Cerebral Palsy General Assessment: Difference between revisions

No edit summary
No edit summary
 
(45 intermediate revisions by 3 users not shown)
Line 1: Line 1:
Intro
<div class="editorbox"> '''Original Editor '''- [[User:Robin Tacchetti|Robin Tacchetti]] based on the course by [https://members.physio-pedia.com/course_tutor/krista-eskay/ Krista Eskay]<br>
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>


Cerebral palsy (CP) is primarily a neuromotor disorder that affects the development of movement, muscle tone and posture (1-3). The underlying pathophysiology is an injury to the developing brain in the prenatal through neonatal period (1-3). Although the initial neuropathologic lesion is non-progressive, children with CP may develop a range of secondary conditions over time that will variably affect their functional abilities (4,5).<ref name=":0">Patel DR, Neelakantan M, Pandher K, Merrick J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082248/ Cerebral palsy in children: a clinical overview.] Translational pediatrics. 2020 Feb;9(Suppl 1):S125.</ref>
== Introduction ==
[https://www.physio-pedia.com/Cerebral_Palsy_Aetiology_and_Pathology Cerebral palsy] (CP) is a non-progressive neuromotor disorder. The primary impairments associated with CP include movement dysfunction, alterations in muscle tone and posture. A range of secondary conditions also develop over time which can affect functional ability. The underlying cause of CP is injury to the developing brain in the prenatal through neonatal periods.<ref name=":0">Patel DR, Neelakantan M, Pandher K, Merrick J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082248/ Cerebral palsy in children: a clinical overview.] Translational pediatrics. 2020 Feb;9(Suppl 1):S125.</ref>


== General Diagnosis ==
In the paediatric practice setting, it is difficult to make a definitive diagnosis of CP during the first 1-2 years of life. During this time period, delays in development can be part of normal variation and may resolve. A more reliable diagnosis is made after 2 years of age based on clinical findings, which typically include: 


General Diagnsos
* Failure to attain certain key milestones at an expected age
* Persistence of primitive [[reflexes]] or primary motor patterns beyond the expected age<ref name=":0" />


* For infants ≤5 months corrected age, the most predictive tools for detecting risk for CP are term-age magnetic resonance imaging (MRI) (86–89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity) (8).
However, an interim diagnosis for "high risk of CP" can be made before the age of 2 years. This risk category requires motor dysfunction and either a clinical history indicating a risk of CP and/or signs of an abnormality on MRI.<ref name=":0" /> In 2017, Novak et al.<ref name=":4">Novak I, Morgan C, Adde L, Blackman J, Boyd RN, Brunstrom-Hernandez J, Cioni G, Damiano D, Darrah J, Eliasson AC, De Vries LS. [https://pure.rug.nl/ws/files/46983262/jamapediatrics_Novak_2017_rv_170003.pdf Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatmen]t. JAMA pediatrics. 2017 Sep 1;171(9):897-907.</ref> proposed ways to predict CP in infants:
* ❖ For infants ≥6 months corrected age, the most predictive tools for detecting CP risk are MRI (86–89% sensitivity), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index) (8).


Novak ''et al.'' [2017] proposed that when a diagnosis of CP cannot be made with certainty in young infants, an interim clinical diagnosis of ‘high risk of CP’ should be made, so that CP specific early interventions can be initiated (8). A diagnosis of high risk for CP requires motor dysfunction and either an abnormality on MRI scan and/ or a clinical history indicating risk for CP (8).
* Infants before 5 months corrected age: "term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity)"<ref name=":4" />
* Infants after 5 months corrected age: "magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index)"<ref name=":4" />


pecific diagnosis of CP in most primary care or pediatric practice settings is difficult to make with certainty during first 1–2 years of life.  A diagnosis of CP is primarily based on clinical findings and is generally more reliable after 2 years of age, because early signs and symptoms suggestive of CP may in fact be a normal variation or developmental lag and tend to resolve in many infants Persistence of primitive reflexes or primary motor pattern beyond the expected age is a key clinical characteristic of CP (11-14,16). Persistence of primitive reflexes prevents or delays typical progression of motor development and sequential acquisition of higher level neuromotor skills. A diagnosis of CP is first suspected when there is a failure to attain certain key milestones at expected age<ref name=":0" />
=='''Specific Tests'''==


==='''The General Movements Assessment'''===
The General Movements Assessment is used to observe movement in infants from birth to 20 weeks. A clinician observes a 3-5 minute video of the child's movement, and makes an assessment using a standardised method. This test has been shown to have high specificity and sensitivity for predicting cerebral palsy.<ref name=":2">Graham D, Paget SP, Wimalasundera N. [https://www.mja.com.au/system/files/2019-02/mja212106.pdf Current thinking in the health care management of children with cerebral palsy]. Medical Journal of Australia. 2019 Feb;210(3):129-35.</ref> It is, therefore, useful for the early detection of CP in high risk groups.<ref name=":2" />


Specific Tests
==== Barry Albright Dystonia Scale ====
The Barry Albright Dystonia Scale (BADS) is used to assess secondary dystonia in patients with traumatic brain injury or CP. The BADS is a criterion-based, ordinal scale covering eight body regions using a 5-point scale.<ref>Stewart K, Lewis J, Wallen M, Bear N, Harvey A. [https://onlinelibrary.wiley.com/doi/10.1111/dmcn.14960 The Dyskinetic Cerebral Palsy Functional Impact Scale: development and validation of a new tool]. Dev Med Child Neurol. 2021 Dec;63(12):1469-75. </ref>


The Gross Motor Function Classification System (GMFCS) is used to describe gross motor function, especially the ability to walk, for children from 2 to 18 years of age (19,20). GMFCS is used to describe self-initiated movements as well as movements assisted by devices such as walkers, crutches, canes or wheelchairs (19,20). The Manual Ability Classification System (MACS) is used to describe the typical use of both hands and upper extremities for children from 4 to 18 years of age (21). The Communication Function Classification System (CFCS) is used to describe the ability of persons with CP for daily routine communication (sending or receiving a message) (22). The CFCS considers all methods of communication including vocalizations, manual signs, eye gaze, pictures, communication boards or speech generating devices (22). The Eating and Drinking Ability Classification System (EDACS) is used to describe the eating and drinking function for children 3 years and older (23). The EDACS assesses the eating and drinking safety (risk for aspiration or chocking), and eating and drinking efficiency (the amount food lost and the time taken to eat) (23).<ref name=":0" />and TABLE 3
==== Gross Motor Function Measure ====
The [[Gross Motor Function Measure]] is an assessment tool used with children with CP. This test uses a 4-point ordinal scale to evaluate a child's ability to complete motor functions such as sitting, standing, rolling, crawling, stair use, jumping, etc.<ref>Russell DJ, Rosenbaum P, Wright M, Avery LM. G[https://www.sciencedirect.com/topics/medicine-and-dentistry/gross-motor-function-measure ross motor function measure (GMFM-66 & GMFM-88) users manual]. Mac keith press; 2002.</ref>


==== The Gross Motor Function Classification System ====
The [[Gross Motor Function Classification System - Expanded and Revised (GMFCS-ER)|Gross Motor Function Classification System]] (GMFCS) is used on children aged 2-18 years old to describe gross motor function, especially the ability to walk. This scale can be used to describe movements that require [[Assistive Devices|assistive devices]] (walkers, crutches, wheelchairs etc), as well as self-initiated movements.<ref name=":0" />


Treatment
==== The Hammersmith Infant Neurological Examination ====
The Hammersmith Infant Neurological Examination (HINE) is used for infants aged from 2 months to 2 years to provide a framework for monitoring and identifying deviations from normal development. The HINE has been shown to have high specificity and sensitivity for predicting cerebral palsy.<ref name=":2" />


A multidisciplinary team (''Table 4'') approach provides the best model for medical care of children and adults with CP across their lifespan to manage various associated and secondary conditions as well as address support system and psychosocial need- TABLE 4<ref name=":0" />
===='''Manual Ability Classification System (MACS)'''====
The Manual Ability Classification System (MACS) details the typical use of upper extremities and hands for children aged 4-18 years.<ref name=":0" />


Spasticity
===='''The Communication Function Classification System (CFCS)'''====
The Communication Function Classification System (CFCS) is used to assess daily routine communication in individuals with CP (i.e. receiving or sending a message). All types of communication can be assessed in the CFCS, including eye gaze, pictures, speech generating devices, vocalisations and communication boards.<ref name=":0" />


he degree or severity of spasticity in CP varies depending upon the stage of arousal of the child at the time and the duration since the inciting event that lead to spasticity (11,16,28-32). Muscle spasticity in a child with CP may interfere with certain functions as well as may serve to facilitate certain functions. Therefore, reduction of spasticity should be considered within the context of its functional impact and multiple factors (''Table 7'') need careful consideration  Different treatment interventions (''Table 8'') have been used to treat spasticity in children with CP (11,16,28-32). The decision to use any particular treatment intervention is guided by the goal of the treatment. In some cases, the goal may be to reduce focal spasticity, whereas in others it may be to reduce generalized spasticity. Also, the risks and benefits of any particular intervention should be carefully considered. Physiotherapy and occupational therapy by age 4–5 years of age have been shown to be relatively more effective than if started at a later age (33,34). Botulinum toxin injection is used to treat focal spasticity with optimal effectiveness between 1 and 6 years of age for the treatment of lower extremity spasticity and between 5 and 15 years of age for spastic hemiplegia (11,16,28-32). Spasticity management is best guided by a physician with expertise and experience with the use of different treatment interventions.TABLE 7,8<ref name=":0" />
===='''Eating and Drinking Ability Classification System (EDACS)'''====
The Eating and Drinking Ability Classification System (EDACS) is used for children aged 3 years and older, and it reports on their eating and drinking function. More specifically, this test assesses eating and drinking efficiency and safety (risk for aspiration or choking).<ref name=":0" />


=== Orthopedic surgical procedures ===
The following table from Paulson et al. (2017)<ref name=":8">Paulson A, Vargus-Adams J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406689/ Overview of four functional classification systems commonly used in cerebral palsy]. Children. 2017 Apr 24;4(4):30.</ref> shows classification levels of CP using the GMFCS, MACS, CFCS and EDACS:
Children with CP develop multiple secondary, often progressive, musculoskeletal conditions (''Table 9'') that may require orthopedic surgical interventions that are best managed by orthopedic surgeons with experience and expertise in these surgical procedures (6,10,13,16,33,34). The type and severity of these conditions vary depending upon the type and severity of CP. A number of factors are considered in planning any of these surgical interventions that include the age of the child, severity and progressive or nonprogressive nature of the condition, support system for post-operative and long term follow-up and care, potential for functional improvement, and potential for amelioration or prevention of complications. A common practice consideration is to perform most procedures as a single event multiple level surgery (SEMLS) to avoid multiple exposure to anesthesia risk and other operative risks (16,33). Also, this approach allows for a planned course of post-operative rehabilitation.- TABLE 9<ref name=":0" />
{| class="wikitable"
! colspan="1" rowspan="1" |Level
! colspan="1" rowspan="1" |GMFCS
! colspan="1" rowspan="1" |MACS
! colspan="1" rowspan="1" |CFCS
! colspan="1" rowspan="1" |EDACS
|-
| colspan="1" rowspan="1" |I
| colspan="1" rowspan="1" |Walks without limitation
| colspan="1" rowspan="1" |Handles objects easily and successfully
| colspan="1" rowspan="1" |Effective sender and receiver
| colspan="1" rowspan="1" |Eats and drinks safely and efficiently
|-
| colspan="1" rowspan="1" |II
| colspan="1" rowspan="1" |Walks with limitations (no mobility aid by 4 years)
| colspan="1" rowspan="1" |Handles most objects with reduced speed/quality
| colspan="1" rowspan="1" |Effective but slow-paced sender and receiver
| colspan="1" rowspan="1" |Eats and drinks safely but with some limitations to efficiency
|-
| colspan="1" rowspan="1" |III
| colspan="1" rowspan="1" |Walks with hand-held mobility device
| colspan="1" rowspan="1" |Handles objects with difficulty, help to prepare or modify activity
| colspan="1" rowspan="1" |Effective sender and receiver with familiar partners
| colspan="1" rowspan="1" |Eats and drinks with some limitations to safely; there may also be limitations to efficiency
|-
| colspan="1" rowspan="1" |IV
| colspan="1" rowspan="1" |Self-mobility with limitations, may use power
| colspan="1" rowspan="1" |Handles limited number of objects in adapted setting
| colspan="1" rowspan="1" |Inconsistent sender and receiver with familiar partners
| colspan="1" rowspan="1" |Eats and drinks with significant limitations to safety
|-
| colspan="1" rowspan="1" |V
| colspan="1" rowspan="1" |Transported in manual wheelchair
| colspan="1" rowspan="1" |Does not handle objects
| colspan="1" rowspan="1" |Seldom effective sender and receiver with familiar partners
| colspan="1" rowspan="1" |Unable to eat or drink safely; consider feeding tube
|}
<ref name=":8" />


=== Spasticity Tests ===


PT
==== Modified Ashworth Scale ====
The most universally accepted tool to measure increases in muscle tone is the [[Modified Ashworth Scale|Modified Ashworth]] scale. As detailed in Harb and Kishner,<ref name=":7">Harb A, Kishner S. [https://www.ncbi.nlm.nih.gov/books/NBK554572/ Modified ashworth scale]. InStatPearls [Internet] 2021 May 9. StatPearls Publishing. Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/),</ref> grading of [[spasticity]] using this scale is as follows:


Physiotherapy has been shown to improve muscle strength, local muscular endurance and joint range of movement in children with CP (35,36). Physiotherapy exercises are used to prevent or reduce joint contractures; this is achieved by passive gentle range of motion exercises and stretches across major joints. Increased muscle strength is achieved by performing regularly scheduled progressively increasing resistive exercises involving all major muscle groups. Low resistance, high repetition exercises of major muscle groups improve local muscular endurance. Specific physiotherapy exercises are designed to improve balance, postural control, gait, and assist with mobility and transfers (for example from bed to wheelchair). Functional strength training combined with plyometric exercises and balance training have been used to improve function in individuals with CP (31,35-38). Plyometric exercise improves muscle power, which includes strength and speed (35,36). In regards to functional strength training, studies have shown that targeting specific muscles is most effective in muscle activation (35,36,38). A study has shown that 12 weeks of an adaptive bungee trampoline program improved lower limb muscle strength (39). This bungee trampoline program included bouncing, hopping, heel jumps, jumping with eyes closed, practicing a sequence of jumps, and games such as dodgeball. The use of constraint-induced therapy centers on the idea of selective upper extremity strengthening in children with CP (8,12-14,40,41). The intervention focuses on having the child use the affected limb, while simultaneously restraining the use of normally functioning limb. Prolonged restraint and disuse of the normally functioning upper limb may result in disuse weakness. The application of conductive education based on the concept that children with or without motor deficits learn the same way (14,30,31,35,42). The conductive education specialist attempts to unify developmental areas including emotional, cognitive, motor and communicative domains in order to improve integration and global functionality in participants (14,30,31,35,42). The effectiveness of conductive education (CE) in improving functional capabilities of children with CP has not been clearly established (14,30,31,35,42).<ref name=":0" />
* 0: No increase in muscle tone
* 1: Slight increase in muscle tone, with a catch and release or minimal resistance at the end of the range of motion when an affected part(s) is moved in flexion or extension
* 1+: Slight increase in muscle tone, manifested as a catch, followed by minimal resistance through the remainder (less than half) of the range of motion
* 2: A marked increase in muscle tone throughout most of the range of motion, but affected part(s) are still easily moved
* 3: Considerable increase in muscle tone, passive movement difficult
* 4: Affected part(s) rigid in flexion or extension<ref name=":7" />


=== Treadmill training ===
==== Tardieu Scale ====
Treadmill training as an intervention for children with CP aims at improving balance as well as lower extremity symmetry (10,30,31,35,43-46). It provides important measures in developing an understanding of how to walk independently. Specific methods of treadmill training vary, with protocols demonstrating differences in training speeds (varied based on age at intervention), use of or lack of body weight support techniques (support under the arms or with utilization of a harness on the patient while on the treadmill), and frequency or duration of the training (10,30,31,35,43-46). Studies have demonstrated that 3–4 sessions per week over a period of 3–4 months of treadmill training in children under 6 years of age with ambulatory capability have led to improvement in gait velocity and enhancement of stepping movements, as well as independence with walking (10,30,31,35,43-46).<ref name=":0" />
The [[Tardieu Scale]] is another tool used to measure [[spasticity]]. This scale assesses resistance to passive movement at different velocities - i.e. fast and slow. It allows the assessor to differentiate between non-neural factors (e.g. contracture) and neural factors (e.g. spasticity) that may explain an increased resistance to passive stretch.<ref name=":6" /> A passive stretch is applied to a muscle group at two velocities<ref name=":6">Glinsky J. Tardieu Scale. [https://www.researchgate.net/publication/305925531_The_Tardieu_Scale J Physiother]. 2016 Oct;62(4):229</ref>:


Treadmill training is time and labor intensive. Robotic gait training has been shown to reduce the time and labor burden associated with traditional treadmill training (47). Robotic assisted device can harness the child appropriately and can be programmed to simulate normal gait. Studies have shown increased walking speed and endurance with the use of robotic gait training. Randomized controlled trials have shown effectiveness of robot assisted gait training in improving gait velocity, spatiotemporal station, and endurance in children with CP (47).<ref name=":0" />
# First stretch is as slow as possible (V1); equivalent to passive range of motion
# Second stretch:
## 'speed of the limb segment falling under gravity' (V2)
## 'as fast as possible' (V3)


=== Occupational therapy ===
<nowiki>**</nowiki> A six point scale is used for grading with 0 indicating ‘no resistance through the course of the passive movement’ and 5 indicating that ‘the joint is immobile’<ref name=":6" />
Occupational therapy is an integral component in the interdisciplinary treatment of individuals with CP, with various studies demonstrating its long-term effects on promoting improvement in fine motor functionality (35). A major focus of occupational therapy is to improve fine motor function of upper extremities to assist the child in performing activities of daily living more efficiently. Occupational therapist also works in organization of child’s play areas, providing adaptive equipment for self-care and learning and to modify child’s learning environment to facilitate attention and information processing (35).<ref name=":0" />


=== Orthotics, adaptive equipment, and assistive technology ===
=== Hip Tests ===
In the long-term management of children with CP, it is important to determine how much assistance is required on a daily basis for optimal functioning. Orthoses, adaptive equipment and assistive technology devices (''Table 6'') are used to improve child’s functional abilities and facilitate activities of daily living (13,14,32-34,48-50). Assistive technology plays an important role in the management of persons who have CP and other developmental disorders. According to the United States Individuals with Disabilities Education Act (IDEA), the term “assistive technology device” means any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of a child with a disability (48). The term does not include a medical device that is surgically implanted, or the replacement of such device. The term “assistive technology service” means any service that directly assists a child with a disability in the selection, acquisition, or use of an assistive technology device. A significant amount of variability exists within adaptive technology for children with CP, as these devices are ideally tailored to the individual’s existing muscle constraints.<ref name=":0" />
==== Barlow and Ortolani Manoeuvres ====
''Barlow Test'': identifies a dislocated hip by adducting a flexed hip using a gentle posterior force.<ref name=":1">Shipman S, Helfand M, Nygren P, et al. Screening for Developmental Dysplasia of the Hip [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Mar. (Evidence Syntheses, No. 42.) 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK33426/</ref>


Others
''Ortolani Test'': attempts to relocate a dislocated hip by abduction of a flexed hip with a gentle anterior force.<ref name=":1" />


Many other specific interventions or intervention approaches have been used in the treatment of CP; however, the evidence for effectiveness and recommendation for routine use of such interventions is equivocal and limited. Some of these interventions or approaches include acupuncture, neurodevelopmental training, sensory integration, electrical stimulation, suit therapy, hippotherapy, music therapy, video game therapy, and stem cell therapy<ref name=":0" />
==== Galeazzi Sign ====
The Galeazzi sign is used when you are looking for instability, dislocation or anterior translation of the hip. The child lies supine with their legs in hooklying and the clinician looks for asymmetry in knee height.
 
This sign is positive if one knee is higher than the other. This indicates that there is instability, dislocation, or anterior translation of the hip socket on the lower side.<ref name=":9">Eskay, K.  Cerebral Palsy General Assessment and Interventions.  Plus. 2022</ref>
 
Please see the videos below for a description and demonstration of these tests.
 
<div class="row">
  <div class="col-md-6"> {{#ev:youtube|imhI6PLtGLc|250}} <div class="text-right"><ref>nabil ebraheim. Barlow & Ortolani test, Congenital Hip Dislocation- Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=imhI6PLtGLc [last accessed 30/11/2022]</ref></div></div>
  <div class="col-md-6"> {{#ev:youtube|Qn-bWuvm0Pk|250}} <div class="text-right"><ref>
Texas Children’s Hospital. TCH Ortho - Hip. Available from: https://www.youtube.com/watch?v=Qn-bWuvm0Pk [last accessed 30/11/2022]</ref></div></div>
 
==== Activity Scale for Kids (ASK) ====
The Activities Scales for Kids (ASK) is a self-administered 30-item questionaire of what the child can do or would do at home, school and in the playground.<ref>Costi S, Mecugni D, Beccani L, Alboresi S, Bressi B, Paltrinieri S, Ferrari A, Pelosin E. [https://www.researchgate.net/publication/271415077_Activities_Scale_for_Kids Construct validity of the activities scale for kids performance in children with cerebral palsy: brief repor]t. Developmental Neurorehabilitation. 2020 Oct 2;23(7):474-7.</ref>
 
==== Pediatric Evaluation of Disability Inventory (PEDI) ====
The Pediatric Evaluation of Disability Inventory (PEDI) is a thorough clinical assessment that checks key functional performances and capabilities in children between the ages of 6 months to 7½ years.<ref>Haley, S.M., Coster, W.J., Kao, Y.C., Dumas, H.M., Fragala-Pinkham, M.A., Kramer, J.M., Ludlow, L.H. and Moed, R., 2010. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3631526/ Lessons from use of the pediatric evaluation of disability inventory (pedi): Where do we go from here?.] ''Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association'', ''22''(1), p.69.</ref>
 
==== Functional Independence Measure for Children (WeeFIM) ====
WeeFIM is an assessment tool that measures a child’s consistent performance in essential daily functional skills. The instrument consists of an 18-item, 7-level ordinal scale over three main domains (self-care, mobility, and cognition).<ref>Wong V, Wong S, Chan K, Wong W. [https://publications.aap.org/pediatrics/article-abstract/109/2/e36/64022/Functional-Independence-Measure-WeeFIM-for-Chinese?redirectedFrom=fulltext Functional independence measure (WeeFIM) for Chinese children: Hong Kong cohort]. Pediatrics. 2002 Feb;109(2):e36-.</ref>
 
=== Functional Balance Tests ===
</div>
 
# [[Timed Up and Go Test (TUG)|Timed Up and Go]]: assesses mobility
# Timed Floor to Stand: assesses transition to and from floor
# [[Five Times Sit to Stand Test|Five Times Sit to Stand]]:assesses 5 consecutive cycles of sit to stand
# Paediatric Reach: assesses the distance one hand can reach forward laterally while maintaining sitting or standing balance<ref>Seek Freaks: Top 9 Functional Balance Tests for School-Based PTs.  2018.  Available from: https://www.seekfreaks.com/index.php/2015/12/19/resource-top-9-functional-balance-tests-for-school-based-pts/</ref>
 
== Resources ==
* [https://www.physio-pedia.com/Functional_Independence_Measure_(FIM) Functional Independence Measure for Children]
 
*[[Cerebral Palsy Aetiology and Pathology]]
* [[10 Metre Walk Test]]
* [[6 Minute Walk Test]]
* [[Timed Up and Go Test (TUG)|Timed Up and Go Test]]
* [[Pediatric Balance Scale]]
*[https://www.canchild.ca/ CanChild]
 
=='''References'''==
<references />
[[Category:ReLAB-HS Course Page]]
[[Category:Course Pages]]
[[Category:Paediatrics]]
[[Category:Cerebral Palsy]]
[[Category:Rehabilitation]]

Latest revision as of 09:48, 8 November 2023

Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti, Jess Bell and Tarina van der Stockt

Introduction[edit | edit source]

Cerebral palsy (CP) is a non-progressive neuromotor disorder. The primary impairments associated with CP include movement dysfunction, alterations in muscle tone and posture. A range of secondary conditions also develop over time which can affect functional ability. The underlying cause of CP is injury to the developing brain in the prenatal through neonatal periods.[1]

General Diagnosis[edit | edit source]

In the paediatric practice setting, it is difficult to make a definitive diagnosis of CP during the first 1-2 years of life. During this time period, delays in development can be part of normal variation and may resolve. A more reliable diagnosis is made after 2 years of age based on clinical findings, which typically include:

  • Failure to attain certain key milestones at an expected age
  • Persistence of primitive reflexes or primary motor patterns beyond the expected age[1]

However, an interim diagnosis for "high risk of CP" can be made before the age of 2 years. This risk category requires motor dysfunction and either a clinical history indicating a risk of CP and/or signs of an abnormality on MRI.[1] In 2017, Novak et al.[2] proposed ways to predict CP in infants:

  • Infants before 5 months corrected age: "term-age magnetic resonance imaging (86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements (98% sensitivity), and the Hammersmith Infant Neurological Examination (90% sensitivity)"[2]
  • Infants after 5 months corrected age: "magnetic resonance imaging (86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index)"[2]

Specific Tests[edit | edit source]

The General Movements Assessment[edit | edit source]

The General Movements Assessment is used to observe movement in infants from birth to 20 weeks. A clinician observes a 3-5 minute video of the child's movement, and makes an assessment using a standardised method. This test has been shown to have high specificity and sensitivity for predicting cerebral palsy.[3] It is, therefore, useful for the early detection of CP in high risk groups.[3]

Barry Albright Dystonia Scale[edit | edit source]

The Barry Albright Dystonia Scale (BADS) is used to assess secondary dystonia in patients with traumatic brain injury or CP. The BADS is a criterion-based, ordinal scale covering eight body regions using a 5-point scale.[4]

Gross Motor Function Measure[edit | edit source]

The Gross Motor Function Measure is an assessment tool used with children with CP. This test uses a 4-point ordinal scale to evaluate a child's ability to complete motor functions such as sitting, standing, rolling, crawling, stair use, jumping, etc.[5]

The Gross Motor Function Classification System[edit | edit source]

The Gross Motor Function Classification System (GMFCS) is used on children aged 2-18 years old to describe gross motor function, especially the ability to walk. This scale can be used to describe movements that require assistive devices (walkers, crutches, wheelchairs etc), as well as self-initiated movements.[1]

The Hammersmith Infant Neurological Examination[edit | edit source]

The Hammersmith Infant Neurological Examination (HINE) is used for infants aged from 2 months to 2 years to provide a framework for monitoring and identifying deviations from normal development. The HINE has been shown to have high specificity and sensitivity for predicting cerebral palsy.[3]

Manual Ability Classification System (MACS)[edit | edit source]

The Manual Ability Classification System (MACS) details the typical use of upper extremities and hands for children aged 4-18 years.[1]

The Communication Function Classification System (CFCS)[edit | edit source]

The Communication Function Classification System (CFCS) is used to assess daily routine communication in individuals with CP (i.e. receiving or sending a message). All types of communication can be assessed in the CFCS, including eye gaze, pictures, speech generating devices, vocalisations and communication boards.[1]

Eating and Drinking Ability Classification System (EDACS)[edit | edit source]

The Eating and Drinking Ability Classification System (EDACS) is used for children aged 3 years and older, and it reports on their eating and drinking function. More specifically, this test assesses eating and drinking efficiency and safety (risk for aspiration or choking).[1]

The following table from Paulson et al. (2017)[6] shows classification levels of CP using the GMFCS, MACS, CFCS and EDACS:

Level GMFCS MACS CFCS EDACS
I Walks without limitation Handles objects easily and successfully Effective sender and receiver Eats and drinks safely and efficiently
II Walks with limitations (no mobility aid by 4 years) Handles most objects with reduced speed/quality Effective but slow-paced sender and receiver Eats and drinks safely but with some limitations to efficiency
III Walks with hand-held mobility device Handles objects with difficulty, help to prepare or modify activity Effective sender and receiver with familiar partners Eats and drinks with some limitations to safely; there may also be limitations to efficiency
IV Self-mobility with limitations, may use power Handles limited number of objects in adapted setting Inconsistent sender and receiver with familiar partners Eats and drinks with significant limitations to safety
V Transported in manual wheelchair Does not handle objects Seldom effective sender and receiver with familiar partners Unable to eat or drink safely; consider feeding tube

[6]

Spasticity Tests[edit | edit source]

Modified Ashworth Scale[edit | edit source]

The most universally accepted tool to measure increases in muscle tone is the Modified Ashworth scale. As detailed in Harb and Kishner,[7] grading of spasticity using this scale is as follows:

  • 0: No increase in muscle tone
  • 1: Slight increase in muscle tone, with a catch and release or minimal resistance at the end of the range of motion when an affected part(s) is moved in flexion or extension
  • 1+: Slight increase in muscle tone, manifested as a catch, followed by minimal resistance through the remainder (less than half) of the range of motion
  • 2: A marked increase in muscle tone throughout most of the range of motion, but affected part(s) are still easily moved
  • 3: Considerable increase in muscle tone, passive movement difficult
  • 4: Affected part(s) rigid in flexion or extension[7]

Tardieu Scale[edit | edit source]

The Tardieu Scale is another tool used to measure spasticity. This scale assesses resistance to passive movement at different velocities - i.e. fast and slow. It allows the assessor to differentiate between non-neural factors (e.g. contracture) and neural factors (e.g. spasticity) that may explain an increased resistance to passive stretch.[8] A passive stretch is applied to a muscle group at two velocities[8]:

  1. First stretch is as slow as possible (V1); equivalent to passive range of motion
  2. Second stretch:
    1. 'speed of the limb segment falling under gravity' (V2)
    2. 'as fast as possible' (V3)

** A six point scale is used for grading with 0 indicating ‘no resistance through the course of the passive movement’ and 5 indicating that ‘the joint is immobile’[8]

Hip Tests[edit | edit source]

Barlow and Ortolani Manoeuvres[edit | edit source]

Barlow Test: identifies a dislocated hip by adducting a flexed hip using a gentle posterior force.[9]

Ortolani Test: attempts to relocate a dislocated hip by abduction of a flexed hip with a gentle anterior force.[9]

Galeazzi Sign[edit | edit source]

The Galeazzi sign is used when you are looking for instability, dislocation or anterior translation of the hip. The child lies supine with their legs in hooklying and the clinician looks for asymmetry in knee height.

This sign is positive if one knee is higher than the other. This indicates that there is instability, dislocation, or anterior translation of the hip socket on the lower side.[10]

Please see the videos below for a description and demonstration of these tests.

[11]
[12]

Activity Scale for Kids (ASK)[edit | edit source]

The Activities Scales for Kids (ASK) is a self-administered 30-item questionaire of what the child can do or would do at home, school and in the playground.[13]

Pediatric Evaluation of Disability Inventory (PEDI)[edit | edit source]

The Pediatric Evaluation of Disability Inventory (PEDI) is a thorough clinical assessment that checks key functional performances and capabilities in children between the ages of 6 months to 7½ years.[14]

Functional Independence Measure for Children (WeeFIM)[edit | edit source]

WeeFIM is an assessment tool that measures a child’s consistent performance in essential daily functional skills. The instrument consists of an 18-item, 7-level ordinal scale over three main domains (self-care, mobility, and cognition).[15]

Functional Balance Tests[edit | edit source]

  1. Timed Up and Go: assesses mobility
  2. Timed Floor to Stand: assesses transition to and from floor
  3. Five Times Sit to Stand:assesses 5 consecutive cycles of sit to stand
  4. Paediatric Reach: assesses the distance one hand can reach forward laterally while maintaining sitting or standing balance[16]

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Patel DR, Neelakantan M, Pandher K, Merrick J. Cerebral palsy in children: a clinical overview. Translational pediatrics. 2020 Feb;9(Suppl 1):S125.
  2. ↑ 2.0 2.1 2.2 Novak I, Morgan C, Adde L, Blackman J, Boyd RN, Brunstrom-Hernandez J, Cioni G, Damiano D, Darrah J, Eliasson AC, De Vries LS. Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment. JAMA pediatrics. 2017 Sep 1;171(9):897-907.
  3. ↑ 3.0 3.1 3.2 Graham D, Paget SP, Wimalasundera N. Current thinking in the health care management of children with cerebral palsy. Medical Journal of Australia. 2019 Feb;210(3):129-35.
  4. ↑ Stewart K, Lewis J, Wallen M, Bear N, Harvey A. The Dyskinetic Cerebral Palsy Functional Impact Scale: development and validation of a new tool. Dev Med Child Neurol. 2021 Dec;63(12):1469-75.
  5. ↑ Russell DJ, Rosenbaum P, Wright M, Avery LM. Gross motor function measure (GMFM-66 & GMFM-88) users manual. Mac keith press; 2002.
  6. ↑ 6.0 6.1 Paulson A, Vargus-Adams J. Overview of four functional classification systems commonly used in cerebral palsy. Children. 2017 Apr 24;4(4):30.
  7. ↑ 7.0 7.1 Harb A, Kishner S. Modified ashworth scale. InStatPearls [Internet] 2021 May 9. StatPearls Publishing. Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/),
  8. ↑ 8.0 8.1 8.2 Glinsky J. Tardieu Scale. J Physiother. 2016 Oct;62(4):229
  9. ↑ 9.0 9.1 Shipman S, Helfand M, Nygren P, et al. Screening for Developmental Dysplasia of the Hip [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Mar. (Evidence Syntheses, No. 42.) 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK33426/
  10. ↑ Eskay, K. Cerebral Palsy General Assessment and Interventions. Plus. 2022
  11. ↑ nabil ebraheim. Barlow & Ortolani test, Congenital Hip Dislocation- Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=imhI6PLtGLc [last accessed 30/11/2022]
  12. ↑ Texas Children’s Hospital. TCH Ortho - Hip. Available from: https://www.youtube.com/watch?v=Qn-bWuvm0Pk [last accessed 30/11/2022]
  13. ↑ Costi S, Mecugni D, Beccani L, Alboresi S, Bressi B, Paltrinieri S, Ferrari A, Pelosin E. Construct validity of the activities scale for kids performance in children with cerebral palsy: brief report. Developmental Neurorehabilitation. 2020 Oct 2;23(7):474-7.
  14. ↑ Haley, S.M., Coster, W.J., Kao, Y.C., Dumas, H.M., Fragala-Pinkham, M.A., Kramer, J.M., Ludlow, L.H. and Moed, R., 2010. Lessons from use of the pediatric evaluation of disability inventory (pedi): Where do we go from here?. Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association, 22(1), p.69.
  15. ↑ Wong V, Wong S, Chan K, Wong W. Functional independence measure (WeeFIM) for Chinese children: Hong Kong cohort. Pediatrics. 2002 Feb;109(2):e36-.
  16. ↑ Seek Freaks: Top 9 Functional Balance Tests for School-Based PTs. 2018. Available from: https://www.seekfreaks.com/index.php/2015/12/19/resource-top-9-functional-balance-tests-for-school-based-pts/
Retrieved from "https://www.physio-pedia.com/index.php?title=Cerebral_Palsy_General_Assessment&oldid=343845"