Voluntary control is commonly been used for motor assessment in stroke rehab. It is commonly been taught in all colleges for in neuro assessment.
Grade II- developing spasticity, partial synergy movement through half range.
Grade III- developed spasticity, full synergy movement through full synergy range.
Grade IV- Out of synergy movement possible.
Grade V- isolated movement possible
Grade VI - normal movement possible.
But there are many problems in practice of use of this in assessment.
Problem 2:Disagreement about the many scaling methods.
Proposed scaling method are: some PT's use six point scale 1-6. But many people use seven point scale 0-6. zero as no movement and grade 1 as min voluntary contraction. this way it will be a seven point scale 0-1-2-3-4-5-6. where as in the original Brunnstrom grading it was only 1-6. now the question arise that - no movement and min voluntary contraction should be graded as zero 0 & 1or 1.
Problem 3: Separate voluntary cotrol for each joint (shoulder/ elbow/ wrist/hip/ knee/ ankle } and and each movement of flexion, extension, abduction or so on.
Can anyone tell me, in which book where this type of assessment methods given.? So that we can use this as reference. As per my knowledge no book has given this type of assessment methods. It is just a method to add to confusion to already complicated scale.
Problem 4: This commonly taught and practice in education system with different ways, whichever is convenient to use. there is no standardization. for every new argument about scale there is new answer and origin of new method of scaling.
Problem 5: There are many good valid and reliable scales are available but there use is less common than voluntary control scaling. Other scale STREAM format Motor assessment scale, Fugl Mayer scale which are reliable, valid, and given the details of scaling
Original Brunnstrom Grading = Stages of Recovery
Grade I- no movement or minimum movement possible in short rangeGrade II- developing spasticity, partial synergy movement through half range.
Grade III- developed spasticity, full synergy movement through full synergy range.
Grade IV- Out of synergy movement possible.
Grade V- isolated movement possible
Grade VI - normal movement possible.
But there are many problems in practice of use of this in assessment.
Problem 1: There is poor reliability of voluntary control. there is lot of discrepancy between the grading when two assessors evaluate the same time same patients. some time this poor reliability play a major role discrepancy between the examiner and the student. now you tell if the student make some mistake during grading using this scale. Is it the scale is at fault or the student? GOD please help the poor student.
Problem 2:Disagreement about the many scaling methods.
Proposed scaling method are: some PT's use six point scale 1-6. But many people use seven point scale 0-6. zero as no movement and grade 1 as min voluntary contraction. this way it will be a seven point scale 0-1-2-3-4-5-6. where as in the original Brunnstrom grading it was only 1-6. now the question arise that - no movement and min voluntary contraction should be graded as zero 0 & 1or 1.
Problem 3: Separate voluntary cotrol for each joint (shoulder/ elbow/ wrist/hip/ knee/ ankle } and and each movement of flexion, extension, abduction or so on.
Can anyone tell me, in which book where this type of assessment methods given.? So that we can use this as reference. As per my knowledge no book has given this type of assessment methods. It is just a method to add to confusion to already complicated scale.
Problem 4: This commonly taught and practice in education system with different ways, whichever is convenient to use. there is no standardization. for every new argument about scale there is new answer and origin of new method of scaling.
Problem 5: There are many good valid and reliable scales are available but there use is less common than voluntary control scaling. Other scale STREAM format Motor assessment scale, Fugl Mayer scale which are reliable, valid, and given the details of scaling
Bang on sir this thought process is very necessary.
ReplyDeleteThanks for your support.
We totslly agree with these discrepancies.
Hope this will help us to make some revolutionary changes in evaluating our patients.
Really amazing..
ReplyDeleteTotally agree with all the points.. especially 1,3 and 4th~!!
Sir, why don't you think up of a good scale for scaling?
We all know you have the potential to do it :)
Thank u avani.i want u people discuss ur problems with use of voluntary control. as Rohan has poited out his difficulties.
ReplyDeletedear Rohan. i need not come with any new scale. as i mentioned above there are many scales already available. only we need to start practicing it regularly and get used to it.
ReplyDeleteI agree with the point that there are many other scales available in literature, but most of them are lengthy and tedious to carry out, which makes most therapists opt for the simplest, quickest way, the Voluntary Control.
ReplyDeleteAlso, although VC has a low inter rater reliability, it has a good intra-rater reliability, which if not helpful in comparing patients, at least helps tracks motor progress. But again, as you already pointed out, there is no 'correct' way of measuring it.
This leads to my last point - I have learnt that these impairment based measurements are now becoming obsolete in the US. Therapists here (like most new therapists in India, and yourself) find it more important to find how the patient moves / transitions / carries out his ADLs.
Nidhi Shah
I would just like to add that using functional scales are more important of which Fugl -Myer and FIM are something which are easy to use.
ReplyDeleteWe always want to know if a patient can move his/her hand irrespective of whether its going to help the patient use that movement functionally.
nidhi, i do agree with ur point that it is easy and siple. My point is,there are lot of variations of voluntory control are created according to our need i.e. individual joint VC. that is not good. we should use the standerdized measurement of stages of recovery which had details of grading and more reliability. and stop doing individual joint voluntary control.
ReplyDeletegajanan
thanks Nilofer for ur suggestions.
ReplyDeleteyes functional scales makes should always be used.
Hello Sir! I found the case study very interesting and the detailed explanation of each task was very informative and helpful. I had the pleasure to learn MRP from you and how we work on missing components has been my focus ever since.
ReplyDeleteBut I always had one question, I have a few patients right now with poor hip flexor activation during walking (causing circumduction). How do you work on these muscles eccentrically in a functional meaningful activity?
Thanks,
Himani.
(P.S. It is great to learn from you again via this blog)
hi himani thanks for your comment and asking que.
ReplyDeletethe answer for ur first part of question about circumduction gait is in my blog on " How to reduce the walking synergy & circumduction gait?"
second part of que about eccentric activation of hip flexors is - u need not work eccentrically on hip flexors. but u can work hip flexion in functional activity.
the simple solution for this is.
use small size hurdle crossing for patients. the height of hurdle should be less so that patient can clear easily do hip knee flexion instead of going around the hurdle with circumduction. The task of going over hurdle itself gives good stimulus for hip knee flexion.
i commonly use chappals/slippers of shoes these hurdles are easily available in every home, the size also small so they can clear easily.
u can use stepping on the stairs with affected leg, the problem of stir is the height is very large. so patients do circumduction in order to complete the task.
Sir as you mentioned in your blog..
ReplyDeleteSeparate voluntary control for each joint (shoulder/ elbow/ wrist/hip/ knee/ ankle } and and each movement of flexion, extension, abduction or so on
Can this be achieved by dividing the ROM into 4 parts.. as in 25% , 50% , 75% and full ROM
For example : Elbow flexion voluntarily exhibited by a patient is 65 degrees out of total ROM of 130 degrees.. that means its 50% of normal ROM n the rest 50% is the synergy pattern
That means that the patient can perform first 50% of ROM properly and the rest is by using a synergy pattern
Sir by this method it will have a better inter-rater and intra-rater reliability specific to joints and their movements
If we divide the movement percentage wise.. IT will be easier to assess the recovery of the patient as well.
This is a very simple method n can be used as:
0= No movement/ the part moves in synergy from the very beginning
1= 25% of normal ROM and rest is synergy
2= 50% of normal ROM and rest is synergy
3= 75% of normal ROM and rest is synergy
4= Full ROM
Please look into it
thankyou,
Rohan Sawant
Thanks Rohan. good creative mind. but we cant make changes in scale like this. if you we we need to do a study for its validity and reliability.
ReplyDeletebut i appreciate your idea.
Thankyou sir...lets do a study on this :)
ReplyDeletehello sir , i am pursuing my masters in physio from england . i am in search of some relevant studies giving evidence regarding effectiveness of facilitation of weight bearing through upper extremity in hemiplegic patient in sitting position . can you please help me with this .
ReplyDeletehello sir , i am pursuing my masters in physio from england . i am in search of some relevant studies giving evidence regarding effectiveness of facilitation of weight bearing through upper extremity in hemiplegic patient in sitting position . can you please help me with this .
ReplyDelete