Cerebral Palsy General Assessment

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

Introduction

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.

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:

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

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. In 2017, Novak et al. 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)"
• 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)"

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. It is, therefore, useful for the early detection of CP in high risk groups.

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.

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.

The Gross Motor Function Classification System

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.

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.

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.

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.

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).

The following table from Paulson et al. (2017) 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

Spasticity Tests

Modified Ashworth Scale

The most universally accepted tool to measure increases in muscle tone is the Modified Ashworth scale. As detailed in Harb and Kishner, 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

Tardieu Scale

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. A passive stretch is applied to a muscle group at two velocities:

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’

Hip Tests

Barlow and Ortolani Manoeuvres

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

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

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.

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

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.

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.

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).

Functional Balance Tests

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

Resources

• Functional Independence Measure for Children

• Cerebral Palsy Aetiology and Pathology
• 10 Metre Walk Test
• 6 Minute Walk Test
• Timed Up and Go Test
• Pediatric Balance Scale
• CanChild