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 a non-progressive neuromotor disorder. The primarily impairments secondary to CP include movement, muscle tone and posture along with a range of secondary conditions over time which may affect functional abilities. Injury to the developing brain in the prenatal through neonatal period is the underlying pathophysiology for CP.

General Diagnosis

In the peadiatric practice setting, it is difficult to make a certain diagnosis of CP during the first 1-2 years of life. During this time period, delays in development could be part of a normal variation and may resolve. Therefore, a more reliable diagnosis is made after 2 years of age based on clinical findings typically:

• failure to attain certain key milestones at an expected age
• persistence of primitive reflexes or
• primary motor patterns beyond the expected age

Despite a definitive diagnosis being made after the age of 2, a diagnosis can be made for "high risk of CP" prior to this age. This risk category requires motor dysfunction and either and clinical history indicating risk of CP and/or MRI scan abnormality. Novak et al., (2017)proposed ways to predict CP in low birth weight infants:

• infants ≤5 months corrected age: 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)
• infants ≥6 months corrected age: MRI (86–89% sensitivity), the Hammersmith Infant Neurological Examination (90% sensitivity), and the Developmental Assessment of Young Children (83% C index)

Specific Tests

The General Movements Assessment

The General Movements Assessment is utilised on infants from birth to 20 weeks to observe movement. A clinician observes a 3-5 minute video of the child's movement making an assessment using a standarised method. This test has shown to have high specificity and sensitivity for predicting cerebral palsy.

The Gross Motor Function Classification System

The Gross Motor Function Classification System (GMFCS) is utilised on children 2-18 years old to describe gross motor function especially the ability to walk. Gross motor function is delineated by movements requiring assisted devices as well as self-initiated movements.

The Hammersmith Infant Neurological Examination

The Hammersmith Infant Neurological Examination is utilised for infants from 2 months to 2 years to provide a framework for monitoring and identifying deviation from normal development. This test has shown to high specificity and sensitivity for predicting cerebral palsy.

Manual Ability Classification System (MACS)

The Manual Ability Classification System (MACS) details the typical use of upper extremities and both hands for children 4-18 years.

The Communication Function Classification System (CFCS)

The Communication Function Classification System (CFCS) is utilised for persons with CP to report on their daily routine communication (receiving or sending a message). Communication for this test include eye gaze, pictures, speech generating devices, vocalisations and communication boards.

Eating and Drinking Ability Classification System (EDACS)

The Eating and Drinking Ability Classification System (EDACS) is utilised on children 3 years and older and reports on their eating and drinking function. More specifically, this test assessed for eating and drinking efficiency and safety (risk for aspiration or chocking).

Patel et al., (2020) incorporated the four above tests into a table to demonstrate how each classifies CP:

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

Spasticity Tests

Modified Ashworth

The most universally accepted tool to measure increase in muscle tone is the modified Ashworth scale. Grading of spasticity follows the below scale:

• 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

Tardieu Scale

The Tardieu Scale is another tool used to measure spasticity. This scale assesses resistance to passive movement at a fast and slow velocity. This test allows to broadly differentiate between two key components explaining increased resistance to passive stretch: non-neural factors like contracture and neural factors such as spasticity. A passive stretch is applied to a muscle group with two velocities:

1. first stretch is 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 37 movement’ and 5 indicating that ‘the joint is immobile’

Hip Tests

Barlow and Ortoloni Manoeuvres

The Barlow and Ortoloni manoeuvres are two provocations:

1. Barlow: identifies a dislocated hip by adducting a flexed hip using a gentle posterior force
2. Ortolani: attempts to relocate a dislocated hip by abduction of a flexed hip with a gentle anterior force

Galeazzi sign

The Galeazzi sign is used when you are looking for instability, dislocation or anterior translation of the hip. The child is lying supine with their legs in hooklying and the clinician looks for asymmetry in knee height. If one knee is lower than the other, that would be a positive sign for that hip joint.

Treatment

While cerebral palsy is a non-progressive disorder, it is often accompanied by comorbidities and secondary complications. Improving functional ability and independence of these secondary issue is the aim of CP management. The most common challenges in CP include spasticity, pain, swallowing, nutrition, dystonia and hip surveillance. An individual with CP may work with a multidisciplinary team including:

• physical therapists,
• occupational therapists
• orthopaedic surgeons
• audiologist
• medical social worker
• nurse
• pediatric neurologist
• speech-language therapist
• special educator
• pediatrician
• pediatric pulmonologist
• nutritionist
• pediatric gastroenterologist
• and the use of assistive technology

Spasticity

Spastic muscles and dystonia leading to difficulties in coordination, strength and selective motor control are the most common movement disorders seen in CP. Spasticity causes joint and bone deformity, functional loss and pain, and is the prime challenge in managing CP. A multi-factoral approach is used to combat spasticity including pharmacotherapy, physiotherapy or surgical interventions.

Pharmacology

The common medications used for spasticity include baclofen, diazepam, clonazepam, dantrolene an tizanidine. These medications target general spasticity.

Botulinum Toxin

To combat focal spasticity, botulinum toxin (botox) is one of the basic therapies used intramuscularly. Decreased spasticity can last from 3-8 months. During this time, rehabilitation is needed to make full use of the reduced spasticity. The effects of botox include increased passive and active motion, reduced discomfort and pain related to muscle tension and facilitates posture correction.Optimal effectiveness has been show between the ages of1-6 for lower extremity spasticity and between 5-15 for spastic hemiplegia.

Surgeries

Selective dorsal rhizotomy is a surgical procedure that reducing spasticity that impairs gait by improving ankle joint junctions. This procedure improves individuals with CP range of movement and walking ability.

Other surgical management for CP children include:

• lengthening of the soft tissues such as adductors and hamstrings

• multilevel surgery of the ankle and foot
• nerve blocks
• tendon transfer
• joint stabilisations

Management of Hand Dysfunction

Individuals with CP may have disturbances in hand function which could be bilateral or unilateral.Two common hand function techniques are constraint-induced movement therapy and hand-arm intensive bimanual therapy.

Constraint-Induced Movement Therapy

Constraint-Induced Movement Therapy (CIMT) is based on the principle to intensively use the affected hand and not use the unaffected hand. Research has shown that CIMT is effective to improve hand function, however, its effect on muscle tone has not be determined.

Hand-arm intensive bimanual therapy

Hand-arm intensive bimanual therapy is another technique used to improve hand function by using both hands. Hand-arm intensive bimanual therapy is more tolerable than CIMT.

Management of Hip and Ankle Deformities

Hip dislocation, subluxation and other related problems are common disorders in children with CP. It is recommended to screen for cases of hip deformities using a hip surveillance program.

Surgically managed hip disorders include reconstructive procedures such as osteotomy and arthroplasty.

To improve ankle range of motion orthotic devices can help improve gait. Ankle foot orthosis (AFOs) can help children with spastic CP reduce energy expenditure by improving ankle range of motion.

Physiotherapy

Research has shown that children with CP can benefit from physiotherapy by:

• improving local muscular endurance: low resistance, high repetition exercises of major muscle groups
• preventing joint contractures: passive gentle range of motion exercises and stretches across major joints
• increase muscle strength: increasing resistive exercises progressively through all major muscle groups

In addition, physiotherapy can help improve balance, postural control, gait and assist with mobility and transfers.

Occupational Therapy

Occupational therapy (OT) is an essential component of the rehabilitation team to help improve fine motor function of the upper extremities. Additionally, OTs can provide adaptive equipment for learning and self-care to help with information processing and attention.

** Physiotherapy and occupational therapy have been shown to be more effective in ages 4-5 rather than a later age.

Summary of CP Interventions

Novak et al., (2013) described systematically the best available intervention evidence for children with cerebral palsy. They placed their findings into green light (interventions shown to be effective), yellow light (had either lower-level evidence supporting their effectiveness or inconclusive evidence) or red light (shown to be ineffective).

Green Light Interventions

1. botulinum toxin (BoNT), diazepam, and selective dorsal rhizotomy for reducing muscle spasticity
2. casting for improving and maintaining ankle range of motion
3. hip surveillance for maintaining hip joint integrity
4. constraint-induced movement therapy, bimanual training, context-focused therapy, goal-directed/functional training, occupational therapy following BoNT, and home programmes for improving motor activity performance and/or self-care;
5. fitness training for improving fitness
6. bisphosphonates for improving bone density
7. pressure care for reducing the risk of pressure ulcers
8. anticonvulsants for managing seizures

Yellow Light Interventions

1. acupuncture
2. alcohol (intramuscular injections for spasticity reduction)
3. AAC; animal-assisted therapy; assistive technology
4. baclofen (oral)
5. hippotherapy
6. cognitive behaviour therapy
7. communication training
8. conductive education
9. dysphagia management
10. early intervention (for motor outcomes)
11. electrical stimulation

Red Light Interventions

1. craniosacral therapy
2. hip bracing
3. hyperbaric oxygen
4. neurodevelopmental therapy
5. sensory integration

Resources

• Functional Independence Measure for Children

• Cerebral Palsy Aetiology and Pathology
• 10 Metre Walk Test
• 6 Minute Walk Test
• Timed Up and Go Test
• Pediatric Balance Scale
• CanChild