Low Functioning Cerebral Palsy Physiotherapy Assessment and Intervention: Difference between revisions
No edit summary |
No edit summary |
||
Line 47: | Line 47: | ||
== Assessment == | == Assessment == | ||
The physical examination of a child with cerebral palsy needs to be systematic.<ref name=":2" /> 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.<ref>Eskay K. Cerebral Palsy General Assessment and Interventions Course. Plus, 2022.</ref> | The physical examination of a child with cerebral palsy needs to be systematic.<ref name=":2" /> 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.<ref name=":4">Eskay K. Cerebral Palsy General Assessment and Interventions Course. Plus, 2022.</ref> | ||
Common outcome measures that are used to assess children with cerebral palsy are discussed [[Cerebral Palsy General Assessment|here]] and key parts of the physiotherapy assessment are discussed below. | Common outcome measures that are used to assess children with cerebral palsy are discussed [[Cerebral Palsy General Assessment|here]] and key parts of the physiotherapy assessment are discussed below. | ||
Line 69: | Line 69: | ||
<blockquote>“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”<ref name=":3">Ganguly J, Kulshreshtha D, Almotiri M, Jog M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8071570/ Muscle Tone Physiology and Abnormalities]. Toxins (Basel). 2021 Apr 16;13(4):282. </ref></blockquote>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.”<ref name=":3" /> | <blockquote>“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”<ref name=":3">Ganguly J, Kulshreshtha D, Almotiri M, Jog M. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8071570/ Muscle Tone Physiology and Abnormalities]. Toxins (Basel). 2021 Apr 16;13(4):282. </ref></blockquote>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.”<ref name=":3" /> | ||
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 clilnical tool” used to assess increases in muscle tone.<ref>Harb A, Kishner S. Modified Ashworth Scale. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554572/</ref> | 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 clilnical tool” used to assess increases in muscle tone.<ref name=":5">Harb A, Kishner S. Modified Ashworth Scale. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554572/</ref> | ||
To measure muscle tone using the Modified Ashworth Scale:<ref>Shirley Ryan Abilitylab. Modified Ashworth Scale Instructions. Available from: https://www.sralab.org/sites/default/files/2017-06/Modified%20Ashworth%20Scale%20Instructions.pdf (last accessed 8 November 2023).</ref> | |||
* 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 flexion and passively moved to maximal flexion over a one-second count | |||
The Modified Ashworth Scale is scored as follows: | |||
{| class="wikitable" | |||
|+Modified Ashworth Score<ref name=":5" /> | |||
!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.<ref name=":4" /> Nokak et al.<ref name=":6">Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035308/ State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy]. Curr Neurol Neurosci Rep. 2020 Feb 21;20(2):3.</ref> 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’s important to check their hips and refer for hip surveillance.<blockquote>“There is moderate-quality evidence and a strong recommendation to use comprehensive hip surveillance practices to facilitate early detection and management of hip displacement”.<ref name=":6" /></blockquote>Specific hip tests include: | |||
* Barlow Test | |||
** aims to detect a dislocated hip by adducting the hip with a gentle posterior force<ref name=":7">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> | |||
* Ortolani Test | |||
** aims to relocate a dislocated hip by abducting the hip with a gentle posterior force<ref name=":7" /> | |||
** a palpable click considered is a positive Ortolani sign<ref name=":4" /> | |||
* Galeazzi Sign<ref name=":4" /> | |||
** The child is positioned in hooklying with their hips and knees bent and their feet flat on the surface | |||
** The therapist compares knee height | |||
** The Galeazzi sign is positive if one knee is higher than the other | |||
** This indicates that there is instability, a dislocation, or an anterior translation of that hip socket on the lower side | |||
** Valid across all ages | |||
== References == | == References == |
Revision as of 09:50, 8 November 2023
Top Contributors - Jess Bell and Kim Jackson
Introduction[edit | edit source]
Cerebral palsy (CP) is a heterogeneous non-progressive neuromotor disorder in an immature brain that affects movement and posture.[1] Primary impairments associated with cerebral palsy include spasticity, weakness, decreased motor control and movement dysfunction.[2] Cerebral palsy can also lead to a number of secondary musculoskeletal conditions, which can also affect functional ability.[2]
Children with cerebral palsy all present differently. Their mobility varies from walking without aids to using a wheelchair at all times.[3] There are various diagnostic sub-types, based on motor type and the distribution of cerebral palsy.
Types of cerebral palsy:[3] [4]
- Spastic cerebral palsy
- most common type and most amenable to treatment[5]
- there are five types of spastic cerebral palsy:[3]
- diplegia - either both arms or both legs are affected (most commonly both legs are affected)
- hemiplegia or hemiparesis - affects the limbs on only 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[6][7]
- involves injury to the basal ganglia
- children have impaired movement control, muscle tone and coordination
- Ataxic cerebral palsy[8][9]
- 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)[edit | edit source]
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.[10]
It is a 5-point ordinal scale[11] that describes a child’s self-initiated movements and use of assistive devices for mobility.[3]
The levels are as follows:[3][12]
- 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.[13] 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 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[edit | edit source]
The physical examination of a child with cerebral palsy needs to be systematic.[1] 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.[14]
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[edit | edit source]
It is essential to assess range of motion in the unaffected and affected joints, comparing sides. More information on performing the range of motion assessment is available here.
Muscle Strength[edit | edit source]
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[edit | edit source]
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 full available range of motion.[15][16] A muscle's ability to lengthen is essential for functional activities,[17] and it can be affected by changes in muscle tone. For more information on muscle length, please see: Assessing Muscle Length.
Muscle Tone[edit | edit source]
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."[1]
- Hypotonia: "abnormal lack of muscle tone".[1]
- Spasticity and hypotonia must be considered together, as both contribute to imbalance around joints and muscle imbalance.[1]
“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”[18]
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.”[18]
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 clilnical tool” used to assess increases in muscle tone.[19]
To measure muscle tone using the Modified Ashworth Scale:[20]
- 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 flexion and passively moved to maximal flexion over a one-second count
The Modified Ashworth Scale is scored as follows:
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[edit | edit source]
Hip dislocation, subluxation and other related problems are common in children with cerebral palsy.[14] Nokak et al.[21] 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’s important to check their hips and refer for hip surveillance.
“There is moderate-quality evidence and a strong recommendation to use comprehensive hip surveillance practices to facilitate early detection and management of hip displacement”.[21]
Specific hip tests include:
- Barlow Test
- aims to detect a dislocated hip by adducting the hip with a gentle posterior force[22]
- Ortolani Test
- Galeazzi Sign[14]
- The child is positioned in hooklying with their hips and knees bent and their feet flat on the surface
- The therapist compares knee height
- The Galeazzi sign is positive if one knee is higher than the other
- This indicates that there is instability, a dislocation, or an anterior translation of that hip socket on the lower side
- Valid across all ages
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 Peterson N, Walton R. Ambulant cerebral palsy. Orthopaedics and Trauma. 2016;30(6):525-38.
- ↑ 2.0 2.1 Sarathy K, Doshi C, Aroojis A. Clinical examination of children with cerebral palsy. Indian J Orthop. 2019 Jan-Feb;53(1):35-44.
- ↑ 3.0 3.1 3.2 3.3 3.4 Mather D. Low Functioning Cerebral Palsy Physiotherapy Assessment and Intervention Course. Plus, 2023. Cite error: Invalid
<ref>
tag; name ":1" defined multiple times with different content - ↑ Paul S, Nahar A, Bhagawati M, Kunwar AJ. A review on recent advances of cerebral palsy. Oxidative Medicine and Cellular Longevity. 2022 Jul 30;2022.
- ↑ Papavasiliou A, Ben-Pazi H, Mastroyianni S, Ortibus E. Cerebral palsy: new developments. Frontiers in Neurology. 2021;12.
- ↑ Eskay K. Cerebral Palsy Aetiology and Pathology Course. Plus, 2023.
- ↑ Li X, Arya K. Athetoid Cerebral Palsy. InStatPearls [Internet] 2021 Sep 28. StatPearls Publishing.
- ↑ Levy JP, Oskoui M, Ng P, Andersen J, Buckley D, Fehlings D, et al. Ataxic-hypotonic cerebral palsy in a cerebral palsy registry: Insights into a distinct subtype. Neurology: Clinical Practice. 2020 Apr 1;10(2):131-9.
- ↑ Eggink HE, Kremer DA, Brouwer OF, Contarino MF, van Egmond ME, Elema AG, et al. Spasticity, dyskinesia and ataxia in cerebral palsy: are we sure we can differentiate them?. European Journal of Paediatric Neurology. 2017 Sep 1;21(5):703-6.
- ↑ Patel DR, Neelakantan M, Pandher K, Merrick J. Cerebral palsy in children: a clinical overview. Transl Pediatr. 2020 Feb;9(Suppl 1):S125-S135.
- ↑ Ko J, Woo J, Her JG. The reliability and concurrent validity of the GMFCS for children with cerebral palsy. Journal of Physical Therapy Science. 2011;23: 255-8.
- ↑ CanChild. Gross Motor Function Classification System - Expanded & Revised. Available from: https://canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded-revised-gmfcs-e-r (last accessed 27 September 2023).
- ↑ Reid SM, Carlin JB, Reddihough DS. Using the Gross Motor Function Classification System to describe patterns of motor severity in cerebral palsy. Developmental Medicine & Child Neurology, 2011 Nov 1;53(11):1007-12.
- ↑ 14.0 14.1 14.2 14.3 Eskay K. Cerebral Palsy General Assessment and Interventions Course. Plus, 2022.
- ↑ Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. FA Davis; 2016 Nov 18.
- ↑ Reese NB, Bandy WD. Joint Range of Motion and Muscle Length Testing-E-book. Elsevier Health Sciences; 2016 Mar 31.
- ↑ Tomalka A. Eccentric muscle contractions: from single muscle fibre to whole muscle mechanics. Pflugers Arch. 2023 Apr;475(4):421-435.
- ↑ 18.0 18.1 Ganguly J, Kulshreshtha D, Almotiri M, Jog M. Muscle Tone Physiology and Abnormalities. Toxins (Basel). 2021 Apr 16;13(4):282.
- ↑ 19.0 19.1 Harb A, Kishner S. Modified Ashworth Scale. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554572/
- ↑ Shirley Ryan Abilitylab. Modified Ashworth Scale Instructions. Available from: https://www.sralab.org/sites/default/files/2017-06/Modified%20Ashworth%20Scale%20Instructions.pdf (last accessed 8 November 2023).
- ↑ 21.0 21.1 Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, et al. State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy. Curr Neurol Neurosci Rep. 2020 Feb 21;20(2):3.
- ↑ 22.0 22.1 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/