to assess the progress o f the child. T his is extrem ely tim e consum ing and highly im practical in the clinical setting. Provided that th e video recordings a re standardised a nd follow an exact sequence (containing the a p ­ pro p riate activities) the a u th o rs calculate th at each stage should last no longer that 20 m inutes. T h u s it would be possible to accurately assess the progress o f th e child within 90 m inutes. Table II: R e la tio n s h ip between the authors' scores and those of the physiotherapists % OF STATIC POSTURES AND TRANSITIONAL MOVEMENTS THAT WERE ABLE TO BE SCORED 63 % BY WHICH AUTHORS’ AND PHYSIOTHERAPISTS’ SCORES DIFFERED 19 AVERAGE % BY WHICH THESE SCORES DIFFERED 1,15 T able II shows th at it was only possible to score 63% o f th e static postures and transitional m ovem ents p resent in S ta u d t’s Functional A ssessm ent in th e 11 videos reviewed. It is significant to n o te th at th e re is only a 19% discrepancy betw een th e a u th o rs’ scores and those o f the physiotherapists. T hus, although this m eth o d relies on subjective evaluation using an objective scoring scale, th e re a p p ea rs to be a high reliability betw een in d ep e n d en t raters. A lthough inform ation from th e first questio n n a ire show ed that 100% o f the physiotherapists felt they had followed an exact se ­ quence of activities b oth pre- and post-operatively, results show that in only 18% of the cases was this true, as shown in T able III. T he sequence is unstandardised n ot m erely because the o rd e r o f activities has been altered but also because the sam e activities a re not being repeated. It was noted that in 50% o f the cases the following aspects were not standardised: • the equipm ent used • the physiotherapist’s position and the am o u n t o f support given to the child • the position of the cam era. An overwhelm ing m ajority o f the physiotherapists as well as the a u th o rs feel th at it is necessary to include activities o f daily living. W e reasoned that the relative ease o r th e d egree o f difficulty a child Physiotherapy, February 1992 Vol 48 no 1 Page 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) e x p e r i e n c e d w h ilst d re s s in g , e a tin g , play in g , e tc . d e te r m i n e s th e child’s quality o f life. It is thus im p o rta n t to evaluate th e p ro c ed u re ’s effect in this respect. However, these m ust b e standardised a n d o f sh o rt d uration. Tablelll: General comments pertaining to the video recordings USE O F EXACT SEQUENCE YES 18% NO &2% ‘ IS IT NECESSARY TO INCLUDE ADL IN THE VIDEO YES 81% NO 9% HAS SPR FULFILLED ITS PURPOSE? YES 56% NO 44% DOES VIDEO SUPPLY ENOUGH OBJECTIVE EVIDENCE TO EVALUATE SPR? YES 50% NO 50% Fifty-six p e rce n t o f the physiotherapists w ho viewed th e eleven cases felt th a t Selective P o ste rio r R hizotom y had fulfilled th e p u r­ pose fo r which it was perform ed. (T ab le III) However, only 50% felt th a t th e v ideo recordings supplied sufficient objective evidence on w hich to base this conclusion. F u rth e rm o re , 56% o f th e p h ysiother­ a pists felt th a t th e child gained o th e r observable benefits from the p rocedure. O nly 10% o f the physiotherapists felt however, th a t the v ideo recordings supply th e objective evidence necessary to su b sta n ­ tia te th e ir standpoints. CONCLUSION T h e results shew th at c u rre n t video recordings being produced fo r th e p urpose o f assessing the effects o f Selective P o ste rio r R h izo ­ tom y on the functional activities o f C erebral Palsied children, lack an a d e q u a te standardised stru c tu re as well as a recognised professional ap p ro ac h regarding th e ir p roduction. T h is re n d e rs them scientifically inad e q u ate fo r indepth objective analysis. In spite o f th e shortcom ings p re sen t in th e existing v ideo re c o r­ dings, th e a u th o rs and 9 1% o f th e physiotherapists feel th at, provided th at fu tu re v ideo recordings a re produced following a precise, sta n d ­ a rdised a n d com prehensive form at, they will play an im p o rta n t role in th e objective evaluation o f th e effects o f Selective P o s te rio r R h i­ zotom y o n C erebral Palsied children. FOOTNOTE: A standardised form at to be followed in th e p ro duction o f fu tu re v ideo recordings is obtain a b le from th e D e p a rtm e n t o f P hysiother­ apy, M edical School, Y ork R o a d , Jo h a n n e sb u rg 2193. REFERENCES 1. Arens U , Peacock WJ, Peter J. Selective Posterior Lumbar Rhizotomy - Criteria for Selection of Cases. SA J Physiotherapy 1989:45(4):97-99. 2. Oppenheim WL, Peacock WJ, Staudt LA, Gage JR . Selective Posterior Rhizotomy for Cerebral Palsy; Issues and Answers. Proceedings from AA CP Congress, C a li­ fornia, 26 O ct 1989. 3. Peacock WJ, Staudt U . Selective Posterior Rhizotomy for the Relief o f Spasticity in Cerebral Palsy. S A fr M ed Journal 1982:82:119-124. 4. Arens U , Peacock WJ, Peter J. Selective Posterior Rhizotomy - A long term fol low up study. Child Nerv Syst 1989:5:148-152. 5. Vaughan C L G ait Analysis o f Spastic Children before and after Selective Posterior Lumbar Rhizotomy. D ev M ed Child N eurol 1987 (Supp 53)29:25. 6. Tinetti M. Performance O rientated Assessment o f Mobility Problems in Elderly Patients. Jags 1986:34(2) 112-126. 7. Rosenbaum P, Kalian L, Sacket D, Backs M, Sussman M, Palmer F. Rhizotomy and other Innovative Therapies for C hildren with Cerebral Palsy. Proceedings from AAC P Conference, California, 1988. 8. Staudt L Pre- and Post-operative Assessment Tailoring the Physical Therapy Programme. Proceedings from AA C P Congress, California, 26 O ct 1989. 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Box 3378 Johannesburg2000 Phone: 29-6931 P.O.Box 195 CapeTown 8000 Phone: 47-4440 P.O.Box 5298 Durban 4000 Phone: 37-1501 P.O.Box 6814 Pretoria 0001 Phone:346-1269 OVER 50 YEARS' SERVICE TO THE PHYSIOTHERAPY PROFESSION Bladsy 12 Fisioterapie, Februarie 1992, dee! 48 no 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )