Evaluating the Child with Cerebral Palsy: Difference between revisions

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'''Original Editor '''- [[Simon Lalor]] as part of [http://www.physio-pedia.com/ICRC_Cerebral_Palsy_Content_Development_Project#Articles_to_be_Developed ICRC Cerebral Palsy Content Development Project]  
'''Original Editor '''- [[User:User Name|Kim Jackson]] as part of [http://www.physio-pedia.com/ICRC_Cerebral_Palsy_Content_Development_Project#Articles_to_be_Developed ICRC Cerebral Palsy Content Development Project]  


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== Introduction  ==
== Introduction  ==
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Most of the information leading to the diagnosis of cerebral palsy is generally obtained from a thorough medical history and examination. The most critical tasks of the health care professional are to identify potentially treatable causes of a child's impairment. The health care professional evaluating the child with possible cerebral palsy should be experienced in neurological examination and assessment of impaired children and well-versed in the potential causes of cerebral palsy. Often, but not necessarily, this practitioner should be a pediatric neurologist. Once the examination is complete, depending on the findings, the practitioner may order laboratory tests to help in the assessment.&nbsp;
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<span style="font-size: 13px;">There is no single test to diagnose cerebral palsy. But since cerebral palsy is the result of multiple different causes, the tests performed are used to identify specific causes when possible. Other tests will be performed to assess the condition of the child (nutritional status for example) or to assess other concomitant conditions that the child might have.</span><br>


Cerebral Palsy (CP) is a neurodevelopmental disorder marked by non-progressive motor function impairment originating from damage to the developing brain. The complexity of this condition necessitates an integrated rehabilitation approach, encompassing multiple professionals in the field<ref>Novak I, Mcintyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental medicine & child neurology. 2013 Oct;55(10):885-910.</ref>. Knowledge of cerebral palsy and experience of managing neurological is necessary to ensure that treatable causes are identified.  The team usually includes physiotherapists, occupational therapists, speech therapists, nutritionists, paediatricians, orthopaedic surgeons, and neurologists, each playing a distinct yet collaborative role in managing the unique challenges presented by CP.
The manifestations of CP often become clearer over time, meaning that a diagnosis may not be confirmed until several months to a year after birth, or even later in cases with milder symptoms. During this time, the child's growth and development are closely monitored, their medical history is reviewed, and physical examinations are conducted.
== Clinical Assessment  ==
== Clinical Assessment  ==


Evaluation of an ambulant child with CP requires a unified Multi-Disciplinary Team&nbsp;(MDT) often comprising of a medical doctor or paediatrician, rehabilitation&nbsp;consultant, neurologist, orthopaedic consultant, physiotherapist, occupational&nbsp;therapist, clinical scientist and orthotist.&nbsp;<ref name="1">Aneja S. Evaluation of a child with cerebral palsy. Indian J Pediatr. [Review]. 2004 Jul;71(7):627-34.</ref>&nbsp;The MDT needs to have a close working&nbsp;relationship with the parents or caregivers to ensure consent is provided for assessment&nbsp;or for any proposed interventions and to ensure the treatment is incorporated into&nbsp;everyday family life.&nbsp;&nbsp;
The evaluation of a child with CP requires a comprehensive, multidimensional approach to accurately identify and address the individual's specific deficits and needs. The assessment process includes a thorough medical history, physical examination, functional assessment, and often, specialized evaluations<ref>Bartlett DJ, Palisano RJ. Physical therapists' perceptions of factors influencing the acquisition of motor abilities of children with cerebral palsy: implications for clinical reasoning. Physical therapy. 2002 Mar 1;82(3):237-48.</ref>. Importantly, the assessment extends beyond the child to incorporate the family, evaluating their needs and resources, as successful management often relies on family-centered care.&nbsp;
 
Observing the child’s movements is the initial and a crucial part of the examination. Observe before you touch. If the child is young, apprehensive or tearful, let them stay on mother’s lap while you watch and talk to the mother. As the child adapts to the environment, slowly place them on the examination table or on the floor still close to the mother/carer and watch them move around. If the child cries a lot and does not cooperate, continue while they are in their mother’s lap. Tools required for the examination are very simple: toys, small wooden/different shaped blocks, and objects with different textures.<br>


A thorough physical and biomechanical evaluation is necessary to decide the specific&nbsp;joints and segment levels to target any intervention. The physical examination&nbsp;of the child with Cerebral Palsy should evaluate:&nbsp;
Observing the child’s movements is the initial and a crucial part of the examination. Observe before you touch. If the child is young, apprehensive or tearful, let them stay on mother’s lap while you watch and talk to the mother. As the child adapts to the environment, slowly place them on the examination table or on the floor still close to the mother/carer and watch them move around. If the child cries a lot and does not cooperate, continue while they are in their mother’s lap. Tools required for the examination are very simple: toys, small wooden/different shaped blocks, and objects with different textures.


*Posture in Prone Lying, Supine Lying, Sitting, Standing and Walking;
A comprehensive physical and biomechanical evaluation is paramount for a child with cerebral palsy (CP) who is ambulant, as it informs targeted interventions at specific joints and segment levels. Essential components of  the clinical examination should include<ref>Novak I, Morgan C, Adde L, Blackman J, Boyd RN, Brunstrom-Hernandez J, Cioni G, Damiano D, Darrah J, Eliasson AC, De Vries LS. Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment. JAMA pediatrics. 2017 Sep 1;171(9):897-907.</ref><ref>Graham HK, Rosenbaum P, Paneth N, Dan B, Lin JP, Damiano DL, Becher JG, Gaebler-Spira D, Colver A, Reddihough DS, Crompton KE. Cerebral palsy (Primer). Nature Reviews: Disease Primers. 2016;2(1).</ref>:


*Muscle Tone of the Extremities, Trunk and Neck, Deep Tendon Reflexes;
# Postural Evaluation: This involves assessing the child's posture in various positions, such as prone lying, supine lying, sitting, standing, and walking. Variations in these postures may provide insights into underlying musculoskeletal imbalances or functional limitations.
# Muscle Tone Assessment: This entails the evaluation of muscle tone in the extremities, trunk, and neck, along with deep tendon reflexes. CP often presents with muscle tone abnormalities, necessitating thorough and regular tone evaluations. Dystonia, characterised by involuntary intermittent muscle contractions leading to twisting movements or abnormal postures, can manifest in cases of hypertonia arising from an extrapyramidal brain lesion<ref>Sanger TD, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW, Task Force on Childhood Motor Disorders. Classification and definition of disorders causing hypertonia in childhood. Pediatrics. 2003 Jan;111(1):e89-97.</ref>. Conversely, hypertonia associated with a pyramidal brain lesion often presents as spasticity, which is the defining motor disorder in approximately 80% of paediatric CP cases<ref>Malhotra S, Pandyan AD, Day CR, Jones PW, Hermens H. Spasticity, an impairment that is poorly defined and poorly measured. Clinical rehabilitation. 2009 Jul;23(7):651-8.</ref>. Spasticity is typified by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from stretch reflex hyperexcitability, a component of the upper motor neuron syndrome<ref>Lance JW. The control of muscle tone, reflexes, and movement: Robert Wartenbeg Lecture. Neurology. 1980 Dec 1;30(12):1303-.</ref> .
# Muscle Strength Evaluation: Accurate muscle strength assessment is critical, given its profound influence on the functional abilities of the child<ref>Stackhouse SK, Binder‐Macleod SA, Lee SC. Voluntary muscle activation, contractile properties, and fatigability in children with and without cerebral palsy. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 2005 May;31(5):594-601.</ref>.
# Joint Range of Motion (ROM) Assessment: ROM should be evaluated at the hip, knee, ankle, sub-talar, and mid-tarsal joints. Joint angles identified during ROM testing, performed at slow, medium, and fast velocities, inform the position of the anatomical joint in any potential orthotic intervention. It further assists in identifying if mechanical joints should be included in the orthotic design and, if so, the specific type.<ref name="p1">Aneja S. [https://link.springer.com/article/10.1007/BF02724123 Evaluation of a child with cerebral palsy.] The Indian Journal of Pediatrics. 2004 Jul;71(7):627-34.</ref><ref name="p2">Brehm M, Bus SA, Harlaar J, Nollet F. [https://journals.sagepub.com/doi/abs/10.1177/0309364611413496 A candidate core set of outcome measures based on the international classification of functioning, disability and health for clinical studies on lower limb orthoses]. Prosthetics and orthotics international. 2011 Sep;35(3):269-77.</ref>


*Muscle Strength; and
The identification and quantification of spasticity remain crucial in determining appropriate orthotic intervention, thereby necessitating detailed evaluations of muscle tone and ROM during clinical assessments.
 
*Joint Range of Motion at the Hip, Knee, Ankle, Sub-talar and Mid-tarsal Joints.&nbsp;<ref name="1" />&nbsp;<ref name="2">Brehm M, Bus SA, Harlaar J, Nollet F. A candidate core set of outcome measures based on the international classification of functioning, disability and health for clinical studies on lower limb orthoses. Prosthet Orthot Int. [Research Support, Non-U.S. Gov't]. 2011 Sep;35(3):269-77.</ref>
 
As Cerebral Palsy is a disorder of movement that commonly presents with muscle tone abnormalities, it is critical to perform an evaluation of muscle tone during the initial and any future physical evaluations. Hypertonia due to an extra pyramidal brain lesion is known as dystonia and presents as involuntary intermittent muscle contractions that cause twisting or repetitive movements of abnormal postures. Hypertonia where a pyramidal brain lesion exists presents as muscle spasticity. Spasticity accounts for 80% of paediatric Cerebral Palsy presentations and is defined as a motor disorder characterised by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks.&nbsp;<ref name="3">Lance JW. Spasticity: Disordered Motor Control. Feldman RG, Young R.R., Koella W.P. , editor. Chicago: Year Book Medical Publishers; 1980.</ref>&nbsp;It results from hyper excitability of the stretch reflex as one component of the upper motor neurone syndrome. The identification and quantification of spasticity is critical when determining appropriate orthotic intervention. Identifying the joint angles during joint Range of Motion (ROM), testing at slow, medium and fast velocities where an increase in muscle tone is first felt and also at the end of joint ROM, helps establish the angle the anatomical joint will be positioned within any potentially prescribed orthosis. It also determines if, and what type, of mechanical joints may be included in the orthotic design.&nbsp;


=== Tone&nbsp;  ===
=== Tone&nbsp;  ===


The measurement tools used to evaluate muscle tone in children with Cerebral Palsy can be divided into two main groups according to their assessment technique and method of quantification. The Tardieu Scale (TS) assesses spasticity by passively moving the joints at three specified velocities (slow, under gravity and fast) while the intensity and duration of the muscle reaction to stretch (X) is rated on a 6-point scale (Table.1), with the joint angle (Y) recorded at where the muscle reaction is first felt.&nbsp;<ref name="4">Scholtes VA, Becher JG, Beelen A, Lankhorst GJ. Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments. Dev Med Child Neurol. [Review]. 2006 Jan;48(1):64-73.</ref>  
In the clinical assessment of children with CP, a comprehensive understanding of muscle tone and strength is paramount. Notably, these children frequently exhibit muscle tone alterations, which often coincide with signs of underlying muscle weakness. Muscle tone can vary substantially in this population, and its accurate evaluation guides the overall clinical intervention strategy. To reliably assess muscle tone and spasticity, clinicians use well-established tools such as the Tardieu Scale (TS), the Modified Tardieu Scale (MTS), and the Ashworth Scale (AS). Each tool adopts unique methodologies for this purpose, although potential sources of error should be considered, including individual variability, measurement tool inaccuracies, and variability in the attributes being measured.<ref name="p4">Scholtes VA, Becher JG, Beelen A, Lankhorst GJ. [https://onlinelibrary.wiley.com/doi/abs/10.1017/S0012162206000132 Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments]. Developmental Medicine & Child Neurology. 2006 Jan;48(1):64-73.</ref>


{| width="100%" border="1" cellpadding="5" cellspacing="5" style="font-size: 13px;"
Specifically, spasticity is a velocity-dependent increase in muscle tone, necessitating the application of tools that accommodate this aspect, such as the Tardieu Scale. The Tardieu Scale uniquely caters to this by incorporating passive muscle stretches at three different speeds, thereby providing a more comprehensive assessment of spasticity. Whereas the Ashworth Scale measures passive resistance to movement at just one speed.
|-
|
'''Velocity'''


|
The TS and MTS have displayed high intra and inter-rater reliability with adequate training, while the AS has shown inconsistent reliability (Fosang et al., 2003). Notably, the TS and MTS capture the velocity-dependent nature of spasticity, making them more suitable for accurately assessing this condition. Conversely, the AS measures passive resistance at a single speed, potentially leading to inaccuracies when identifying spasticity, particularly in the presence of muscle contracture<ref>Haugh AB, Pandyan AD, Johnson GR. A systematic review of the Tardieu Scale for the measurement of spasticity. Disability and rehabilitation. 2006 Jan 1;28(15):899-907.</ref>.
'''Description'''


|-
==== Tardieu Scale ====
|
The [[Tardieu Scale|Tardieu Scale (TS)]] measures spasticity (velocity-dependent) by passively moving the joints at three specified speeds - slow, under gravity, and fast. The muscle's reaction to stretch (X) is rated on a 6-point scale and the joint angle (Y) recorded at the point where the muscle reaction is first felt (Boyd & Graham, 1999).
V1


|  
{{#ev:youtube|O1fnK1OyHUE|600}}
As slow as possible (slower than the natural drop of the limb segment under gravity)  
===== Scoring =====
The scoring is done as follows<ref name=":0">Morris S. Ashworth and Tardieu Scales: Their clinical relevance for measuring spasticity in adult and paediatric neurological populations. Physical Therapy Reviews. 2002 Mar 1;7(1):53-62.</ref> 


Quality of Muscle Reaction
{| class="wikitable"
!0
!No resistance throughout passive movement
|-
|-
|  
|1
V2
|Slight resistance throughout,with no clear catch at a precise angle
 
|  
Speed of the limb segment falling under gravity
 
|-
|-
|  
|2
V3
|Clear catch at a precise angle followed by release
 
|  
As fast as possible (faster than the rate of the natural drop of the limb segment under gravity)
 
|-
|-
|  
|3
'''Grade'''
|Fatiguable Clonus (< 10 secs) occurring at a precise angleFatiguable Clonus (< 10 secs) occurring at a precise angle
 
|
'''Decsription'''
 
|-
|  
0
 
|
No resistance throughout passive movement
 
|-
|-
|  
|4
1
|Unfatiguable Clonus (> 10 secs) occurring at a precise angle
 
|  
Slight resistance throughout, with no clear catch at as precise angle  
 
|-
|-
|  
|5
2
|Joint immobile
 
|}Velocity to Stretch
|  
{| class="wikitable"
Clear catch at a precise ankle followed by a release
!V1
 
!As slow as possible
|-
|-
|  
|V2
3
|Speed of the limb segment falling (with gravitational pull)
 
|  
Fatigable clonus (&lt;10 seconds) occurring at a precise angle
 
|-
|-
|  
|V3
4
|At a fast rate (>gravitational pull)
 
|}Spasticity Angle
|  
{| class="wikitable"
Unfatigable clonus (&gt;10 seconds) occurring at a precise angle
|R1
 
|Angle of catch seen at Velocity V2 or V3
|-
|-
|  
|R2
5
|Full range of motion achieved when muscle is at rest and tested at V1 velocity
 
|  
Joint immobile
 
|}
|}


'''TABLE 1''': Definition of the velocities used and the 6-point scale used to grade the quality of muscle reaction when using the Tardieu Scale to assess spasticity&nbsp;
However, the TS's extensive nature often makes it time-consuming to perform. This led to the development of a more time-efficient variant - the Modified Tardieu Scale (MTS).


<br>Due to the large amount of time required to perform the full Tardieu Scale, the Modified Tardieu&nbsp;Scale (MTS) was developed. It records the joint angles during the fast and slow velocities only. It uses the most clinically significant parts of the TS: the angle of catch at the most rapid velocity (R1) and the joint angle when the muscle length is at its maximum (R2), assessed by moving the joint through full ROM using slow passive movement.&nbsp;<ref name="6">Love SC, Novak I, Kentish M, Desloovere K, Heinen F, Molenaers G, et al. Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement. Eur J Neurol. [Consensus Development Conference Practice Guideline]. 2010 Aug;17 Suppl 2:9-37</ref>&nbsp;The MTS has been found to be a valid, reliable and sensitive abridged version of the TS.&nbsp;<ref name="5" />&nbsp;<ref name="7">Boyd RN, Barwood S., Baillieu C.E., Graham H.K. Validity of a clincial measure of spasticity in children with cerebral palsy in a randomised control trial. Dev Med Child Neurol. 1998;40((Supp 78)):7.</ref>&nbsp;<ref name="8">Fosang AL, Galea MP, McCoy AT, Reddihough DS, Story I. Measures of muscle and joint performance in the lower limb of children with cerebral palsy. Dev Med Child Neurol. [Research Support, Non-U.S. Gov't Validation Studies]. 2003 Oct;45(10):664-70.</ref>&nbsp;The difference in degrees between the angles R2 and R1 is referred to as the dynamic component of spasticity and estimates the relative contribution of spasticity compared to muscle contracture.&nbsp;<ref name="5">Boyd RN, Graham H.K. Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy European Journal of Neurology 1999;6:S23-S35</ref>&nbsp;<ref name="6" />&nbsp;<ref name="9">Graham H.K., Autti-Ramo I., Boyd R.N., Delgado M.R., Gaebler-Spira D.J., Gormley M.J., Guyer B.M., Heinen F., Holton A.F., Matthews D., Molenaers G., Motta F., Garcia Ruiz P.J., Wissel J.  . Recommendations for the use of borulinum toxin type A in the management of cerebral palsy. Gait Posture. 2000;11:67-79</ref><br>
==== Modified Tardieu Scale (MTS) ====
This scale is an abbreviated version of the TS, focusing only on joint angles at fast and slow velocities. It takes into account the angle of muscle 'catch' at the highest velocity (R1) and the joint angle when the muscle length is at its maximum (R2), gauged by slow passive movement through full Range of Motion (ROM) (Patrick & Ada, 2006). The difference in degrees between R2 and R1, known as the dynamic component of spasticity, helps estimate the relative contribution of spasticity compared to muscle contracture.


The Ashworth Scale (AS) grades the intensity of muscle tone through joint ROM on a five-point scale at one non-specified velocity. (TABLE 2) Modifications of the AS are referred to as the Modified Ashworth Scale (MAS). Literature has also described the&nbsp;MAS to include a 6-point grading scale, a grading for the severity of the muscle tone and also the assessment of the muscle tone at an unspecified ‘fast’ velocity.&nbsp;<ref name="4" /><br>
==== Ashworth Scale ====
The Ashworth Scale (AS) is used to grade the intensity of muscle tone through joint ROM on a five-point scale at one non-specified speed. Despite the widespread use of the AS and its ability to identify general hypertonia, it is recommended that this tool no longer be used and that the TS or MTS be used to evaluate the muscle tone in ambulant children with Cerebral Palsy.&nbsp;<ref name="p6">Love SC, Novak I, Kentish M, Desloovere K, Heinen F, Molenaers G, O’flaherty S, Graham HK. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1468-1331.2010.03126.x Botulinum toxin assessment, intervention and after‐care for lower limb spasticity in children with cerebral palsy: international consensus statement.] European Journal of Neurology. 2010 Aug;17:9-37.</ref> The [[Modified Ashworth Scale]] (MAS), a derivative of the AS, includes a 6-point grading scale and severity grading of muscle tone at an unspecified 'fast' speed.


{| width="100%" border="1" cellpadding="5" cellspacing="5" style="font-size: 13px;"
===== Scoring =====
The scoring is done as follows<ref name=":0" />
{| class="wikitable"
!0
!No increase in tone
|-
|-
|  
|1
'''Grade'''
|Slight increase in tone giving a catch when slight increase in muscle tone, manifested by the limb was moved in flexion or extension
 
|  
'''Description'''
 
|-
|-
|  
|1+
0
|Slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout (ROM )
 
|  
No increase in muscle tone  
 
|-
|-
|  
|2
1
|More marked increase in tone but more marked increased in muscle tone through most limb easily flexed
 
|  
Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected joint is moved in flexion or extension
 
|-
|
1+
 
|
Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less that half) of the ROM
 
|-
|
2
 
|
More marked increase in muscle tone through most of the ROM, but affected joint is easily moved
 
|-
|-
|  
|3
3  
|Considerable increase in tone, passive movement difficult
 
|  
Considerable increase in muscle tone, passive movement is difficult  
 
|-
|-
|  
|4
4  
|Limb rigid in flexion or extension
 
|  
Affected joint is rigid in flexion and extension  
 
|}
|}


'''TABLE 2:&nbsp;'''The Grading Scale and description for the Ashworth Scale of Spasticity Evaluation&nbsp;<ref name="10">Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987 Feb;67(2):206-7.</ref><br>  
Thus, the evaluation of lower limb muscle strength is an essential part of the clinical picture in ambulant children with CP. Muscle strength has a direct bearing on a child's motor function, walking speed, energy expenditure, and gait characteristics<ref>Damiano DL, Arnold AS, Steele KM, Delp SL. Can strength training predictably improve gait kinematics? A pilot study on the effects of hip and knee extensor strengthening on lower-extremity alignment in cerebral palsy. Physical therapy. 2010 Feb 1;90(2):269-79.</ref>.<br>  
=== Strength&nbsp;  ===


<br>  
Muscle weakness is a key contributing factor in children with CP, often resulting in an imbalance across various joints. This imbalance is associated with the development of muscle shortening and rotational deformities, which can further impede a child's motor function<ref>Wiley ME, Damiano DL. Lower‐extremity strength profiles in spastic cerebral palsy. Developmental Medicine & Child Neurology. 1998 Feb;40(2):100-7.


As with any measurement tool, common sources of error are attributed to the individual taking the measurements, inaccuracies in the measurement instruments and variability in the characteristics being measured.&nbsp;<ref name="11">Portney L. WM. Foundations of clinical research. 1st ed. Stamford CT: Appleton &amp; Lange USA; 1993.</ref>&nbsp;Studies on the reliability of the TS and the MTS have demonstrated high intra and inter rater reliability when assessing children with Cerebral Palsy, provided sufficient time is allowed for training and practice.&nbsp;<ref name="8" />&nbsp;<ref name="12">Gracies JM, Burke K, Clegg NJ, Browne R, Rushing C, Fehlings D, et al. Reliability of the Tardieu Scale for assessing spasticity in children with cerebral palsy. Arch Phys Med Rehabil. [Comparative Study Evaluation Studies Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't]. 2010 Mar;91(3):421-8.</ref>&nbsp;However, the AS displayed poor test and re-test results for both inter and intra rater reliability.&nbsp;<ref name="4" />&nbsp;<ref name="8" /><br>
BibTeXEndNoteRefManRefWorks</ref>. It is therefore important to carry out a comprehensive muscle strength assessment of the lower limb during an orthotic assessment for children with CP.


Spasticity is defined as the velocity dependent increase in muscle tone, which means only the Tardieu Scale is an appropriate assessment tool as it accounts for the velocity dependent nature of spasticity by passively stretching the muscles at three different speeds.&nbsp;<ref name="3" />&nbsp;The AS assessment tool measures passive resistance to motion at one speed, leading to inconstancies and over-estimations in the identification of spasticity, especially in the presence of muscle contracture.&nbsp;<ref name="13">Patrick E, Ada L. The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it. Clin Rehabil. [Comparative Study]. 2006 Feb;20(2):173-82</ref>&nbsp;Despite the widespread use of the AS and its ability to identify general hypertonia, it is recommended that this tool no longer be used and that the TS or MTS be used to evaluate the muscle tone in ambulant children with Cerebral Palsy.&nbsp;<ref name="6" /><br>
There are many tools available to assess muscle strength, but a widely recognised tool used for children with CP is the [[Oxford Scale]] (aka Medical Research Council Scale (MRCS)) for manual muscle testing, which grades muscle strength<ref name="p5">Boyd RN, Graham HK. [https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1468-1331.1999.tb00031.x Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy.] European Journal of Neurology. 1999 Nov;6:s23-35.</ref><ref name="p9">Graham HK, Aoki KR, Autti-Rämö I, Boyd RN, Delgado MR, Gaebler-Spira DJ, Gormley Jr ME, Guyer BM, Heinen F, Holton AF, Matthews D. [https://www.sciencedirect.com/science/article/pii/S0966636299000545 Recommendations for the use of botulinum toxin type A in the management of cerebral palsy.] Gait & posture. 2000 Feb 1;11(1):67-79.</ref>. Throughout this assessment, it's imperative to be mindful of any signs of non-cooperation, inability to isolate the muscle being tested, or comprehension difficulties in the child.


Children with Cerebral Palsy who present with altered states in muscle tone often show signs of underlying muscle weakness and it is therefore important to evaluate the lower limb muscle strength in ambulatory children with Cerebral Palsy.&nbsp;<ref name="14">Wiley ME, Damiano DL. Lower-extremity strength profiles in spastic cerebral palsy. Dev Med Child Neurol. [Comparative Study]. 1998 Feb;40(2):100-7</ref>&nbsp;<ref name="15">Thompson N, Stebbins, J., Seniorou, M., Newham D. Muscle strength and walking ability in diplegic cerebral palsy: implications for assessment and management. Gait Posture. 2011;33:321-5</ref>&nbsp;The child with Cerebral Palsy who has greater muscle strength will achieve a higher motor function level as muscle strength is more highly correlated to function than the presence of spasticity.&nbsp;<ref name="16">Ross SA, Engsberg J.R.,. Relationship between spasticity, strength, gait and the GMFM-66 in persons with spastic diplegic cerebral palsy. Archieve of physical and medical rehabiliation. 2007;88(9):1114-20</ref>&nbsp;There is a direct correlation between muscle strength and a child’s motor function, walking speed, energy expenditure and the temporo spatial characteristics of gait.&nbsp;<ref name="17">Kramer J.F. MHEA. Relationships among measures of walking efficiency, gross motor ability and isokinetic strength in adolscents with cerebral palsy. Pediatr Phys Ther. 1994;6:3-8</ref>&nbsp;<ref name="18">Damiano DL, Kelly LE, Vaughn CL. Effects of quadriceps femoris muscle strengthening on crouch gait in children with spastic diplegia. Phys Ther. 1995 Aug;75(8):658-67; discussion 68-71</ref>&nbsp;There is also an incremental drop in muscle strength in all muscle groups, with increasing walking difficulty from GMFCS levels I to III.&nbsp;<ref name="15" /><br>
In cases where a more detailed quantification of muscle strength is needed, clinicians may resort to using handheld dynamometers<ref name="p4" /> <ref>Burns J, Redmond A, Ouvrier R, Crosbie J. Quantification of muscle strength and imbalance in neurogenic pes cavus, compared to health controls, using hand-held dynamometry. Foot & ankle international. 2005 Jul;26(7):540-4.</ref>. These instruments provide a more objective measure, enhancing the assessment's overall precision and reliability.


=== Strength&nbsp;  ===
'''Oxford Scale'''


The presence of muscle weakness leads to muscle imbalance across other joints. This muscle imbalance is thought to be a factor in the development of muscle shortening, contributes towards rotational deformities and further affects the motor function of a child.&nbsp;<ref name="14" />&nbsp;<ref name="15" />&nbsp;Hence, when performing the orthotic assessment of a child with Cerebral Palsy, a full muscle strength profile of the lower limbs is vital. The Medical Research Council Scale (MRCS) for manual muscle testing is the widely accepted clinical evaluation tool used to grade the muscle strength a child with Cerebral Palsy.&nbsp;<ref name="5" />&nbsp;(TABLE 3) During the assessment it is important to note if the child does not cooperate, is unable to isolate the muscle being tested or comprehend what is being asked of them. If further quantification of muscle strength is required, a hand held dynamometer may be used.&nbsp;<ref name="5" />&nbsp;<ref name="14" />  
{| class="wikitable"
 
!Muscle Groups Tested<ref name=":2" />
{| width="100%" border="1" cellpadding="5" cellspacing="5" style="font-size: 13px;"
|-
|Wrist Extension
|-
|Elbow Flexion
|-
|Shoulder Abduction
|-
|Ankle Dorsiflexion
|-
|Knee Extension
|-
|-
|  
|Hip Flexion
'''Grade'''
|}
 
{| class="wikitable"
|  
! colspan="2" |Muscle Grading Scores <ref name=":2" />
'''Description'''
 
|-
|-
|  
|0
0  
|No detectable muscle contraction (visible or palpation)
 
|  
No movement is observed
 
|-
|-
|  
|1
1  
|Detectable contraction (visible or palpation), but no movement achieved
 
|  
Only a flicker or trace of muscle movement is seen or felt in the muscle or fasiculations are observed in the muscle
 
|-
|-
|  
|2
2  
|Limb movement achieved, but unable to move against gravity
 
|  
Muscle can only move if the resistance of gravity is removed
 
|-
|-
|  
|3
3  
|Limb movement against resistance of gravity
 
|  
Muscle strength is further reduced such that the joint can be moved only against gravity with the examiner’s resistance completely removed
 
|-
|-
|  
|4
4  
|Limb movement against gravity and external resistance
 
|  
Muscle strength is reduced but muscle contraction can still move the joint against resistance  
 
|-
|-
|  
|5
5  
|Normal strength
 
|  
Muscle contracts normally against full resistance
 
|}
|}
'''TABLE 3:'''&nbsp;The Medical Research Council Scale (MRCS) for muscle strength evaluation&nbsp;<ref name="19">Montgomery T.G. H. J., Daniel's and Worthingham's Muscle Testing: Techniques of Manual Examination. Philadelphia: W.B. Saunders; 1995</ref>


=== Range of Movement&nbsp;  ===
=== Range of Movement&nbsp;  ===
Identifying and understanding the range of motion (ROM) in children with cerebral palsy is integral to their orthotic assessment and overall care. Secondary musculoskeletal issues, such as muscle contractures and bony deformities, frequently observed in children with cerebral palsy, can significantly reduce the available lower limb joint ROM. Reduced mobility, the presence of spasticity, and dystonia, as well as factors like age, gender, pain thresholds, health conditions, injuries, and levels and types of physical activity, can all have an impact on decreased ROM.  Therefore, it becomes essential to evaluate and quantify both passive and dynamic lower limb joint ROM, as muscle and joint movement can impact the ability to move freely.


Muscle contracture and bony deformities are the commonly observed secondary musculoskeletal problems that children with Cerebral Palsy may develop. These secondary musculoskeletal problems cause a decrease in the child’s available lower limb joint<br>ROM. Therefore, evaluation and quantification of the passive and dynamic lower limb joint ROM is a crucial part of the orthotic assessment of any ambulant child with Cerebral Palsy. The findings assist with the prescription of orthoses, evaluation of the intervention and the monitoring of change due to growth.&nbsp;
Torsional deformities, which arise from muscle imbalances and abnormal bone growth due to increased tone or weakness, are common in ambulatory children with CP<ref name="p3">Lance JW. Spasticity: Disordered Motor Control. Feldman RG, Young R.R., Koella W.P. , editor. Chicago: Year Book Medical Publishers; 1980.</ref>. As such, a rotational assessment of the lower limb joints is necessary. This includes assessing the:
 
The hip joint should be assessed for the amount of available passive and dynamic&nbsp;ROM in flexion, extension, abduction and adduction. Hip flexion contractures are a frequent presentation in a child with a predominantly spastic presentation of Cerebral Palsy. A primary hip flexion contracture adversely affects the kinematics of a child’s gait by:&nbsp;  
 
*Restricting heel contact at initial contact;
 
*Altering the position of the body’s weight line during stance phase;
 
*Changing the degree of inclination of the femur and the tibia during stance phase;
 
*Reducing the amount of hip extension possible, causing an interruption of transfer through the second and third rockers of stance phase.
 
The knee joint needs to be assessed for flexion and extension in both passive and dynamic ROM. It is also important to assess the joint range of motion of the passive, active and velocity specific knee extension with the child supine and the hip flexed to approximately 30°. This position replicates the degree of the hip flexion that occurs at initial contact during gait and establishes the degree of knee extension that is possible during early stance phase.<br>


To establish the ROM of plantar and dorsi flexion at the ankle joint, it is important the sub-talar joint is maintained in a neutral alignment and the tests are best carried out with a child in a supine position. Movement of the sub-talar joint into either eversion or inversion while dorsi flexing the ankle affects the length of the gastrocnemius muscle and may produce erroneous findings of the available dorsiflexion ROM.&nbsp;<ref name="20">Carmick J. Importance of orthotic subtalar alignment for development and gait of children with cerebral palsy. Pediatr Phys Ther. [Case Reports]. 2012 Winter;24(4):302-7</ref>&nbsp;A plantar extensor pattern generally exists in the lower limbs of a child with a spastic presentation of Cerebral Palsy. This often causes either the gastrocnemius or soleus muscles to be affected by increases in muscle tone. The gastrocnemius is a bi-articular muscle, originating proximal to the femoral condyles and inserting at the base of the calcaneus. Flexing the hip and knee to 90° and then dorsi flexing the ankle eliminates the effects of the gastrocnemius muscle on the foot and ankle and makes it possible to check the available ROM and muscle tone specifically attributed to the soleus muscle. (FIGURE 1A)&nbsp;
* hip's internal/external rotation
* degree of femoral ante/retro version
* degree of tibial torsion, sub-talar inversion/eversion
* mid-tarsal ab/adduction. Establishing this torsional profile aids in orthotic prescription by identifying if there is a torsional lever arm deficiency.


{| width="100%" border="0" cellpadding="5" cellspacing="5" style="font-size: 13px;"
A thorough assessment of both range and torsional deformities is crucial when prescribing  orthoses, evaluating the effectiveness of the intervention, and monitoring growth-induced changes​​.
|-
| width="33%" align="center" |
'''A'''
 
| width="33%" align="center" |
'''B'''
 
|-
| colspan="2" align="center" |
[[Image:Flex Soleus.jpg|800px]]


|}
==== Hip Joint ====
In the hip joint, the extent of available passive and dynamic ROM in flexion, extension, abduction, and adduction must be examined. It's important to note that hip flexion contractures are a common occurrence in children with a predominantly spastic presentation of cerebral palsy. Such contractures can adversely affect a child’s gait by altering the body's weight line during the stance phase, restricting heel contact at initial contact, changing the inclination degree of the femur and the tibia during stance phase, and reducing possible hip extension, thereby disrupting transfer through the second and third rockers of stance phase​​.


'''FIGURE 1:'''&nbsp;Physical evaluation of the ROM of the ankle joint due to the Soleus Muscle (A) and the Gastrocnemius Muscle (B)&nbsp;<ref name="21">Cottalorda J, Violas P, Seringe R. Neuro-orthopaedic evaluation of children and adolescents: a simplified algorithm. Orthop Traumatol Surg Res. [Comparative Study Review]. 2012 Oct;98(6 Suppl):S146-53</ref>
==== Knee Joint ====
The knee joint also requires evaluation for flexion and extension in both passive and dynamic ROM. The joint range of motion should also be assessed for passive, active, and velocity specific knee extension when the child is in a supine position with the hip flexed to approximately 30°. This position emulates the degree of hip flexion at initial contact during gait and establishes the extent of knee extension possible during the early stance phase​[[Evaluating the Child with Cerebral Palsy|1]]​.


<br>  
==== Ankle Joint ====
The evaluation of the ankle joint's range of motion (ROM), specifically focusing on dorsiflexion and plantarflexion, is an essential aspect of assessing children with cerebral palsy, especially those exhibiting spasticity. While assessing, it is crucial to keep the sub-talar joint in a neutral position. Any variation from this, such as moving the sub-talar joint into eversion or inversion during dorsiflexion, can alter the length of the gastrocnemius muscle, potentially resulting in an inaccurate measurement of available dorsiflexion ROM<ref>Chisholm MD, Russell DJ, Munteanu SE. Effectiveness of interventions for increasing the ankle joint dorsiflexion: a systematic review and meta-analysis. J Foot Ankle Res. 2018;11:37</ref>.


Alternatively, positioning the hip in 30° of flexion, the knee in the maximum attainable extension, the sub-talar joint in a neutral alignment and then dorsi flexing the foot establishes the ROM of ankle dorsiflexion that is attributable to either changes in muscle tone or contracture of the gastrocnemius muscle. (FIGURE 1B) Assessing the ankle ROM due to gastrocnemius length ascertains the child’s plantar flexion-knee extension couple. This is used during the prescription of an AFO to determine the Angle of the Ankle in the AFO (AAAFO) and is the degree of ankle dorsi or plantar flexion the ankle is positioned within the AFO. It is defined as the angle of the foot relative to the tibial shank when viewed in the sagittal plane.&nbsp;<ref name="22">Eddison N, Chockalingam N. The effect of tuning ankle foot orthoses-footwear combination on the gait parameters of children with cerebral palsy. Prosthet Orthot Int. 2012 Jul 24</ref>
These tests are ideally conducted while the child is in a supine position. In some instances, children with a spastic presentation of cerebral palsy may exhibit a plantar extensor pattern in their lower limbs. This pattern often affects the [[gastrocnemius]] or [[soleus]] muscles due to increased muscle tone. Flexing the hip and knee to 90 degrees and then dorsiflexing the ankle can help to isolate the effects of the gastrocnemius muscle on the foot and ankle. This isolation allows for a more specific assessment of the ROM and muscle tone related to the soleus muscle.


Torsional deformities in ambulant children with Cerebral Palsy occur when there are muscle imbalances and abnormal loading and growth of bones due to increased tone or weakness.&nbsp;<ref name="23">Hughes C, Gardner, R., Pyman, J., Toomey, K., Gargan, M. Orthopaedic assessment and management of cerebral palsy. Orthopaedics and trauma. 2012;26(4):280-91</ref>&nbsp;Therefore it is important to include a rotational assessment of the joints of the lower limbs. The particular areas to assess are hip internal/external rotation, femoral ante/retro version, degree of tibial torsion, sub-talar inversion/eversion and mid-tarsal ab/adduction. Establishing the torsional profile of a child’s lower limbs aids orthotic prescription by identifying if a torsional lever arm deficiency is present.&nbsp;<ref name="24">Rogozinski BM, Davids JR, Davis RB, 3rd, Jameson GG, Blackhurst DW. The efficacy of the floor-reaction ankle-foot orthosis in children with cerebral palsy. J Bone Joint Surg Am. 2009 Oct;91(10):2440-7</ref><br>
For a more precise evaluation, passive non-weight-bearing goniometric measurements of dorsiflexion can be carried out with the knee extended to 0° and flexed to 45°. Measurements taken with the knee extended are intended to assess the flexibility of the gastrocnemius muscle. In contrast, measurements taken with the knee flexed are thought to provide insight into the flexibility of the soleus muscle<ref>Hussain J, Cohen C, Sealey K, Tariah HA, Wyatt M. Comparison of the non-weight bearing and weight bearing ankle joint range of motion. J Phys Ther Sci. 2013;25(7):885–887</ref>​​.


Goniometric measures are the most widely used technique to assess either passive or velocity dependent lower limb joint ROM in a child with Cerebral Palsy.&nbsp;<ref name="25">McDowell BC, Hewitt V, Nurse A, Weston T, Baker R. The variability of goniometric measurements in ambulatory children with spastic cerebral palsy. Gait Posture. [Research Support, Non-U.S. Gov't]. 2000 Oct;12(2):114-21</ref>&nbsp;Factors such as the number of assessors, patient compliance and the method used for measuring can affect the reliability and repeatability of measures. Several studies involving children with spastic Cerebral Palsy found that goniometric measurements display high levels of inter and intra reliability and repeatability for observers who are trained and experienced.&nbsp;<ref name="8" />&nbsp;<ref name="26">Allington NJ, Leroy N, Doneux C. Ankle joint range of motion measurements in spastic cerebral palsy children: intraobserver and interobserver reliability and reproducibility of goniometry and visual estimation. Journal of pediatric orthopedics Part B. [Comparative Study]. 2002 Jul;11(3):236-9</ref>&nbsp;<ref name="27">Stuberg WA, Fuchs RH, Miedaner JA. Reliability of goniometric measurements of children with cerebral palsy. Dev Med Child Neurol. [Research Support, U.S. Gov't, P.H.S.]. 1988 Oct;30(5):657-66</ref>&nbsp;<ref name="28">Thompson NS, Baker RJ, Cosgrove AP, Saunders JL, Taylor TC. Relevance of the popliteal angle to hamstring length in cerebral palsy crouch gait. J Pediatr Orthop. [Research Support, Non-U.S. Gov't]. 2001 May-Jun;21(3):383-7</ref>&nbsp;This is provided a strict measuring protocol is adhered to.<br>
When implementing an ankle-foot orthosis (AFO), the angle of the ankle within the device and the pitch of the heel sole differential play a significant role. The passive length of the gastrocnemius muscle, measured with the knee extended, determines the angle of the ankle in the AFO. If the ankle in the AFO is in plantarflexion, an adjustment is made to the AFO to achieve a vertical bench alignment​2​.


{{#ev:youtube|O1fnK1OyHUE|600}}<span style="text-align: justify;">&nbsp;</span>  
Assessments of this nature allow for a more comprehensive understanding of the individual's unique musculoskeletal dynamics, facilitating the creation of a more tailored and effective treatment plan. It's important to remember that the limitation in the motion of the ankle joint, specifically dorsiflexion and plantarflexion, is influenced by the joint capsule and surrounding ligaments and muscles, including the gastrocnemius and soleus muscles​​.<ref>Journal of Prosthetics and Orthotics. The Use of the AAAFO in the Management of Cerebral Palsy. [Accessed 25 May 2023] Available from: <nowiki>https://journals.lww.com/jpojournal/Fulltext/2017/07000/The_Use_of_the_AAAFO_in_the_Management_of.4.aspx</nowiki></ref><ref>American Physical Therapy Association. Ankle Dorsiflexion: Knee Extended, Knee Flexed. [Accessed 25 May 2023] Available from: <nowiki>https://www.apta.org/patient-care/evidence-based-practice-resources/test-measures/ankle-dorsiflexion-knee-extended-knee-flexed</nowiki></ref>


==== Goniometry ====
The most common method to assess passive or velocity-dependent lower limb joint ROM in children with CP is goniometry. <ref name="p5" /> The number of people conducting the assessment, the patient's level of cooperation, and the measurement technique chosen can all have an impact on the dependability and repeatability of these measurements.
== Resources  ==
== Resources  ==


{{pdf|Hambisela_Module_2_Evaluating_Your_Child.pdf|Hambisela_Module_2_Evaluating_Your_Child}}&nbsp; &nbsp;In: Getting to Know Cerebral Palsy: A learning resource for facilitators, parents, caregivers, and persons with cerebral palsy
{{pdf|Hambisela_Module_2_Evaluating_Your_Child.pdf|Hambisela_Module_2_Evaluating_Your_Child}}&nbsp; &nbsp;In: Getting to Know Cerebral Palsy: A learning resource for facilitators, parents, caregivers, and persons with cerebral palsy
== References  ==


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<references />  
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== References<br> ==


<references />
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[[Category:Cerebral_Palsy]]
[[Category:Cerebral_Palsy]]
[[Category:Assessment]]
[[Category:Paediatrics - Assessment and Examination]]
[[Category:ICRC Cerebral Palsy Content Development Project]]

Latest revision as of 10:17, 2 November 2023

Original Editor - Kim Jackson as part of ICRC Cerebral Palsy Content Development Project

Top Contributors - Naomi O'Reilly, Kim Jackson, Admin, 127.0.0.1, WikiSysop, Simisola Ajeyalemi, Wendy Walker, Rucha Gadgil, Jess Bell and Aminat Abolade  

Introduction[edit | edit source]

Cerebral Palsy (CP) is a neurodevelopmental disorder marked by non-progressive motor function impairment originating from damage to the developing brain. The complexity of this condition necessitates an integrated rehabilitation approach, encompassing multiple professionals in the field[1]. Knowledge of cerebral palsy and experience of managing neurological is necessary to ensure that treatable causes are identified. The team usually includes physiotherapists, occupational therapists, speech therapists, nutritionists, paediatricians, orthopaedic surgeons, and neurologists, each playing a distinct yet collaborative role in managing the unique challenges presented by CP.

The manifestations of CP often become clearer over time, meaning that a diagnosis may not be confirmed until several months to a year after birth, or even later in cases with milder symptoms. During this time, the child's growth and development are closely monitored, their medical history is reviewed, and physical examinations are conducted.

Clinical Assessment[edit | edit source]

The evaluation of a child with CP requires a comprehensive, multidimensional approach to accurately identify and address the individual's specific deficits and needs. The assessment process includes a thorough medical history, physical examination, functional assessment, and often, specialized evaluations[2]. Importantly, the assessment extends beyond the child to incorporate the family, evaluating their needs and resources, as successful management often relies on family-centered care. 

Observing the child’s movements is the initial and a crucial part of the examination. Observe before you touch. If the child is young, apprehensive or tearful, let them stay on mother’s lap while you watch and talk to the mother. As the child adapts to the environment, slowly place them on the examination table or on the floor still close to the mother/carer and watch them move around. If the child cries a lot and does not cooperate, continue while they are in their mother’s lap. Tools required for the examination are very simple: toys, small wooden/different shaped blocks, and objects with different textures.

A comprehensive physical and biomechanical evaluation is paramount for a child with cerebral palsy (CP) who is ambulant, as it informs targeted interventions at specific joints and segment levels. Essential components of the clinical examination should include[3][4]:

  1. Postural Evaluation: This involves assessing the child's posture in various positions, such as prone lying, supine lying, sitting, standing, and walking. Variations in these postures may provide insights into underlying musculoskeletal imbalances or functional limitations.
  2. Muscle Tone Assessment: This entails the evaluation of muscle tone in the extremities, trunk, and neck, along with deep tendon reflexes. CP often presents with muscle tone abnormalities, necessitating thorough and regular tone evaluations. Dystonia, characterised by involuntary intermittent muscle contractions leading to twisting movements or abnormal postures, can manifest in cases of hypertonia arising from an extrapyramidal brain lesion[5]. Conversely, hypertonia associated with a pyramidal brain lesion often presents as spasticity, which is the defining motor disorder in approximately 80% of paediatric CP cases[6]. Spasticity is typified by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from stretch reflex hyperexcitability, a component of the upper motor neuron syndrome[7] .
  3. Muscle Strength Evaluation: Accurate muscle strength assessment is critical, given its profound influence on the functional abilities of the child[8].
  4. Joint Range of Motion (ROM) Assessment: ROM should be evaluated at the hip, knee, ankle, sub-talar, and mid-tarsal joints. Joint angles identified during ROM testing, performed at slow, medium, and fast velocities, inform the position of the anatomical joint in any potential orthotic intervention. It further assists in identifying if mechanical joints should be included in the orthotic design and, if so, the specific type.[9][10]

The identification and quantification of spasticity remain crucial in determining appropriate orthotic intervention, thereby necessitating detailed evaluations of muscle tone and ROM during clinical assessments.

Tone [edit | edit source]

In the clinical assessment of children with CP, a comprehensive understanding of muscle tone and strength is paramount. Notably, these children frequently exhibit muscle tone alterations, which often coincide with signs of underlying muscle weakness. Muscle tone can vary substantially in this population, and its accurate evaluation guides the overall clinical intervention strategy. To reliably assess muscle tone and spasticity, clinicians use well-established tools such as the Tardieu Scale (TS), the Modified Tardieu Scale (MTS), and the Ashworth Scale (AS). Each tool adopts unique methodologies for this purpose, although potential sources of error should be considered, including individual variability, measurement tool inaccuracies, and variability in the attributes being measured.[11]

Specifically, spasticity is a velocity-dependent increase in muscle tone, necessitating the application of tools that accommodate this aspect, such as the Tardieu Scale. The Tardieu Scale uniquely caters to this by incorporating passive muscle stretches at three different speeds, thereby providing a more comprehensive assessment of spasticity. Whereas the Ashworth Scale measures passive resistance to movement at just one speed.

The TS and MTS have displayed high intra and inter-rater reliability with adequate training, while the AS has shown inconsistent reliability (Fosang et al., 2003). Notably, the TS and MTS capture the velocity-dependent nature of spasticity, making them more suitable for accurately assessing this condition. Conversely, the AS measures passive resistance at a single speed, potentially leading to inaccuracies when identifying spasticity, particularly in the presence of muscle contracture[12].

Tardieu Scale[edit | edit source]

The Tardieu Scale (TS) measures spasticity (velocity-dependent) by passively moving the joints at three specified speeds - slow, under gravity, and fast. The muscle's reaction to stretch (X) is rated on a 6-point scale and the joint angle (Y) recorded at the point where the muscle reaction is first felt (Boyd & Graham, 1999).

Scoring[edit | edit source]

The scoring is done as follows[13]

Quality of Muscle Reaction

0 No resistance throughout passive movement
1 Slight resistance throughout,with no clear catch at a precise angle
2 Clear catch at a precise angle followed by release
3 Fatiguable Clonus (< 10 secs) occurring at a precise angleFatiguable Clonus (< 10 secs) occurring at a precise angle
4 Unfatiguable Clonus (> 10 secs) occurring at a precise angle
5 Joint immobile

Velocity to Stretch

V1 As slow as possible
V2 Speed of the limb segment falling (with gravitational pull)
V3 At a fast rate (>gravitational pull)

Spasticity Angle

R1 Angle of catch seen at Velocity V2 or V3
R2 Full range of motion achieved when muscle is at rest and tested at V1 velocity

However, the TS's extensive nature often makes it time-consuming to perform. This led to the development of a more time-efficient variant - the Modified Tardieu Scale (MTS).

Modified Tardieu Scale (MTS)[edit | edit source]

This scale is an abbreviated version of the TS, focusing only on joint angles at fast and slow velocities. It takes into account the angle of muscle 'catch' at the highest velocity (R1) and the joint angle when the muscle length is at its maximum (R2), gauged by slow passive movement through full Range of Motion (ROM) (Patrick & Ada, 2006). The difference in degrees between R2 and R1, known as the dynamic component of spasticity, helps estimate the relative contribution of spasticity compared to muscle contracture.

Ashworth Scale[edit | edit source]

The Ashworth Scale (AS) is used to grade the intensity of muscle tone through joint ROM on a five-point scale at one non-specified speed. Despite the widespread use of the AS and its ability to identify general hypertonia, it is recommended that this tool no longer be used and that the TS or MTS be used to evaluate the muscle tone in ambulant children with Cerebral Palsy. [14] The Modified Ashworth Scale (MAS), a derivative of the AS, includes a 6-point grading scale and severity grading of muscle tone at an unspecified 'fast' speed.

Scoring[edit | edit source]

The scoring is done as follows[13]

0 No increase in tone
1 Slight increase in tone giving a catch when slight increase in muscle tone, manifested by the limb was moved in flexion or extension
1+ Slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout (ROM )
2 More marked increase in tone but more marked increased in muscle tone through most limb easily flexed
3 Considerable increase in tone, passive movement difficult
4 Limb rigid in flexion or extension

Thus, the evaluation of lower limb muscle strength is an essential part of the clinical picture in ambulant children with CP. Muscle strength has a direct bearing on a child's motor function, walking speed, energy expenditure, and gait characteristics[15].

Strength [edit | edit source]

Muscle weakness is a key contributing factor in children with CP, often resulting in an imbalance across various joints. This imbalance is associated with the development of muscle shortening and rotational deformities, which can further impede a child's motor function[16]. It is therefore important to carry out a comprehensive muscle strength assessment of the lower limb during an orthotic assessment for children with CP.

There are many tools available to assess muscle strength, but a widely recognised tool used for children with CP is the Oxford Scale (aka Medical Research Council Scale (MRCS)) for manual muscle testing, which grades muscle strength[17][18]. Throughout this assessment, it's imperative to be mindful of any signs of non-cooperation, inability to isolate the muscle being tested, or comprehension difficulties in the child.

In cases where a more detailed quantification of muscle strength is needed, clinicians may resort to using handheld dynamometers[11] [19]. These instruments provide a more objective measure, enhancing the assessment's overall precision and reliability.

Oxford Scale

Muscle Groups Tested[20]
Wrist Extension
Elbow Flexion
Shoulder Abduction
Ankle Dorsiflexion
Knee Extension
Hip Flexion
Muscle Grading Scores [20]
0 No detectable muscle contraction (visible or palpation)
1 Detectable contraction (visible or palpation), but no movement achieved
2 Limb movement achieved, but unable to move against gravity
3 Limb movement against resistance of gravity
4 Limb movement against gravity and external resistance
5 Normal strength

Range of Movement [edit | edit source]

Identifying and understanding the range of motion (ROM) in children with cerebral palsy is integral to their orthotic assessment and overall care. Secondary musculoskeletal issues, such as muscle contractures and bony deformities, frequently observed in children with cerebral palsy, can significantly reduce the available lower limb joint ROM. Reduced mobility, the presence of spasticity, and dystonia, as well as factors like age, gender, pain thresholds, health conditions, injuries, and levels and types of physical activity, can all have an impact on decreased ROM. Therefore, it becomes essential to evaluate and quantify both passive and dynamic lower limb joint ROM, as muscle and joint movement can impact the ability to move freely.

Torsional deformities, which arise from muscle imbalances and abnormal bone growth due to increased tone or weakness, are common in ambulatory children with CP[21]. As such, a rotational assessment of the lower limb joints is necessary. This includes assessing the:

  • hip's internal/external rotation
  • degree of femoral ante/retro version
  • degree of tibial torsion, sub-talar inversion/eversion
  • mid-tarsal ab/adduction. Establishing this torsional profile aids in orthotic prescription by identifying if there is a torsional lever arm deficiency.

A thorough assessment of both range and torsional deformities is crucial when prescribing orthoses, evaluating the effectiveness of the intervention, and monitoring growth-induced changes​​.

Hip Joint[edit | edit source]

In the hip joint, the extent of available passive and dynamic ROM in flexion, extension, abduction, and adduction must be examined. It's important to note that hip flexion contractures are a common occurrence in children with a predominantly spastic presentation of cerebral palsy. Such contractures can adversely affect a child’s gait by altering the body's weight line during the stance phase, restricting heel contact at initial contact, changing the inclination degree of the femur and the tibia during stance phase, and reducing possible hip extension, thereby disrupting transfer through the second and third rockers of stance phase​​.

Knee Joint[edit | edit source]

The knee joint also requires evaluation for flexion and extension in both passive and dynamic ROM. The joint range of motion should also be assessed for passive, active, and velocity specific knee extension when the child is in a supine position with the hip flexed to approximately 30°. This position emulates the degree of hip flexion at initial contact during gait and establishes the extent of knee extension possible during the early stance phase​1​.

Ankle Joint[edit | edit source]

The evaluation of the ankle joint's range of motion (ROM), specifically focusing on dorsiflexion and plantarflexion, is an essential aspect of assessing children with cerebral palsy, especially those exhibiting spasticity. While assessing, it is crucial to keep the sub-talar joint in a neutral position. Any variation from this, such as moving the sub-talar joint into eversion or inversion during dorsiflexion, can alter the length of the gastrocnemius muscle, potentially resulting in an inaccurate measurement of available dorsiflexion ROM[22].

These tests are ideally conducted while the child is in a supine position. In some instances, children with a spastic presentation of cerebral palsy may exhibit a plantar extensor pattern in their lower limbs. This pattern often affects the gastrocnemius or soleus muscles due to increased muscle tone. Flexing the hip and knee to 90 degrees and then dorsiflexing the ankle can help to isolate the effects of the gastrocnemius muscle on the foot and ankle. This isolation allows for a more specific assessment of the ROM and muscle tone related to the soleus muscle.

For a more precise evaluation, passive non-weight-bearing goniometric measurements of dorsiflexion can be carried out with the knee extended to 0° and flexed to 45°. Measurements taken with the knee extended are intended to assess the flexibility of the gastrocnemius muscle. In contrast, measurements taken with the knee flexed are thought to provide insight into the flexibility of the soleus muscle[23]​​.

When implementing an ankle-foot orthosis (AFO), the angle of the ankle within the device and the pitch of the heel sole differential play a significant role. The passive length of the gastrocnemius muscle, measured with the knee extended, determines the angle of the ankle in the AFO. If the ankle in the AFO is in plantarflexion, an adjustment is made to the AFO to achieve a vertical bench alignment​2​.

Assessments of this nature allow for a more comprehensive understanding of the individual's unique musculoskeletal dynamics, facilitating the creation of a more tailored and effective treatment plan. It's important to remember that the limitation in the motion of the ankle joint, specifically dorsiflexion and plantarflexion, is influenced by the joint capsule and surrounding ligaments and muscles, including the gastrocnemius and soleus muscles​​.[24][25]

Goniometry[edit | edit source]

The most common method to assess passive or velocity-dependent lower limb joint ROM in children with CP is goniometry. [17] The number of people conducting the assessment, the patient's level of cooperation, and the measurement technique chosen can all have an impact on the dependability and repeatability of these measurements.

Resources[edit | edit source]

Hambisela_Module_2_Evaluating_Your_Child   In: Getting to Know Cerebral Palsy: A learning resource for facilitators, parents, caregivers, and persons with cerebral palsy

References[edit | edit source]

  1. ↑ Novak I, Mcintyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental medicine & child neurology. 2013 Oct;55(10):885-910.
  2. ↑ Bartlett DJ, Palisano RJ. Physical therapists' perceptions of factors influencing the acquisition of motor abilities of children with cerebral palsy: implications for clinical reasoning. Physical therapy. 2002 Mar 1;82(3):237-48.
  3. ↑ Novak I, Morgan C, Adde L, Blackman J, Boyd RN, Brunstrom-Hernandez J, Cioni G, Damiano D, Darrah J, Eliasson AC, De Vries LS. Early, accurate diagnosis and early intervention in cerebral palsy: advances in diagnosis and treatment. JAMA pediatrics. 2017 Sep 1;171(9):897-907.
  4. ↑ Graham HK, Rosenbaum P, Paneth N, Dan B, Lin JP, Damiano DL, Becher JG, Gaebler-Spira D, Colver A, Reddihough DS, Crompton KE. Cerebral palsy (Primer). Nature Reviews: Disease Primers. 2016;2(1).
  5. ↑ Sanger TD, Delgado MR, Gaebler-Spira D, Hallett M, Mink JW, Task Force on Childhood Motor Disorders. Classification and definition of disorders causing hypertonia in childhood. Pediatrics. 2003 Jan;111(1):e89-97.
  6. ↑ Malhotra S, Pandyan AD, Day CR, Jones PW, Hermens H. Spasticity, an impairment that is poorly defined and poorly measured. Clinical rehabilitation. 2009 Jul;23(7):651-8.
  7. ↑ Lance JW. The control of muscle tone, reflexes, and movement: Robert Wartenbeg Lecture. Neurology. 1980 Dec 1;30(12):1303-.
  8. ↑ Stackhouse SK, Binder‐Macleod SA, Lee SC. Voluntary muscle activation, contractile properties, and fatigability in children with and without cerebral palsy. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine. 2005 May;31(5):594-601.
  9. ↑ Aneja S. Evaluation of a child with cerebral palsy. The Indian Journal of Pediatrics. 2004 Jul;71(7):627-34.
  10. ↑ Brehm M, Bus SA, Harlaar J, Nollet F. A candidate core set of outcome measures based on the international classification of functioning, disability and health for clinical studies on lower limb orthoses. Prosthetics and orthotics international. 2011 Sep;35(3):269-77.
  11. ↑ 11.0 11.1 Scholtes VA, Becher JG, Beelen A, Lankhorst GJ. Clinical assessment of spasticity in children with cerebral palsy: a critical review of available instruments. Developmental Medicine & Child Neurology. 2006 Jan;48(1):64-73.
  12. ↑ Haugh AB, Pandyan AD, Johnson GR. A systematic review of the Tardieu Scale for the measurement of spasticity. Disability and rehabilitation. 2006 Jan 1;28(15):899-907.
  13. ↑ 13.0 13.1 Morris S. Ashworth and Tardieu Scales: Their clinical relevance for measuring spasticity in adult and paediatric neurological populations. Physical Therapy Reviews. 2002 Mar 1;7(1):53-62.
  14. ↑ Love SC, Novak I, Kentish M, Desloovere K, Heinen F, Molenaers G, O’flaherty S, Graham HK. Botulinum toxin assessment, intervention and after‐care for lower limb spasticity in children with cerebral palsy: international consensus statement. European Journal of Neurology. 2010 Aug;17:9-37.
  15. ↑ Damiano DL, Arnold AS, Steele KM, Delp SL. Can strength training predictably improve gait kinematics? A pilot study on the effects of hip and knee extensor strengthening on lower-extremity alignment in cerebral palsy. Physical therapy. 2010 Feb 1;90(2):269-79.
  16. ↑ Wiley ME, Damiano DL. Lower‐extremity strength profiles in spastic cerebral palsy. Developmental Medicine & Child Neurology. 1998 Feb;40(2):100-7. BibTeXEndNoteRefManRefWorks
  17. ↑ 17.0 17.1 Boyd RN, Graham HK. Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy. European Journal of Neurology. 1999 Nov;6:s23-35.
  18. ↑ Graham HK, Aoki KR, Autti-Rämö I, Boyd RN, Delgado MR, Gaebler-Spira DJ, Gormley Jr ME, Guyer BM, Heinen F, Holton AF, Matthews D. Recommendations for the use of botulinum toxin type A in the management of cerebral palsy. Gait & posture. 2000 Feb 1;11(1):67-79.
  19. ↑ Burns J, Redmond A, Ouvrier R, Crosbie J. Quantification of muscle strength and imbalance in neurogenic pes cavus, compared to health controls, using hand-held dynamometry. Foot & ankle international. 2005 Jul;26(7):540-4.
  20. ↑ 20.0 20.1 Cite error: Invalid <ref> tag; no text was provided for refs named :2
  21. ↑ Lance JW. Spasticity: Disordered Motor Control. Feldman RG, Young R.R., Koella W.P. , editor. Chicago: Year Book Medical Publishers; 1980.
  22. ↑ Chisholm MD, Russell DJ, Munteanu SE. Effectiveness of interventions for increasing the ankle joint dorsiflexion: a systematic review and meta-analysis. J Foot Ankle Res. 2018;11:37
  23. ↑ Hussain J, Cohen C, Sealey K, Tariah HA, Wyatt M. Comparison of the non-weight bearing and weight bearing ankle joint range of motion. J Phys Ther Sci. 2013;25(7):885–887
  24. ↑ Journal of Prosthetics and Orthotics. The Use of the AAAFO in the Management of Cerebral Palsy. [Accessed 25 May 2023] Available from: https://journals.lww.com/jpojournal/Fulltext/2017/07000/The_Use_of_the_AAAFO_in_the_Management_of.4.aspx
  25. ↑ American Physical Therapy Association. Ankle Dorsiflexion: Knee Extended, Knee Flexed. [Accessed 25 May 2023] Available from: https://www.apta.org/patient-care/evidence-based-practice-resources/test-measures/ankle-dorsiflexion-knee-extended-knee-flexed


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