Evaluating the Child with Cerebral Palsy
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]:
- 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[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] .
- Muscle Strength Evaluation: Accurate muscle strength assessment is critical, given its profound influence on the functional abilities of the child[8].
- 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 Cerebral Palsy, 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 utilize 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]
Tardieu Scale[edit | edit source]
The Tardieu Scale (TS) measures spasticity by passively moving the joints at three specified velocities - 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]
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 (AS)[edit | edit source]
This scale is used to grade the intensity of muscle tone through joint ROM on a five-point scale at one non-specified velocity. 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' 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 (Haugh et al., 2006).
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[12].
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.
|
Velocity |
Description |
|
V1 |
As slow as possible (slower than the natural drop of the limb segment under gravity) |
|
V2 |
Speed of the limb segment falling under gravity |
|
V3 |
As fast as possible (faster than the rate of the natural drop of the limb segment under gravity) |
|
Grade |
Decsription |
|
0 |
No resistance throughout passive movement |
|
1 |
Slight resistance throughout, with no clear catch at as precise angle |
|
2 |
Clear catch at a precise ankle followed by a release |
|
3 |
Fatigable clonus (<10 seconds) occurring at a precise angle |
|
4 |
Unfatigable clonus (>10 seconds) occurring at a precise angle |
|
5 |
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
Due to the large amount of time required to perform the full Tardieu Scale, the Modified Tardieu 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. [13] The MTS has been found to be a valid, reliable and sensitive abridged version of the TS. [14] [15] [16] 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. [14] [13] [17]
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 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. [11]
|
Grade |
Description |
|
0 |
No increase in muscle tone |
|
1 |
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 |
Considerable increase in muscle tone, passive movement is difficult |
|
4 |
Affected joint is rigid in flexion and extension |
TABLE 2: The Grading Scale and description for the Ashworth Scale of Spasticity Evaluation [18]
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. [9] 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. [16] [10] However, the AS displayed poor test and re-test results for both inter and intra rater reliability. [11] [16]
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. [19] 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. [19] 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. [13]
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. [11] [14] 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. [13] 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. [15] [16] There is also an incremental drop in muscle strength in all muscle groups, with increasing walking difficulty from GMFCS levels I to III. [14]
Strength [edit | edit source]
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. [11] [14] 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. [14] (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. [14] [11]
|
Grade |
Description |
|
0 |
No movement is observed |
|
1 |
Only a flicker or trace of muscle movement is seen or felt in the muscle or fasiculations are observed in the muscle |
|
2 |
Muscle can only move if the resistance of gravity is removed |
|
3 |
Muscle strength is further reduced such that the joint can be moved only against gravity with the examiner’s resistance completely removed |
|
4 |
Muscle strength is reduced but muscle contraction can still move the joint against resistance |
|
5 |
Muscle contracts normally against full resistance |
TABLE 3: The Medical Research Council Scale (MRCS) for muscle strength evaluation [17]
Range of Movement [edit | edit source]
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
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.
The hip joint should be assessed for the amount of available passive and dynamic 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:
- 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.
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. [18] 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)
|
A |
B |
|
| |
FIGURE 1: Physical evaluation of the ROM of the ankle joint due to the Soleus Muscle (A) and the Gastrocnemius Muscle (B) [9]
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. [10]
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. [19] 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. [11]
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. [14] 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. [16] [13] [15] [16] This is provided a strict measuring protocol is adhered to.
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]
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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).
- ↑ 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.
- ↑ 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.
- ↑ Lance JW. The control of muscle tone, reflexes, and movement: Robert Wartenbeg Lecture. Neurology. 1980 Dec 1;30(12):1303-.
- ↑ 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.
- ↑ 9.0 9.1 9.2 Aneja S. Evaluation of a child with cerebral palsy. The Indian Journal of Pediatrics. 2004 Jul;71(7):627-34.
- ↑ 10.0 10.1 10.2 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. Prosthetics and orthotics international. 2011 Sep;35(3):269-77.
- ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 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.
- ↑ 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.
- ↑ 13.0 13.1 13.2 13.3 13.4 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.
- ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 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.
- ↑ 15.0 15.1 15.2 Boyd RN, Barwood SA, Baillieu CE, Graham HK. Validity of a clinical measure of spasticity in children with cerebral palsy in a randomized clinical trial. Dev Med Child Neurol. 1998 Aug;40(Suppl 78):7.
- ↑ 16.0 16.1 16.2 16.3 16.4 16.5 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. Developmental medicine and child neurology. 2003 Oct;45(10):664-70.
- ↑ 17.0 17.1 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.
- ↑ 18.0 18.1 Rw B, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys ther. 1987;67(2):206-7.
- ↑ 19.0 19.1 19.2 Lance JW. Spasticity: Disordered Motor Control. Feldman RG, Young R.R., Koella W.P. , editor. Chicago: Year Book Medical Publishers; 1980.
