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P-334
Kaba Motor Fonksiyon S›n›fland›rma Sistemi'nin "Geniflletilmifl ve Yeniden
Düzenlenmifl fiekli" nin Türkçe Versiyonunun Güvenilirli¤i
Özlem El 1, Meltem Baydar 1, Haluk Berk 2, Özlen Peker 1, Can Koflay 2, Yücel Demiral 3
1 Dokuz Eylül Üniversitesi T›p Fakültesi Fiziksel T›p ve Rehabilitasyon Anabilim Dal›, ‹zmir
2 Dokuz Eylül Üniversitesi T›p Fakültesi Ortopedi ve Travmatoloji Anabilim Dal›, ‹zmir
3 Dokuz Eylül Üniversitesi T›p Fakültesi Halk Sa¤l›¤› Anabili Dal›, ‹zmir
AMAÇ: Serebral palsi (SP)’li hastalarda fonksiyonel de¤erlendirmenin yap›lmas› tedavinin
planlanmas› ve etkinli¤inin anlafl›lmas› için önemlidir. 1997 y›l›nda gelifltirilen “Kaba Motor S›n›rland›rma
Sistemi” (KMFSS) rehabilitasyon alan›nda giderek daha yayg›n kullan›lmaya bafllanm›flt›r.
Bu sistem 2007 y›l›nda yeniden gözden geçirilerek 12-18 yafl aral›¤›ndaki genç populasyon
de¤erlendirmeleri eklenmifl ve bu yeniden gözden geçirilmifl formda Dünya Sa¤l›k
Örgütü’nün uluslararas› fonksiyon, özürlülük ve sa¤l›k s›n›flamas›na özgü kavramlar› vurgulanm›flt›r.
Bu çal›flmada KMFSS’nin geniflletilmifl ve yeniden düzenlenmifl fleklinin Türkçe versiyonun
gözlemciler aras› güvenilirli¤i araflt›r›lm›flt›r.
GEREÇ-YÖNTEM: Çal›flmaya Dokuz Eylül Üniversitesi T›p Fakültesi multidisipliner SP poliklini-
¤inde düzenli olarak izlenen 136 olgu kat›ld›. KMFSS’nin gözlemciler aras› güvenilirli¤in araflt›r›lmas›
için olgular iki fiziksel t›p ve rehabilitasyon uzman› taraf›ndan birbirlerinden ayr› olarak
klinik de¤erlendirme ve aileden bilgi alma yöntemi ile de¤erlendirilip s›n›fland›r›ld›. Ayr›ca
test-retest güvenilirli¤inin araflt›r›lmas› için bir hekim taraf›ndan 48 olgunun tekrar s›n›fland›rmas›
yap›ld›. Olgular›n yafl, cins, SP klinik tipi ve efllik eden görme sorunu ve epilepsi olup
olmad›¤› sorguland›. Güvenilirli¤in de¤erlendirmesinde intracass corelation coefficient (ICC)
ve Kappa istatistikleri kullan›ld›. KMFSS ve görme bozuklu¤u ve epilepsi aras›ndaki iliflki ise
Spearmen korelasyon analizi kullan›larak araflt›r›ld›.
BULGULAR: 127 (%93,6) olgu spastik tip SP olarak de¤erlendirildi. Bunlar›n 28’i (%20,6)
spastik hemiplejik, 63’ü (%46,3) spastik diplejik ve 35’i (%25,7)spastik quadriplejik olarak s›n›fland›r›ld›.
Ayr›ca 10 (%7,4) olgu diskinetik tipte yer ald›. Avrupa SP çal›flma grubunun s›n›fland›rmas›na
göre 31 (%22,8) olgu spastik unilateral, 95 (%69,9) olgu spastik bilateral ve 10
(%7,4) u disknetik tipte idi. Olgular›n yafl ortalamas› 7,4±4,21 y›l olarak bulundu. ‹ki hekim aras›ndaki
de¤erlendirmelerde ICC 0,97 (%95 güven aral›¤›) ve Kappa de¤eri 0,86 bulundu.
Test-retest güvenilirli¤in de¤erlendirildi¤i 48 olguda ise ICC 0,94 (%95 güven aral›¤›) saptand›.
Görme bozuklu¤u ve KMFSS aras›nda (r=0,250, p=0,003) ve epilepsi ile KMFSS aras›nda
(r=0,359, p=0,000) anlaml› korelasyon saptand›.
SONUÇ: KMFSS'nin geniflletilmifl ve yeniden gözden geçirilmifl fleklinin Türkçe versiyonu hekimler
aras› ve test-retest de¤erlendirmede yüksek güvenilirli¤e sahip olarak bulunmufltur.
Anahtar Kelimeler: Kaba motor fonksiyon s›n›fland›rma sistemi, serebral palsi, güvenilirlik
P-335
Spastisiteye Ba¤l› Klonusun Yürüme ve Ayakta
Durma Üzerine Olumsuz Etkisi
Murat Ersöz, Selçuk Say›l›r, ‹lkay Karabay, Selami Akkufl
Ankara Fizik Tedavi ve Rehabilitasyon E¤itim ve Araflt›rma Hastanesi
6. Fizik Tedavi ve Rehabilitasyon Klini¤i, Ankara
Klinik pratikte spastisitenin ayakta durma ve yürüme üzerine olan olumlu etkisine s›kl›kla
vurgu yap›l›r. Buna karfl›l›k spastisiteye ba¤l› ortaya ç›kan Achilles klonusunun ayakta durma
ve yürüme s›ras›nda stabiliteyi bozucu etkisi klinikte s›k yaflanan bir sorundur. Bu olgu
sunumunda bu konuya dikkat çekilmek istenmifltir. Otuzyedi yafl›nda erkek hasta kollar ve
bacaklarda güçsüzlük ve kas›lma flikayetleri ile baflvurdu. Yaklafl›k 15 y›l önce bafllayan dengesizlik
flikayetlerinden sonra servikal vertebralara yönelik operasyon geçiren, operasyondan
sonra flikayetleri gerilemeyen, Nisan 2010’da kollar ve bacaklarda güçsüzlük, kas›lma flikayetleri
ile beyin cerrahi poliklini¤ine baflvuran hastan›n bu dönemde çekilen servikal BT sinde C1
vertebra kesitlerde izlenmemifl (operasyona sekonder), odontoid proses normalden yukar›da
yerleflimli ve posteriora yer de¤ifltirmifl olarak izlenmifl, bu düzeyde aç›lanma ve beyin sap›na
bas› gözlenmifl, foramen magnumda sklerotik de¤ifliklikler ve bu düzeyde miyelomalazi saptanm›flt›.
Hastaya beyin cerrahi klini¤i taraf›ndan transoral odontoidektomi yap›lm›fl,
operasyondan sonra k›smen kollar ve bacaklardaki kas›lma ve güçsüzlük flikayetleri
gerilemiflti. Hastan›n klini¤imize operasyondan 8 ay sonraki baflvurusunda yap›lan muayenesinde
bilateral üst ve alt ekstremitlerde 3/5 motor kuvveti, her iki ayak bile¤inde 5-6 at›ml›k
klonus ve bilateral alt ve üst eksremitelerde Ashworth 3 spastisite saptand›. Hasta bir kiflinin
daimi deste¤inde gövde hafif öne fleksiyonda, bilateral topuk vurufllar›n› tam yapamadan
küçük ad›mlarla ve her ad›mda dengeyi olumsuz etkileyen 2-3 at›ml›k klonuslar ortaya ç›karak
yaklafl›k 10 m oldukça yavafl bir h›zda yürüyebiliyordu. Hasta rehabilitasyon program›na
al›narak Tizanidin HCl baflland› ve kademeli olarak 8 mg /güne ç›k›ld›. ‹zlemde hastan›n
spastisitesinde belirgin gerileme sa¤land›, yürüme s›ras›nda ortaya ç›kan klonus kayboldu ve
hasta bir adet walker ile yaklafl›k 30 m rahat ve eskisine göre oldukça h›zl› olarak ba¤›ms›z
ambule hale geldi. Spastisteye ba¤l› ortaya ç›kan klonusun ayakta durma ve yürüme s›ras›nda
stabiliteyi bozabilece¤i buna karfl›l›k spastisiteye yönelik uygun medikal ve rehabilitatif
yaklafl›mlarla bu sorunda belirgin düzelme sa¤lanabilece¤i ak›lda tutulmal›d›r.
Anahtar Kelimeler: Spastisite, klonus, ambulasyon
319
23. Ulusal Fiziksel T›p ve Rehabilitasyon Kongresi / 23 rd National Physical Medicine & Rehabilitation Congress
Türk Fiz Rehab Derg 2011:57Özel Say›; 1-334 /Turk J Phys Med Rehab 2011:57Suppl; 1-334
P-334
Interobserver Reliability of the Turkish Version of the Expanded and
Revised Gross Motor Function Classification System
Özlem El 1, Meltem Baydar 1, Haluk Berk 2, Özlen Peker 1, Can Koflay 2, Yücel Demiral 3
1 Dokuz Eylul University Department of Physical and Rehabilitation Medicine, Izmir
2 Dokuz Eylül University Faculty of Medicine Department of Orthopaedics, Izmir
3 Dokuz Eylül University Faculty of Medicine Department of Public Health, Izmir
OBJECTIVE: Functional assessment of cerebral palsy patients has a great importance for
planning and assessing the effectiveness of treatment. Gross motor function classification
system (GMFCS) was developed in 1997 and used increasingly common in rehabilitation settings.
Expanded and revised (E&R) version of GMFCS which includes age band for youth 12 to
18 years of age was developed in 2007. This version emphasizes the concepts inherent in the
World Health Organization’s International Classification of Functioning, Disability and Health.
The aim of this study was to evaluate the reliability of Turkish version of E&R GMFCS
MATERIALS-METHODS: A total of 136 children with CP participated in the study. All patients
were regularly assessed and managed in our multidiciplinary CP outpatient unit. Two
physical medicine and rehabilitation specialists separately classified the patients by obtaining
information from patients and also according to clinical assessment. The test–retest
reliability was investigated by re-classifying a total of 48 patients. ICC and Kappa statistics
were used to evaluate interobserver reliability of the Turkish version of GMFCS E&R form.
Spearman’s rank correlation coefficient was used to assess the correlation between the
GMFCS and visual impairments and epilepsy.
RESULTS: Of the 127 (93.6%) children with spastic type, 28 (20.6%) had spastic hemiplegia,
63 (46.3%) had spastic diplegia, 35 (25.7%) had spastic quadriplegia, and 10 (7.4%) had
dyskinetic type. According to the SCPE classification system, of the total sample of 136
children, 31 (22.8%) were spastic unilateral, 95 (69.9%) were spastic bilateral, 10 (7.4%)
were dyskinetic CP. The mean age of children was 7.4±4.21 years. The ICC between two
physicians was 0.97 and the total agreement was 89%. Test-retest reliability was assessed
for 48 patients High test-retest reliability was found (ICC:0.94 95 % confidence interval). The
correlation between the number of children with visual impairments and GMFC level was
r=0.250, p=0.003 and epilepsy and the GMFC level was r=0.359, p=0.000.
CONCLUSION: The Turkish version of the GMFCS E&R form has high interrater and
intrarater reliability.
Keywords: Gross motor function classification system, cerebral palsy, reliability
P-335
The Negative Effects of Clonus Occurrence Due to
Spasticity on Walking and Standing
Murat Ersöz, Selçuk Say›l›r, ‹lkay Karabay, Selami Akkufl
Ankara Physical Medicine and Rehabilitation Education and
Research Hospital, 6th PMR Clinic, Ankara
In clinical practice, the positive effects of spasticity on standing and walking are frequently
emphasized. However, the negative effect of the Achilles clonus due to spasticity on the
stability during standing and walking is a frequently encountered problem. In this case report,
we aimed to call attention to this problem. Thirty-seven years old male patient applied to our
outpatient clinic due to weakness and spasm on the arms and legs. The patient underwent a
cervical vertebrae operation due to the complaint of imbalance 15 years ago and his
complaints did not regress after that operation. The patient consulted the neurosurgery
clinic due to the complaints of weakness and spasm in arms and legs in April 2010 and his
cervical CT was taken: C1 vertebrae was not visualized (secondary to operation), the odontoid
process was placed more superiorly than normal and moved posteriorly and at this level,
angulation and compression on the spinal cord, sclerotic changes on foramen magnum
and myelomalacia were detected. Transoral odontoidectomy was performed by the
neurosurgeons and weakness and spasm in arms and legs regressed. 8 months after the
operation in his physical examination, the muscle strengths of upper and lower extremities
were 3/5, 5-6 beats clonus on both ankles and Ashworth 3 spasticity on upper and lower
extremities were found. The patient was able to walk approximately 10 meters without heel
beat on both feet and with small steps; 2-3 beats clonus appeared on each step and
negatively affected the balance. The trunk was in mild flexion and the patient needed a
constant support of one person. The patient was taken to a rehabilitation program and
Tizanidine HCL was given and the dose was gradually increased to 8 mg/day. Significant
improvement was achieved in spasticity and clonus occurrence on walking disappeared
and the patient became ambulatory with walker support for 30 meters more easily and
faster. It has to be kept in mind that clonus occurrence due to spasticity may interfere with
stability on standing and walking, however, this problem can be improved significantly by
appropriate medical and rehabilitative approach against spastisity.
Keywords: Spasticity, clonus, ambulation