The use of the Spinal Alignment and Range of Motion Measure with children and young people with cerebral palsy

Abstract

This commentary is on the original article by Chen et al. on pages 745–750 of this issue. The development of spinal malalignments and extremity range of motion limitations are well-known secondary musculoskeletal conditions experienced by many children and young people with cerebral palsy (CP). Accordingly, they should be measured so that their development can be understood and managed better. The Spinal Alignment and Range of Motion Measure (SAROMM)1 was originally developed as a discriminative and predictive instrument to obtain an overall estimate of limitations in alignment and range of motion for use in comprehensive outcomes research in rehabilitation.2 Chen et al.3 have extended its use to include evaluative purposes. Over a 6-month period, they detected improvements in spinal alignment and lower extremity range of motion in a group of young children with CP, 90% of whom received regular (i.e. one to two times per week) physical or occupational therapy programs. Implications of this work for clinical practice include the establishment of values of the minimal detectable change (MDC) and minimal clinically important difference (MCID). The MDC is the value beyond which one can be relatively certain (in this case 90%) that a true change has occurred. The authors used the sum of both scale and total scores in conducting their work; and in clinical practice, it would be prudent to use the full integer values when making clinical decisions. Therefore, values of the MDC for use with young children with CP would be ±2, 4, and 4 for the spinal alignment scale, range of motion scale, and total SAROMM score respectively. Comparable cut-off points for the MCID (i.e. a clinically meaningful difference) would be ±2, 4, and 6 points. Their work contributes to understanding whether children are either improving or experiencing greater impairments. As Chen et al. correctly indicate, the SAROMM is intended as a global measure to provide an overall estimate of status. Detailed examination of specific body regions is better done through carefully conducted, standardized range of motion assessments using goniometry. Although not mentioned in the article, we have found one aspect of the SAROMM to be particularly problematic in training for use in research2: differentiating scores of 0 and 1 for the extremity items, despite the details in the training manual (which is found at http://www.canchild.ca/en/measures/saromm.asp). I appreciate this opportunity to clarify this aspect, for those who wish to use the SAROMM in either practice or research. Consider a child with spastic hemiplegia whose typical posture includes the affected lower extremity in hip flexion, adduction, internal rotation, knee flexion, and ankle plantarflexion and who has full range of motion. This child would receive the following scores: hip flexion (0), hip extension (1), hip adduction (0), hip abduction (1), hip internal rotation (0), hip external rotation (1), knee extension (1), ankle plantarflexion (0), and ankle dorsiflexion (1). The scores of ‘1’ in this case reflect the fact that posturing predisposes the joint to a future contracture (and, in effect, marks a risk factor). Although the SAROMM was not translated into Chinese for use in this study, those who wish to conduct a translation should follow the well-established guidelines of forward translation, reconciliation of two or more translations, back translation, back translation review, and harmonization.4 I also appreciate the opportunity to raise this issue; some of the nuances of differentiating the levels of item scores have been ‘lost in translation’. We are currently using the SAROMM as one of many measures for which we aim to develop reference centile curves, similar to what we have done for the Gross Motor Function Measure,5 to assist clinicians in establishing whether an individual child is doing ‘as expected’, ‘better than expected’, or ‘more poorly than expected’. Through a program of developmental surveillance of many determinants of outcomes2 we propose that outcomes of motor function, participation in self-care and leisure activities, and playfulness can be optimized.