High Functioning Cerebral Palsy Physiotherapy Assessment and Intervention

Original Editor - Jess Bell based on the course by Dana Mather
Top Contributors - Jess Bell

Introduction

Cerebral palsy (CP) is a heterogeneous non-progressive neuromotor disorder that affects movement and posture. Primary impairments associated with cerebral palsy include spasticity, weakness, decreased motor control and movement dysfunction. Cerebral palsy can also lead to a number of secondary musculoskeletal conditions, which can also affect functional ability.

Gross Motor Function Classification System (GMFCS)

The Gross Motor Function Classification System (GMFCS) is a valid and reliable system that classifies children with cerebral palsy aged 2-18 years based on their gross motor function.

It is a 5-point ordinal scale that describes a child’s self-initiated movements and use of assistive devices for mobility.

The levels are as follows:

• Level I: able to walk without limitations
• Level II: can walk with limitations (e.g. balance, endurance limitations)
• Level III: can walk using a hand-held mobility device (may use additional support, such as wheeled mobility, for longer distances, outdoors)
• Level IV: self-mobility is limited - may be transported in a manual wheelchair or may use powered mobility
• Level V: transported in a manual wheelchair

Reid et al. note that a child classified as Level I will be able to perform the same activities as their peers, but their speed, balance or coordination may be impacted. However, a child classified as Level V will have difficulty achieving voluntary control of movement, and their head/trunk control is affected in many positions.

This page focuses on the assessment and management of children with a GMFCS of Level 1. For information on children with a GMFCS of Level 5, please see: Low Functioning Cerebral Palsy Physiotherapy Assessment and Intervention.

Assessment

The physical examination of a child with cerebral palsy needs to be systematic. There are several tests and outcome measures that rehabilitation professionals may use, which are discussed here: Cerebral Palsy General Assessment.

During a clinical assessment, we want to gain an understanding of the child’s medical, surgical, medication and developmental history, the child’s / caregivers’ chief concerns, as well as the child’s cognitive and behavioural status, functional mobility, family and environmental conditions and any assistive devices.

Essential components of the clinical examination include the following areas.

Postural Evaluation

In children with cerebral palsy, movement and posture can be affected by muscle tone, weakness, poor selective motor control, muscle imbalance, balance problems, etc. We, therefore, need to assess a child's posture in various positions, including prone, supine, sitting, standing, and walking. Variations in these postures may provide insights into underlying musculoskeletal imbalances or functional limitations.

Joint Range of Motion Assessment

Range of motion must be regularly assessed in children with cerebral palsy. For more information on assessing range of motion, please see: Assessing Range of Motion.

It is important to note that children with spastic cerebral palsy often develop torsional conditions of the hip, shank or foot. Torsional conditions in the lower extremity can affect function, causing issues such as in-toeing or out-toeing gait and decreased energy efficiency when walking.

A rotational assessment of the lower limbs is, therefore, important,  including:

• hip internal/external rotation
• degree of femoral ante/retro version
• degree of tibial torsion, sub-talar inversion/eversion
• mid-tarsal abduction and adduction

Understanding a child's torsional profile aids in orthotic prescription. For more information on torsional conditions, please see: Paediatric Lower Extremity Torsional Conditions.

Muscle Tone Assessment

As mentioned above, children with cerebral palsy often present with altered muscle tone. We must, therefore, regularly assess muscle tone.

• Spasticity is defined as "a clinical phenomenon in which muscles overreact to passive stretch due to lack of supraspinal inhibition, and [it] is detected clinically as a velocity-dependent increase in tone."
• Hypotonia is an "abnormal lack of muscle tone".
• Spasticity and hypotonia must be considered together, as both contribute to imbalance around joints and muscle imbalance.

There are a number of well-established tools that are used to assess muscle tone, including the Ashworth Scale, Tardieu Scale and the Modified Tardieu Scale. Please follow the linked texts if you want to find out more about these scales.

Muscle Strength Evaluation

Muscle weakness is common in children with cerebral palsy, and it can significantly impact function.

• Children with cerebral palsy tend to have shorter, smaller muscles, which are stiff and weak because of:
  • decreased fibre diameter
  • fewer but longer sarcomeres
  • hypertrophied extracellular matrix
  • immature myosin
  • up to 70% fewer satellite cells
• Their muscles tend to grow slower than their neighbouring long bones. This causes the muscle-tendon units to shorten. The antagonist muscles may lengthen to accommodate the shorter muscles, resulting in muscle imbalance around the joint.

In clinical practice, the Oxford Scale (also known as the Medical Research Council Scale (MRCS)) is usually used for manual muscle testing. In cases where a more detailed quantification of muscle strength is needed, clinicians might use hand-held dynamometers if available.

For information on how to assess muscle strength, please see: Assessing Muscle Strength.

Balance Assessment

In children with a GMFCS of Level 1, it is important to make sure the balance assessment is sufficiently challenging and fun. Assess static and dynamic balance, and consider using tools such as a mock balance beam in your assessment.

Functional balance tests include:

• Pediatric Balance Scale
• Timed Up and Go
• Timed Floor to Stand
• Five Times Sit to Stand
• Pediatric Reach Test

Gait Assessment

Assess gait with and without orthotics in a transverse, coronal and sagittal plane. Peterson et al. suggest that the following questions are considered during a gait assessment in individuals with cerebral palsy:

• What is the walking velocity?
• Is their gait symmetrical? (look at features such as stance duration, difference in movement between sides)
• Is the child using a walking aid?
• Does the child have a typical arm swing?

To check for the child’s rotation profile, assess gait in the transverse plane and consider:

• Is the child’s foot progression angle neutral, internal or external
• Is the patellar progression angle neutral, internal or external

In the coronal plane, consider:

• Is there a coronal sway?
• Are the child’s shoulders / trunk moving up / down during the swing phase?

In the sagittal plane, consider:

• What part of the foot is making initial contact?
• Is the knee extended in terminal stance?
• Does the ankle dorsiflex during the swing phase? 

Endurance

There are a number of objective measures to assess endurance, including:

• 10-metre walk test
• One-minute walk test
• Six-minute walk test
• 10-minute walk test
• 600-yard walk and run test
• Six-minute push test

Skin Assessment

When working with children with cerebral palsy, it is important to regularly check their skin in areas where there may be increased pressure (e.g. around orthotics or areas of restriction).

Participation Assessment

When assessing children with cerebral palsy, we must also consider participation restrictions. Specific measures that can be helpful include:

• Activity Scale for Kids (ASK)
• Pediatric Evaluation of Disability Inventory (PEDI)
• WeeFIM (Functional Independence Measure for Children)

Interventions

Your assessment findings will always guide your intervention. When selecting an intervention for children with cerebral palsy, we should choose active interventions (e.g. active movements rather than passive stretching). Interventions should be goal- and task-oriented and focus on the contexts in which a child will be playing and working.

When working with children, interventions will ideally be fun and engaging. Play is often incorporated into rehabilitation for children as it provides opportunities for them to learn about their body and the environment. It also supports multiple developmental domains: motor, social-emotional, language, cognition and adaptive behaviour. If you would like to learn more about therapeutic play, please see: Therapeutic Play.

Evidence-based Interventions

In 2020, Novak et al. published an updated systematic review of available interventions for children with cerebral palsy. They used a traffic light system to indicate which treatments have demonstrated evidence and which need more research.

Green light allied health interventions:

• acceptance and commitment therapy
• action observations
• serial casting
• constraint-induced movement therapy (CIMT)
  • CIMT aims to improve the function of the affected upper limb by restricting use of the unaffected / less affected side
• environmental enrichment
• fitness training
• goal-directed training (to improve gross motor skills)
• hippotherapy (to increase symmetry)
• home programmes
• literacy interventions
• mobility training
• oral sensorimotor
• oral sensorimotor plus electrical stimulation
• pressure care
• stepping stones triple P (to help with behaviour)
• strength training
• task-specific training
• treadmill training (partial body weight supported treadmill training and weight-bearing)

"In stark contrast, bottom-up, generic, and/or passive motor interventions are less effective and sometimes clearly ineffective for improving function and movement for children with cerebral palsy. These include craniosacral therapy, hyperbaric oxygen, neurodevelopmental therapy in the original passive format, and sensory integration (red lights)."

Another review on neurodevelopmental therapy (also known as Bobath therapy) by Te Velde et al. is also available: Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis.

Green light medical, surgical, pharmacological, and regenerative therapy interventions include, but are not limited to:

• botulinum toxin
• botulinum toxin plus occupational therapy
• botulinum toxin plus casting (to increase range of motion)
• selective dorsal rhizotomy
• scoliosis correction
• hip surveillance

For more information, please see: State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy for a full list of medical, surgical, pharmacological and regenerative therapy interventions.

Specific Exercises

The following table suggests some play-based and functional exercises for children with high-functioning cerebral palsy.

Type of Exercise	Exercise
Strengthening exercises	Bridge (ask the child to roll a ball under their body while in the bridge position to maintain the position for longer) Clam (use a ball or other toy as a target to achieve the intended range) Snow angels (i.e. hip abduction) Sitting on exercise ball (core)
Balance exercises	Mock balance beam Wobble board Sitting on an exercise ball
Functional / play-based exercises	Sliding Swinging (improves core strength) Monkey bars (upper limb strength) Riding a tricycle (reciprocal movement) Throwing games focusing on the more affected arm - e.g. throw a ball in a sock (upper limb strength, coordination) Climbing frames at a playground (motor planning, strength) Jumping games (motor coordination, strength) Wobbly bridge at a playground (balance)