Determining the Reliability of an Axial Rotation Measure for Children with Cerebral Palsy: Empowering Greater Activity, a Proof of Concept Study
by Quimby Wechter, University of Hartford
Abstract: Children with cerebral palsy (CP) tend to hold their body stiffly and lack normal axial rotation, limiting their movement and interfering with full participation in activities with their peers. A valid and reliable method for quantifying axial rotation is necessary to systematically address this deficit. The goal of the current study was to determine if a device originally created to measure functional axial rotation in adults could be modified for a child-friendly, reliable measure of axial rotation in typically developing (TD) children and children with CP. Child-friendly modifications to a published adult functional rotation measure were completed. Four TD children (TD, 5-7 years old) and three children with severe CP, (3-7 years old) were tested by two different raters. The raters rescored all video recorded evaluations along with two additional raters. Inter-rater reliability for video data and intra-rater reliability for in-person versus video data were excellent. Inter-rater reliability during live testing was moderate to good. External trunk support reduced degrees of rotation for TD children, however it allowed children with severe CP to participate in the study. Significant differences in degree of axial rotation were noted when comparing TD children to children with CP. This method of quantifying degrees of rotation was reliable across testers and well tolerated by children. With a better understanding of axial rotation, further studies can be completed, and new interventions can be developed to help children with disabilities participate more fully in physical activities.
Limited axial rotation is a clinically recognized issue for children with cerebral palsy (CP); however, little research has been completed on this topic. Cerebral palsy is a disorder that causes children to have slow motor development, abnormal muscle tone, and unusual posture as a result of a lack of trunk control (Krigger 91). This neurological condition affects about 0.002% of children born in the United States due to a brain injury before complete development of the brain (Krigger 91). The severity of CP varies for each child and different symptoms and developmental delays manifest. Increases in the severity of CP are associated with limited range of motion, spinal misalignment, and pain (Bartlett et al.155). While there are a number of tests that evaluate trunk postural control in children with CP, there are currently no tests that quantify functional axial rotation for this population (Butler et al. 246; Heyrman et al. “Clinical Tool” 2624; McCoy et al. 375).
Axial rotation is the ability to rotate the spine around its axis, allowing people to twist to the left or right while remaining upright. Many everyday activities require axial rotation. For example, turning and looking back while reversing a car or turning to look back as someone approaches both require axial rotation. Experiencing a stiff neck or back often lead to people turning their whole body to see something because they cannot rotate. This is the perfect example of the importance of axial rotation. Children with CP tend to hold their body more stiffly, which in theory leads to deficits in axial rotation. These deficits in axial rotation can make it more challenging for children with CP to participate in physical activities such as dance. In order to eventually explore the relationship between axial rotation, functional activities, and children’s ability to participate in recreational activities, a reliable device is needed.
Currently, there are several options for measuring cervical rotation including clinical evaluation, X-ray, CT and MRI, goniometers, inclinometers, Cybex, and 3D kinematic analysis (Antonaci et al. 46-52). However, these measures are used for measuring cervical rotation, not axial rotation. Axial rotation is rotation of the trunk, whereas cervical rotation is rotation of the neck and head. Some measures of trunk control include a basic rotational measure. Both the Trunk Control Measurement Scale and Trunk Mobility Scale evaluate axial rotation on a basic three and four number scale, respectively (Heyrman et al. “Clinical Characteristics” 329; Franco et al. 637). When graded via the Trunk Control Measurement Scale, most children with CP showed deficits in axial rotation (Heyrman et al. “Clinical Characteristics” 332). However, this scale does not give a clear degree of axial rotation which would be useful in a clinical setting, such as a physical therapy clinic or medical treatment facility. These assessments also require that the child be able to sit independently with adequate stability for movement thus they are only possible for children with mild to moderate CP and cannot be used for children with severe CP who are in greatest need for quantification and improved interventions for trunk posture control.
Within the medical field, it is recognized that limited rotation interferes with daily activities across a variety of diagnoses. Thus, devices have been created to measure axial rotation primarily in adult populations, to determine if changes in rotation lead to increased performance in daily tasks. A Functional Rotation Test has been tested on patients with and without Parkinson’s Disease (PD) (Batavia and Gianutsos “Healthy Adults” 185; Batavia and Gianutsos “Parkinson’s Disease” 259). This test was deemed reliable for healthy adults and adults with PD, although patients with PD achieved less rotation than healthy adults and were only tested in a seated position (Batavia and Gianutsos “Healthy Adults” 185,192; Batavia and Gianutsos “Parkinson’s Disease” 259,266). However, this device is not conducive to a clinical measure for patients with CP. The test must be performed in a circular room and the degree of rotation is measured using an angular ruler, which would be difficult in a clinical setting (Batavia and Gianutsos “Healthy Adults” 188). In addition, this test is not appropriate for participants who cannot maintain upright posture without external support, thus eliminating the possibility for it to be used with children with severe CP (Batavia and Gianutsos “Healthy Adults” 194). The test is meant to assess neck rotation, chest rotation, and rotation including the upper extremity through a seated and standing assessment in healthy adults (Batavia and Gianutsos “Healthy Adults” 187).
Another research study developed a Functional Axial Rotation (FAR) measure and tested it on community-dwelling adults and adults with PD (Schenkman et al. “Clinical Tool” 151; Schenkman et al. “Spinal Flexibility” 441). The FAR device was deemed reliable and valid for both populations (Schenkman et al. “Clinical Tool” 151; Schenkman et al. “Spinal Flexibility” 441). The average degree of rotation for participants with PD was 180.3 degrees compared to 208.7 degrees for adults without PD (Schenkman et al. “Spinal Flexibility” 443). The axial rotation device referenced in the current study is a modified variant of the FAR device developed by Schenkman and colleagues (“Clinical Tool” 152-153). The FAR device was also used as a measure of functional limitation in patients who had cervical spine disorders (Hermann and Reese 906). Researchers found a correlation between level of impairment due to cervical spine disorder and limited ROM and decreased axial rotation (Hermann and Reese 903).
The FAR device appears to have greater clinical utility than the Functional Rotation Test in adults and may be feasible for testing functional axial rotation in children. The goal of the current study was to determine if adaptations to the FAR device would allow functional axial rotation to be measured in TD children and children with CP. For this purpose, we created a child-friendly version of the device and completed testing with a small group of children. Our research questions were: 1) Can children with and without CP follow the directions and be patient enough to complete the test? 2) Does external trunk support influence axial rotation range? 3) Are measurements of axial rotation in children reliable during test-retest with the same and different testers? and finally, 4) Is accuracy of clinical observation for this measure improved through video recording and coding?
Human Ethics: IRB approval for this project was obtained from the University of Hartford IRB. The procedure was explained to children and their parents and informed consents were signed by at least one parent and verbal assent was given by the child prior to participation in the study.
Participants: A control group of four typically developing (TD) children (3 males ages 5,5,7 years and one female age 7 years) were tested first. Then, three children with CP (3 males ages 3,5,7 years) were recruited through word of mouth and the University of Hartford Pediatric Balance Lab (PBL) data base. The demographics of the children with CP can be found in Table 1. Non-ambulatory children with CP who would likely be more challenged by the task were purposefully selected. This allowed us to create the modifications necessary to make this protocol possible for all children with CP regardless of their level of trunk control or severity of CP. Participants were excluded if they were younger than three years or older than ten years. They were also excluded if they had been diagnosed with fixed scoliosis or had any previous history of spinal surgeries or any other surgeries within the past year. All children were tested on one occasion at the University of Hartford.
Device and Set up: The device used in this research study was created based on a previous publication showing a similar device for testing functional axial rotation in adults with and without Parkinson’s disease (Schenkman et al. “Clinical Tool” 152-153; Schenkman et al. “Spinal Flexibility” 441). We made three primary modifications to this testing device to make it more child friendly. First, a 180-degree structure was used instead of 360-degree to allow researchers to strap the children to the bench more easily, to access the children more efficiently, and to speak to the child more directly during the study. Second, colorful, clipart animal images were used to label the 180-degree structure and served as enticement for the children. Each animal correlated to 5 degrees, but each degree was indicated by a tick mark to increase precision. The animals were used to entice children to turn to their maximum potential. The study was presented as a “safari” for the children and researchers asked them to turn to different animals to determine their maximal degree of rotation. Finally, a laser headpiece was used to determine the degree of rotation for the child. The laser headpiece was also a modification that made it more fun for the children. The headpiece was strapped on the child’s head, with the laser placed on the middle of their forehead. The laser is less constraining and was theorized to track the movements more clearly than the head pointer device used in the FAR. The laser allows quick movements to be tracked so that when a child briefly illuminates the animal marker, the degree of rotation can still be recorded.
In order to evaluate the device for use in children with moderate to severe cerebral palsy who have partial trunk control, an additional trunk support was required. An additional device
(Meerkat stander base with one chest band) was used to give additional support for children with CP based on their level of trunk control during the trials (see fig 1A). The Meerkat chest band was raised or lowered to the level of additional trunk support required. The stander was positioned behind the bench with the chest band extended to wrap around the child keeping the torso vertically aligned over the pelvis.
Figure 1: Children being tested in the device. Two seven-year-old children, one child with CP (left image) and one TD child (right). Pelvic strapping was achieved with the Leckey SATCo bench and pelvic cradle and trunk support was created using the chest band of a Meerkat stander.
Four cameras were used during the axial rotation test. One camera was directly in front of the children at 0 degrees, while another camera was directly behind the child at 180 degrees. The camera at 180 degrees was raised up on a table to ensure the entire setup was visible. The camera height at 0 degrees was adjusted for the child to ensure the entire body was visible. Two other cameras were positioned at 45 degrees, to the right and left of the child. The cameras at 45 degrees to the right and left were adjusted based on the child to ensure the child’s trunk and the device were visible (see fig 2).
Figure 2: Camera setup and degree measurements. The Xs mark cameras. The degree measurements are shown as what is noted on the animal marker of the device, the degree of L and R rotation for TD children when the device is behind them, and the degree of rotation for children with CP when the device is in front of them.
The children were positioned so that 0 degrees was in front of them and the device was behind them (Fig 1B). The degrees were positive to the right and left. The children began the test once they had turned 90 degrees. The maximum degree of rotation that could be obtained was 270 degrees total. If the child was unable to achieve 90 degrees of rotation, he was turned so that the device was in front of him (Fig 1A). They were positioned so that the marker in front of them was noted as 90 degrees but represented 0 degrees of rotation. Technically, the degrees declined as they turned, but the number of degrees turned counted as their positive rotation. The maximum amount of rotation that can be recorded in this position was 90 degrees in each direction.
Protocol: Children were introduced to pelvic stability strapping and a Segmental
Assessment of Trunk Control (SATCo) evaluation was completed to determine the child’s level of trunk control. The SATCo is a clinical test used to differentiate between seven levels of trunk control. The test measures static, active, and reactive control.
Following SATCo, the children were taken to the axial rotation set up, seated on the bench and the footrest and other straps were applied. Then children were introduced to the laser head piece and given a few minutes to explore how it could light up the various animals.
Once the children were seated on the Leckey SATCo bench and their hips and knees were in a 90-degree alignment, neoprene straps were attached to help them keep their feet in place. Pelvic position for all children was secured using the Leckey pelvic cradle strapping system (fig 1). The children with CP were offered mid-thoracic support unless they required a higher level of support to sit upright and rotate (as determined by their SATCo score (see table 1)). The children with CP completed all trials with external trunk support and pelvic support. The TD children completed 2 sets of trials, one set with only pelvic support and one set with trunk support at the mid-thoracic level and pelvic support.
Children were asked to rotate as far as they could to each side while pointing to animals using the head laser. The test was completed three times in each direction. The children were instructed to keep their hands on their lap and their feet in place. If the tester noted that the child’s hands or feet were not correctly placed, they reminded the child to keep them in place and asked the child to repeat the rotation. The children were allowed to rotate their head as long as their trunk remained upright. Live scorers noted the maximum degree of axial rotation for each turn (indicated by tick marks at each degree). Only turns where the restrictions were abided by and the laser made contact with the animal markers were scored. Then, all data was video behavior coded by four researchers (two who had also scored it live and two who had not scored live). Statistics were run on the data to determine reliability of scoring and the difference in axial rotation between the groups (CP, TD with thoracic support, TD without thoracic support).
Data Analysis: The primary outcome measure was degrees of rotation. The degree of rotation was recorded live by the scorer and via video analysis. It was based on the light from the laser touching the degree mark on the animal marker. Observation was used to determine if children with and without CP could follow directions and be patient enough to complete the test. Next, to determine if external trunk support influences axial rotation range, an Analysis of Variance (ANOVA) was used. An ANOVA is primarily for determining if there is a significant difference in means for two or more groups of data. Thus, we compared the TD children’s rotation when they had pelvic support to when they had additional thoracic support. In addition, we used an ANOVA to compare rotation for TD children (with pelvic and thoracic support) to the rotation for children with CP.
Intraclass Correlation Coefficient (ICC) was used to determine inter-rater reliability between scorers and intra-rater reliability between live and video scoring for the same scorer (see Figure 3). ICC is a statistic used to compare quantitative measurements that are arranged in groups. It determines the agreement within the group. We calculated the inter-rater reliability using ICC to determine if measurements of axial rotation in children were reliable during test-retest with different live scorers, and to determine if measures of axial rotation were reliable across raters when scored from video recordings. We hypothesized that the video recordings might be more reliable because children moved quickly during the live sessions. To answer the question, “Is accuracy of clinical observation for this measure improved by video recording and coding?” we used an ICC to calculate intra-rater reliability by comparing the live and video scoring results. Figure 3 shows a schematic of the ICC calculation plan. The results were interpreted as: poor (<0.5), moderate (0.5 to 0.75), good (>0.75 to 0.9), and excellent (>0.9) (Koo and Li 155-163).
Figure 3: Three reliability comparisons. Interrater reliability with 4 raters (video, green blocks and arrows) and with 2 raters (live, orange blocks and arrow), and Intra-rater reliability (Live vs. video rescore, blue blocks and blue arrows).
Viability of Test: Our first question was, “can TD children with and children with CP follow the directions and be patient enough to complete the test?” All children were able to complete 3 rotations in each direction during each set of trials for two different testers. The complete axial rotation test, not including the SATCo portion, took roughly 30 minutes for each participant to complete. Viable data was recorded from all participants.
Modifications for children with CP: Given the device modifications, TD children were able to complete the test per the protocol. However, some modifications were made for the children with CP. These children have GMFCS scores of 4 and 5 meaning they are the most severe (table 1) (Palisano et al. 424-428). All three children with CP were non-ambulatory and unable to remain upright and stable for the axial rotation testing with just pelvic support. Thus, they were tested with thoracic support adjusted at the height needed to accommodate their level of trunk control, based on their SATCo level (table 1). Children with CP were unable to keep their hands and feet planted throughout the duration of the testing. Most children with CP had difficulty controlling hand movements; however, one child with CP struggled with controlling his feet movements. Thus, the hand and foot movement restriction was alleviated for children with CP and the trials were still scored. In addition, none of the children with CP could obtain greater than 90 degrees of rotation. Thus, unlike the TD children, all the children with CP needed the device flipped in front of them (see fig 1 A & B).
Differences between populations: Children with CP displayed significantly less degrees of rotation compared to TD children with thoracic support (ANOVA, F(1,81)=952.5, p< 0.001). As seen in Table 2 and Figure 4, there is a 98-degree difference between children with CP and TD children without support. There was an 80-degree difference between children with CP and TD children, both with thoracic support. Although it was easy to differentiate between the scores of children with CP and TD children in our small cohort, it is undetermined if this would hold true for a larger cohort.
Figure 4: Box Plot showing range of axial rotation. CP= children with CP with trunk support, TDN = TD children with only pelvic support, TDY = TD children with trunk support
External Trunk Support: The next question was, “does external trunk support influence rotation?” To determine if trunk support influenced rotation, the TD children were also tested with mid-thoracic support. To avoid order bias, the children were tested once with support and once without, in no particular order. This was completed with two different scorers. The difference between the degree of rotation for TD children with and without thoracic support was significant, as determined by the ANOVA (F(1,94)=49, p< 0.001). On average, an 18 degree decrease in rotation was observed when TD children were given thoracic support (see table 2 and fig 4).
Reliability: Then we asked, “are the measurements of rotation reliable during test-retest with the same and different testers?” The ICC reliability output data can be found in Table 3. While the ICCs vary for left and right rotation, the cohort is too small to make a distinction regarding etiology. The inter-rater reliability between testers was determined via video behavior coding. The video inter-rater reliability was excellent (ICC= 0.98) The reliability from live to video was determined using an intra-rater evaluation of live scores versus video scores for each child. The intra-rater reliability was also excellent (ICC= 0.94-0.98). The live inter-rater reliability was moderate to excellent (ICC= 0.63-0.86). Thus, the test is reliable during test-retest with the same and different testers. In addition, the reliability of the test indicates that the test can be scored live, without the need for additional video analysis because of the excellent intra-rater reliability.
Viability of Test: Overall, the protocol was possible for both groups of children, while some modifications were necessary for children with CP. The protocol was successful with regards to ability to distinguish the degree of rotation reliably between testers, scorers and live versus video. Children expressed enthusiasm for the task and remained engaged in the process for more than thirty minutes. Modifications are needed for the angular surround system to accommodate the full range of rotation possible in children with CP as well as those who are TD. The clinical outcomes were as accurate as the video, eliminating the need for the video during further testing.
Modifications for children with CP: The children with CP needed additional trunk support, in addition to the pelvic support to complete the test. Due to the children with CP’s inability to complete the test while leaving their hands on their lap and feet planted, this restriction was alleviated for them. Future testing might be needed to verify the effect of hand placement in TD children or children with less severe CP and to determine if this can be removed from all tests or if there might be a range of rotation beyond which hands and feet need to remain in place. Originally, the intent was for all children to complete the test with the device behind them. However, the lack of rotation in children with CP necessitated a change to position the device in front of them. Future studies should include a device that encompasses a full 270 degrees, leaving a smaller opening directly in front of the child so that children with CP can sit with the device behind them. This would allow children with CP to be encouraged to rotate more while also allowing success within their range of rotation. The child with the least amount of range achieved at least 45 degrees on 2 out of 3 attempts, meaning that they should be capable of sitting with the device behind them if this modification was made.
Differences in populations: The children with CP and TD children were able to follow directions and were patient enough to successfully complete the test. Both populations tolerated the device and support from the bench. During one or two trials, the laser headpiece slipped. These trials were repeated. To avoid this difficulty in future studies, it is recommended that researchers adjust the straps for each child and instruct the child not to tip their head too far backwards. The TD children completed the rotations faster than the participants with CP who seemed to need to exert more effort to complete the test. In addition, while it was apparent that all populations understood the task, the children with CP needed more direction and incentive. While the TD children understood the directions, they were more creative in finding deviations in order to achieve greater degrees of rotation. In the future, it is recommended that the TD children are not continuously enticed to rotate further as this is when many deviations from protocol were noted. When the TD children tried to rotate more or reach the next animal marker, this was often accompanied by a change in hand or foot placement. In addition, in the future, stricter directions should be given to the TD children. They should be limited to three rotations on each side per test, given that no deviations occur. Finally, in order to reduce deviations, future studies should explore the need for rules about hand and foot placement.
It is also recommended that one person communicates and corrects deviations and entices the child, while another scores. However, this may not be possible in a clinical setting. It would still be possible to complete with one tester; however, the tester must carefully observe positioning while also recording the scores. Sometimes extra trials were needed if the tester thought they might have missed seeing the marker.
External Trunk Support: This study suggests that external trunk support influences rotation. When TD children were allowed to turn without thoracic support, they were able to achieve significantly higher degrees of rotation. Thus, further research could be done to discover if a child with CP’s level of trunk control affects their ability to rotate. In a previous study using the Schenkman FAR device, it was noted that patients with PD’s functional loss was attributed to the disease progress (Schenkman et al. “Functional Limitations” 1339). As the disease progressed, the patients achieved significantly lower degrees of rotation (Schenkman et al. “Functional Limitations” 1351). This correlation could be investigated in children with CP to determine if their SATCo level or their level of severity is related to their degree of axial rotation. Given the TD children’s data, it would be predicted that the less trunk control the participant has, the less rotation they will achieve due to the external trunk support being provided more superiorly and therefore constricting more movement.
Reliability: Given the high inter-rater reliability, it was determined that the measurements of axial rotation are reliable during test-retest with the same and different testers regardless of the population (TD or CP). This supports that the device could be used to measure axial rotation in a clinical setting. To track improvements in axial rotation, the therapist could take a baseline measurement during the evaluation and complete the test at different milestones during treatment. In addition, the test would not need to be completed by two therapists due to the high reliability. One therapist could assess the patient’s rotation by scoring three turns in each direction. This will make the testing faster so that it fits nicely into the evaluation visit. In addition, this could be completed by the same or different therapists at each visit and still yield useful information, although it is always best for any measures to be collected by the same person.
Clinical observation did not differ from video coding as evidenced by intra-rater reliability of live versus video scores. Thus, this measure would be convenient and less time consuming in a clinical setting. The therapist would be able to score the patient live, saving hours of video equipment setup time and post-session analysis. In addition, the tester or therapist will have more freedom in where they position themselves. During this study, the tester had to ensure they were not blocking the cameras.
Future Research: While the device yields relevant data, improvements could be made to make it more conducive to a clinical setting. It was timely to measure out the proper degree from the bench that each post needed to be at in order to hold up the device markers. Thus, a PVC pipe support base and top would be helpful in eliminating the need for angle measurement during set up. If the device consisted of a PVC pipe 270-degree base and top with an adjustable pipe between, this would be ideal. For storage purposes, it would be best for the device to breakdown into pieces that can be easily constructed before measurement. Once configured, the cardboard roll of animal markers could be attached to the top PVC pipe arc. The bench would be positioned so that the child’s back is in line with 90 degrees on both sides and the center of their body is at 180 degrees (see fig 5). Future studies should be completed to test the efficacy and reliability of these device modifications in a larger population of children.
Figure 5: Suggestions to improve device and degree measurements. The degree measurements are noted for right and left rotation with all children seated with the device behind them.
In order to further reduce error and entice the children, a future study could explore the technology required to have targets that light up when reached. In other words, when the child turns and hits a certain degree marker, the animal and degree of rotation would light up. This could potentially excite the child and make the scoring more automatized.
In addition, future studies can be done to see if increases in axial rotation allow for dance and other physical activities to be more feasible for this population and to examine specific restrictions on function that are related to the amount of axial rotation available to the child. Additional research can also be done to determine if dance therapy aids in increasing axial rotation. Dance therapy helps “improve overall health for adolescents with cerebral palsy to combat their tendency of increased sedentary lifestyle” (Owens and Silkwood-Sherer 1). Dance has also been shown to increase balance confidence and functional abilities, both of which would be beneficial for children with CP (Owens and Silkwood-Sherer 1). Ultimately, this device can be used to gain a better understanding of the implications of limited axial rotation and inspire the creation of new interventions to help children with disabilities participate more fully in physical activities, which thereby could increase their motor function and overall quality of life.
This research would not have been possible without Dr. Sandra Saavedra’s expertise and time. Dr. Saavedra, part of the University of Hartford Pediatric Balance Lab, served as the advisor for the project and as the co-author of this manuscript. Thank you so much for your unwavering support and commitment to this research! Additionally, thank you to James Anderson, Emma Brown, and Matthew Glassoff for their help with protocol development, data collection, and video behavior coding. Thank you to Dr. Michael Wininger for statistical analysis support. A special thank you to Dr. Claudia Oakes and Dr. Donald Jones for their support of this Honors Program project. Support for this work was provided by The Women’s Advancement Initiative’s Dorothy Goodwin Scholars Program, which was made possible thanks to a generous bequest from Dorothy Goodwin. The Women’s Advancement Initiative at the University of Hartford is proud to continue the legacy of advancing each woman’s potential in the Hartford College for Women tradition. This support does not necessarily imply endorsement by the University of Hartford or The Women’s Advancement Initiative of research conclusions.
Supplementary Device Information
The axial rotation device was constructed using pool noodles, rolled cardboard, paper animal markers, PVC pipe stands, Velcro, tape, and string. The pool noodles were held in a 180-degree semi-circle by inserting string through the noodles and tightening the string until the noodles were the desired half circle shape. The noodles were then attached via Velcro to the PVC pipe stands. This allowed the structure to be moved up or down to adjust to the child’s eye level. The rolled cardboard was then attached to the pool noodles using tape to round out the structure better. Then, the paper animal markers were attached to the top of the rolled cardboard. This ensures that the markers were attached in a straight line. The degrees were marked on the animals and cardboard to allow the researcher to record the degree of rotation easily. The PVC pipe stands were held in place using weights.
A protractor and string were used to construct the 180-degree semi-circle. Zero degrees, 60 degrees, 120 degrees, and 180 degrees were marked, and this is where the PVC pipe stands were placed. The 90-degree mark was also used to ensure that it aligned with the 90-degree mark on the animal markers and cardboard. There was also a straight line marking the diameter of the semicircle that was outlined using a string. The bench was setup so that the back of the Leckey bench strapping system was in line with the diameter of the semicircle. This ensured that the child’s hips were in line with the diameter of the semicircle for consistency between participants. The center of the diameter was also marked to ensure that the child was centered on the bench so that their initial position was 0 degrees.
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