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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 an early-onset, lifelong neurodevelopmental condition. Impaired movement and posture, often caused by altered muscle tone (spasticity, dystonia, choreoathetosis, or ataxia) lead to activity limitations. CP is caused by injury to, or malformation of, the fetal/infant brain. It is not a degenerative condition, but the clinical and functional manifestations of CP change with age. CP is complex and heterogeneous, with each person presenting differently. It is also associated with a range of primary and secondary impairments, all of which can affect participation in daily life.[1]

The full, updated definition of CP is available here: Updated description of cerebral palsy.

General Diagnosis

In paediatric practice, it has traditionally been difficult to make a definitive diagnosis of CP during the first 1-2 years of life. During this period, delays in development can be part of normal variation and may resolve. A more reliable diagnosis was traditionally made after 2 years of age based on clinical findings, which typically include a failure to attain certain key milestones at an expected age, and persistence of primitive reflexes or primary motor patterns beyond the expected age.[2]

However, current guidelines support earlier diagnosis. A diagnosis for "high risk for CP" can be made before the age of 2 years. This designation requires motor dysfunction and either a clinical history indicating a risk of CP or signs of an abnormality on MRI.[2]

In 2017, Novak et al.[3] proposed tools to predict CP in infants. For infants before 5 months corrected age, recommended assessments include 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).[3] For infants after 5 months corrected age, recommended assessments include MRI (86%-89% sensitivity), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index)"[3]

Despite international consensus on these assessment tools, their integration into routine clinical practice remains inconsistent, and early diagnosis is an ongoing challenge.[4]

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.[5] It is, therefore, useful for the early detection of CP in high risk groups.[5]

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.[6]

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.[7]

The Gross Motor Function Classification System

The Gross Motor Function Classification System (GMFCS) is used on children and young people up to 18 years, with age-specific descriptors. It describes 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.[2]

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.[5]

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.[2]

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.[2]

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).[2]

The following table from Paulson et al. (2017)[8] 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

[8]

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,[9] 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[9]

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.[10] A passive stretch is applied to a muscle group at two velocities[10]:

  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’[10]

Hip Tests

Barlow and Ortolani Manoeuvres

Barlow Test: identifies a dislocated hip by adducting a flexed hip using a gentle posterior force.[11]

Ortolani Test: attempts to relocate a dislocated hip by abduction of a flexed hip with a gentle anterior force.[11]

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.[12]

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

[13]
[14]

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.[15]

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.[16]

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).[17]

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[18]

Resources

References

  1. ↑ Dan B, Rosenbaum P, Carr L, Gough M, Coughlan J, Nweke N. Updated description of cerebral palsy. Dev Med Child Neurol. 2026 Jan 29.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Patel DR, Neelakantan M, Pandher K, Merrick J. Cerebral palsy in children: a clinical overview. Translational pediatrics. 2020 Feb;9(Suppl 1):S125.
  3. ↑ 3.0 3.1 3.2 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.
  4. ↑ Hidalgo-Robles Á, Merino-Andrés J, Cisse MRS, Pacheco-Molero M, León-Estrada I, Gutiérrez-Ortega M. The pathway is clear but the road remains unpaved: a scoping review of implementation of tools for early detection of cerebral palsy. Children (Basel). 2025 Jul 17;12(7):941.
  5. ↑ 5.0 5.1 5.2 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.
  6. ↑ 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.
  7. ↑ Russell DJ, Rosenbaum P, Wright M, Avery LM. Gross motor function measure (GMFM-66 & GMFM-88) users manual. Mac keith press; 2002.
  8. ↑ 8.0 8.1 Paulson A, Vargus-Adams J. Overview of four functional classification systems commonly used in cerebral palsy. Children. 2017 Apr 24;4(4):30.
  9. ↑ 9.0 9.1 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/),
  10. ↑ 10.0 10.1 10.2 Glinsky J. Tardieu Scale. J Physiother. 2016 Oct;62(4):229
  11. ↑ 11.0 11.1 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/
  12. ↑ Eskay, K. Cerebral Palsy General Assessment and Interventions. Plus. 2022
  13. ↑ 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]
  14. ↑ Texas Children’s Hospital. TCH Ortho - Hip. Available from: https://www.youtube.com/watch?v=Qn-bWuvm0Pk [last accessed 30/11/2022]
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ Wong V, Wong S, Chan K, Wong W. Functional independence measure (WeeFIM) for Chinese children: Hong Kong cohort. Pediatrics. 2002 Feb;109(2):e36-.
  18. ↑ 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/
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