Low Functioning Cerebral Palsy Physiotherapy Assessment and Intervention

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

Introduction

Cerebral palsy (CP) is a heterogeneous, non-progressive neuromotor disorder in an immature brain 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.

Children with cerebral palsy all present differently. Their mobility varies from walking without aids to using a wheelchair at all times. There are various diagnostic sub-types, which are related to motor type and distribution.

Types of cerebral palsy:

• Spastic cerebral palsy
  • most common type and most amenable to treatment
  • there are five types of spastic cerebral palsy:
    • diplegia - either both arms or both legs are affected (most commonly, both legs are affected)
    • hemiplegia or hemiparesis - affects the limbs on one side of the body
    • quadriplegia or quadriparesis - all four limbs are affected
    • monoplegia - only one limb is affected (extremely rare)
    • triplegia - three limbs are affected
• Dyskinetic cerebral palsy
  • involves injury to the basal ganglia
  • children have impaired movement control, muscle tone and coordination
• Ataxic cerebral palsy
  • least common form of cerebral palsy
  • children present with incoordination of goal-directed movements

The distribution of cerebral palsy can be unilateral or bilateral.

For more information on the types of cerebral palsy, please see: Cerebral Palsy Aetiology and Pathology.

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 V will have difficulty achieving voluntary control of movement, and their head/trunk control is affected in many positions.

This page focuses on some of the key physiotherapy assessments for children with a GMFCS of Level 5 and offers some ideas for interventions. For information on the physiotherapy assessment and management of high-functioning cerebral palsy, please see: High Functioning Cerebral Palsy Physiotherapy Assessment and Intervention.

Assessment

The physical examination of a child with cerebral palsy needs to be systematic. During the clinical assessment, we want to gain an understanding of each 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.

Common outcome measures that are used to assess children with cerebral palsy are discussed here, and key parts of the physiotherapy assessment are discussed below.

Range of Motion

It is essential to assess range of motion in the unaffected and affected joints, always comparing sides. More information on performing the range of motion assessment is available here.

Muscle Strength

Children with cerebral palsy often present with weakness, so it is essential to assess their strength. To find out about assessing strength, please see: Assessing Muscle Strength.

Muscle Length

Muscle length refers to the ability of a muscle crossing a joint or joints to lengthen, thus allowing the joint or joints to move through their available range of motion. A muscle's ability to lengthen is essential for functional activities, and it can be affected by changes in muscle tone. For more information on muscle length, please see: Assessing Muscle Length.

Muscle Tone

Key definitions related to muscle tone:

• Spasticity: "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: "abnormal lack of muscle tone".
• Spasticity and hypotonia must be considered together, as both contribute to imbalance around joints and muscle imbalance.

“Muscle tone is a complex and dynamic state, resulting from hierarchical and reciprocal anatomical connectivity.”

Traditional definitions include: “the tension in the relaxed muscle” or “the resistance, felt by the examiner during passive stretching of a joint when the muscles are at rest”. These definitions have some ambiguities, but as Ganguly et al. note, tone is essentially “a construct of motor control, upon which power is intrinsically balanced.”

Children with cerebral palsy often present with altered muscle tone, so it forms a key component of the assessment. The Modified Ashworth Scale is the “most universally accepted clinical tool” used to assess increases in muscle tone.

To measure muscle tone using the Modified Ashworth Scale:

• Patient lies prone
• A muscle that is primarily involved in flexing a joint is placed in maximal flexion and passively moved to maximal extension over a one-second count
• A muscle that is primarily involved in extending a joint is placed in maximal extension and passively moved to maximal flexion over a one-second count

The Modified Ashworth Scale is scored as follows:

Modified Ashworth Score

o	"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"

Other scales used to assess tone include the Tardieu Scale and the Modified Tardieu Scale.

Hip Surveillance

Hip dislocation, subluxation and other related problems are common in children with cerebral palsy. Nokak et al. note that one in three children in high-resource settings have progressive hip displacement associated with their cerebral palsy. Therefore, if a child reports hip pain during their assessment, it is important to check their hips and refer them on for further review.

“There is moderate-quality evidence and a strong recommendation to use comprehensive hip surveillance practices to facilitate early detection and management of hip displacement”.

Specific hip tests include:

• Barlow Test
  • aims to detect a dislocated hip by adducting the hip with a gentle posterior force
• Ortolani Test
  • aims to relocate a dislocated hip by abducting the hip with a gentle posterior force
  • a positive Ortolani sign = a palpable click
• Galeazzi Sign
  • the child is positioned in hook lying with their hips and knees bent and their feet flat on the surface
  • the therapist compares the height of the knees
  • a positive Galeazzi sign = one knee is higher than the other
  • this suggests that there is instability, a dislocation, or an anterior translation of the hip socket on the lower side

Positioning

Children with cerebral palsy often need external postural support in different positions to enhance participation and prevent secondary complications. When assessing positioning, consider the following questions:

• Is the child's position symmetrical?
• Is the child well-aligned?  
• Is the child comfortable?
• Is the child stable, but able to move?

Please note that positions should be frequently changed to help prevent pressure areas, stiffness and contractures and to allow the child to experience movement in different positions.

For more information on positioning, please see: Positioning the Child with Cerebral Palsy.

Interventions

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 they should be fun and engaging.

Children learn best in an environment which provides discovery, exploration and play. 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, including motor, social-emotional, language, cognition and adaptive behaviour. To learn more about therapeutic play for children with higher GMFCS levels, please see: Therapeutic Play for the Severely Disabled Population.

Positioning

A range of equipment is used to help children with cerebral palsy maintain a stable, symmetrical posture when lying, sitting or standing.

Lying: aim for a range of positions (supine, side lying, prone), and encourage children to move around freely. Equipment might include cushions, wedges, foam rolls and towels.

Sitting: It is important to choose the right chair and adapt it to a child’s needs. This will help them maintain a stable, symmetrical sitting posture, with their hands free for play, feeding, communication and learning. Using adaptive seating can help a child develop motor skills, facilitate arm and hand mobility, self-feeding, visual scanning and tracking and reduce the need for assistance from caregivers. As shown in the images below, there are many different adaptive seating options.

• 

  corner chair

• 

  bolster chair

• 

  sensory cushion

• 

  swiss ball chair

• 

  adaptive swing

When choosing a chair, seating guidelines typically recommend the following:

• feet resting on the floor
• ankles dorsiflexed to 90 degrees
• knees flexed 90 degrees
• hips flexed 90 degrees
• hips well back in the chair
• if applicable, both arms resting comfortably on the desk without causing the shoulders to elevate / shrug

Wheelchairs: should be adapted to ensure comfort. Wheelchairs can be adapted with cushions, power tilt, recline, elevating leg rests, elevating seating and back/trunk supports.

For more information, please see: Adaptive Seating for Children.

Standing: has a number of benefits for non-ambulatory children, including:

• improvements in bone mineral density
• improved bowel function
• increased independence, participation and social function

A lack of independent standing has been shown to increase the risk of hip dislocations, osteopenia, and lower extremity contractures. It can also impact gastrointestinal and respiratory health. Using standers has been linked to a reduction in pain, contractures and hip dislocations.

Types of standers include:

• prone standers
• sit-to-stand standers
• dynamic standers
• box standers
• multiposition standers

For more information, please see: Standers.

Other types of equipment that can be used for therapy include:

• exercise balls: the child can use their belly to support themselves on the ball. This often requires moderate to maximum assistance from the therapist.
• rody toys: can be used to facilitate head control weight-bearing through the lower extremities, reaching and upper limb activities.