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

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (8/11/2023)

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, based on motor type and the distribution of cerebral palsy.

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 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
  • 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 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

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, 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 full 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 clilnical 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 flexion 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’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”.

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 palpable click considered is a positive Ortolani sign
• Galeazzi Sign
  • 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