Research Evidence for Targeted Training

and the upright segmental approach

Research has shown that trunk control is fundamental to function and movement in the upright posture, such as sitting [1] and it has also been shown to be a fundamental contributor to walking ability [2]. Children with moderate or severe cerebral palsy and other problems of movement control show deficits of trunk control [3]. The training of head and trunk control, or ‘core control’, is the basis of Targeted Training: this enables hand and arm function to develop and provides the means for improving gross motor functional abilities. Those more able children who have milder disability may have good trunk control but show problems of lower limb control (Gross Motor Function Measure Expanded and Revised [4]). These can also be helped by Targeted Training.
Targeted Training is unique in having a sound background based on the biomechanics of the upright posture [5, 6, 7]. Research evidence has confirmed the way in which typically developing infants gain control of the upright posture [8, 9, 10, 11]. These fundamental principles have been brought together into Targeted Training, a therapy that simplifies the learning of control of the upright posture – the trunk and lower limbs. The Segmental Assessment of Trunk Control (SATCo) is of value in research and intervention by providing detail on trunk control status and is a critical component of Targeted Training [12, 13] .
Any therapy should demonstrate that it is effective i.e. does it produce the changes that it claims to make? The publication by Curtis and co-authors[1] provides strong support for the Targeted Training approach that improvement in movement control will help improve functional abilities. A further question then arises of ‘which therapy is most effective/produces the quickest/fastest results – and for which specific patient groups’? This question is often addressed in medical situations by conducting a Randomised Controlled Trial (RCT). RCTs rely on the principle that all the trial participants are essentially the same – they have the same problems and the same difficulties. Children with cerebral palsy and other neuromotor disabilities have a very varied presentation and it is well understood that no two children are precisely alike. This makes an RCT extremely difficult, and at this time it is not possible to say that any therapy approach is superior to any other in these ‘pure research terms’.
However, there are other research methodologies available which have been used to demonstrate the benefit of Targeted Training. Preliminary single case design research showed that Targeted Training therapy can assist in the acquisition of sitting balance in children with cerebral palsy in an average time of 18 weeks [14]. A series of four case reports has also confirmed the efficacy of Targeted Training [15]. In addition, Targeted Training has been shown to improve walking performance in children with cerebral palsy [16] and also following head injury in an adult [17]. A child walking with a crouch gait also responded well to Targeted Training [18].

A retrospective review of Targeted Training combined with physiotherapy treatment as usual for children with cerebral palsy showed [19]:
• a statistically significant improvement in motor function exceeding the expected norm, especially in those children with more severe gross motor function disability
• a statistically significant improvement in activities of daily living (Pediatric Evaluation of Disability Inventory)
• a statistically significant improvement in posture including sitting and standing (Chailey Levels of Ability)
• a statistically significant improvement in trunk control (SATCo)
Although more research evidence is certainly needed, the encouraging results thus far suggest that Targeted Training therapy is a worthwhile option in the ‘therapy tool bag’.

References

[1] Curtis DJ, Butler P, Saavedra S, Bencke J, Kallemose T, Sonne-Holm S and Woollacott M (2014). ‘The central role of trunk control in the gross motor function of children with cerebral palsy: a retrospective cross-sectional study’. Dev Med Child Neurol 57(4), 351-357.

[21] Heyrman L, Feys H, Molenaers G, Jaspers E, Monari D, Nieuwenhuys A and Desloovere K (2014). ‘Altered trunk movements during gait in children with spastic diplegia: Compensatory or underlying trunk control deficit?’. Research in Developmental Disabilities 35, 2044–2052.

[3] Saavedra SL and Woollacott MH. (2015) ‘Segmental contributions to trunk control in children with moderate-to-severe cerebral palsy’. Archives of Physical Medicine and Rehabilitation, doi: 10.1016/j.apmr.2015.01.016.

[4] Hanna SE, Bartlett DJ, Rivard LM, Russell DJ (2008).Tabulated reference percentiles for the GMFM-66 Gross Motor Function Measure for use with children having cerebral palsy, April 2008, available at www.canchild.ca

[5] Butler PB and Major RE (1992). ‘The learning of motor control. Biomechanical considerations’, Physiotherapy 78(1) 1-6.

[6] Major RE and Butler PB (1995). ‘Discussion of segmental stability with implications for motor learning’, Clinical Rehabilitation, 9, 167-172.

[7] Butler PB, Major RE, Saavedra S, Jarvis SE. (2004). ‘Biomechanical considerations of postural strategies: a neglected facet of postural control (or ‘Kids do what’s good for them!)’. Abstract, Proc of meeting of the Collaborative Project on Developmental Neurology, Groningen, The Netherlands.

[8] Saavedra SL, van Donkelaar P and Woollacott MH (2012). ‘Learning about gravity: segmental assessment of upright control as infants develop independent sitting’. J Neurophysiol 108, 2215-2229.

[9] Pin TW, Butler, PB, Cheung H-W, Shum S. (2018) Segmental Assessment of Trunk Control in infants from 4 to 9 months of age- a psychometric study. BMC Pediatrics; 18:182.

[10] Pin TW, Butler PB, Cheung H-M, Shum S L-F. (2019) Longitudinal Development of Segmental Trunk Control in Full Term and Preterm Infants- a Pilot Study: Part I. Developmental Neurorehabilitation: doi.org/10.1080/17518423.2019.1648580

[11] Pin TW, Butler PB, Cheung H-M, Shum S L-F. (2019) Longitudinal Development of Segmental Trunk Control in Full Term and Preterm Infants- a Pilot Study: Part II. Developmental Neurorehabilitation: doi.org/10.1080/17518423.2019.1629661

[12] Butler PB, Saavedra S, Sofranac M, Jarvis SE, Woollacott MH. (2010) ‘Refinement, Reliability, and Validity of the Segmental Assessment of Trunk Control’. Pediatric Physical Therapy 22(3):246-257. Winner of the Toby Long Award for the best manuscript published in Paediatric Physical Therapy, 2010.

[13] Pin TW, Butler PB, Cheung H-M, Shum S. (2017) Psychometric study on Segmental Assessment of Trunk Control in infants from 4 to 9 months of age. Dev Med Child Neurol: 59(suppl. 2):5.

[14] Butler PB. (1998). ‘A preliminary report on the effectiveness of trunk targeting in achieving independent sitting balance in children with cerebral palsy’, Clinical Rehabilitation, 12, 281-293.

[15] Pin TW, Butler PB and Shum SL-F. (2018) Targeted Training in managing children with poor trunk control: 4 case reports. Pediatric Physical Therapy; 30: E8–E13

[16] Butler PB, Thompson N and Major RE (1992).  ‘Improvement in walking performance of children with cerebral palsy: Preliminary results’.  Developmental Medicine and Child Neurology, 34, 567-576.

[17] Butler PB, Farmer SE and Major RE. (1997).  ‘Improvement in gait parameters following late intervention in post traumatic hemiplegia: a long term follow up report of a single case.  Clinical Rehabilitation, 11, 220-226.

[18] Farmer SE, Butler PB and Major RE (1999). ‘Targeted Training for crouch posture in cerebral palsy’, Physiotherapy, 85(5), 242-247.

[19] Curtis DJ, Holbrook P, Bew S, Ford L, Butler P (2018) Functional change in children with cerebral palsy https://arxiv.org/abs/1811.12490