Cerebral Palsy Assessment

Assessment of the child gives a baseline to appropriate treatment and management aims and techniques. Re-assessment should be continuing part of treatment, which allows for improvement or deterioration to be noted, thus enabling treatment to be more effective.

The therapist must have knowledge of normal development. During physical examination, it is important to discriminate between delay in motor development and abnormal motor patterns.

It is very essential for the therapist to explain, what he is going to do before handling the child.

Assessment needs to be playful, interesting and non-threatening. Assess young child as much as possible on parent’s lap. Observe child among familiar toys as well as with selected toys to activate interest as well as reveal dormant abilities.

Keep sessions within the bounds of a child’s concentration. Have an unhurried atmosphere. Have easy, successful actions of a child interspersed with difficult tasks.

Subjective Examination:

Subjective information should be obtained from the parents especially mother or from relatives and through case-sheet.

General details includes • Name • Age & Sex • Address

When did the mother first noticed the dysfunctions Siblings having same type of symptoms Prenatal History • Age of mother • Consanguity marriage • Any drugs taken during pregnancy • Any trauma & stress • Any addiction – smoking or alcoholism • History of rubella or cytomegalovirus, toxoplasmosis infection • History of previous abortions, still born or death after birth • Multiple pregnancies (duration between pregnancies) • Status & cast of the mother

Perinatal History • Place of delivery • History preterm or full-term delivery • History of asphyxia at birth

• Type of delivery – Forceps delivery • Presentation of child – Breech presentation • Any history of prolonged labour pain • Condition of mother at the time of delivery

Postnatal History • Delayed birth cry (when child cried) • Weight of the child at birth – Low Birth Weight (LBW) • History of any trauma to brain during the first 2 years of life • History of neonatal meningitis, jaundice, or hypoglycemia • Hydrocephalus or Microcephaly • Nutritional habits of the child (malnutrition) • Feeding difficulties

Any medical or surgical treatment taken Any physiotherapy treatment previously taken • What was the ability level of child at that time? • What obstructs the child from progress? • What treatment was used? • Was the treatment effective or not?

Apgar Score from the case-sheet Objective Examination:

On Observation:

Behaviour of the child • Whether child is alert, irritable or fearful in the session or during particular

activities • Child becomes fatigued easily or not during activity • Find out what motivates his action – particular situation, person or special

plaything Communication of the child • How child communicates with the parents • Whether child initiates or responds with gestures, sounds, hand or finger

pointing, eye pointing or uses words and speech Attention span • What catches child’s attention? • For how much time child’s attention is maintained on particular thing • How does parent assist him to maintain attention? • What distracts the child?

Does child follows suggestions to move or promptings to act? Position of the child • Which position does the child prefer to be in? • Can child get into that position on his own or with help?

• With assistance, child makes any effort to go in that position • Symmetry of the child (actively or passively maintained) • If involuntary movements present, then in which positions these movements

are decreased or increased Postural control & alignment • How much parental support is given • Postural stabilization and counterpoising in all postures • Proper & equal weight bearing • If the child’s center of gravity appears to be unusually high, resulting in

floating legs and poor ability to raise head against gravity • Fear of fall in child due to poor balance

Use of limbs & hands • Limb patterns in changing or going into position as well as using them in

position • Attitudes of limbs during playing in all positions • Whether one or both hands are used, type of grasp and release • Accuracy of reach and hand actions • Any involuntary movements, tremors or spasms, which interfere with actions,

are present Sensory aspects • Observe child’s use of vision, hearing, of touch, smell and temperature in

relevant tasks • Does child enjoys particular sensations • Whether child enjoys being moved or having position changed

Form of Locomotion • How child is carried • Any use of wheelchair or walking aids • Which daily activities motivates child to roll, creep, crawl, bottom shuffle or

walk Deformities • Observe any recurring position of the whole child • Any part of the body, which remains in particular position in all postures & in

the movements • The positional preferences typically seen in spastic cerebral palsies are for mid

positions of the body - In the arm, this generally consists of

Shoulder protraction or retraction, adduction and internal rotation Elbow flexion Forearm pronation Wrist & Fingers flexion

- In the legs, it includes Hip semi-flexion, internal rotation and adduction Knee semi-flexion Ankle plantar flexion

Foot pronation or supination Toes flexion

• Athetoid or dystonic posturing usually incorporates extremes of movement such as total flexion or extension

• Windswept Deformity of hip – One hip flexed, abducted and externally rotated; other hip flexed, adducted and internally rotated and in danger of posterior dislocation

On Examination:

Sensory Assessment • It is difficult to assess sensation in babies and young children with severe

multiple impairments. • If any hearing or visual or psychological abnormalities are present then

assessment done by specialist is required Motor Assessment • Growth Parameters

- Height Until 24 to 36 months of age, length in recumbency is measured using an infantometer. After the age of 2 years standing height is recorded by a stadiometer.

Height Centimeters InchesAt birth 50 20 At 1 year 75 30

2 to 12 years (Age in years × 6) + 77 (Age in years × 2) + 30 - Weight of the child

Weight Kilograms PoundsAt birth 3.25 7

3 to 12 months (Age in months + 9) / 2 Age in months + 11 1 to 6 years (Age in years × 2) + 8 (Age in years × 5) + 17

7 to 12 years [(Age in years × 7) + 5] / 2 (Age in years × 7) + 5

- Head circumference of the child The tape is used to measure the occipitofrontal head circumference from external occipital protuberance to the glabella.

Head circumference Centimeters At birth 35 3 months 40

1 year 45 2 years 48

12 years 52

• Developmental Assessment

Age Developmental Milestones 4 to 6 weeks Social smile

3 months Head holding 6 months Sits with support 7 months Sits without support

5 to 6 months Reaches out for a bright object & gets it 6 to 7 months Transfers object from one hand to other 6 to 7 months Starts imitating cough

8 to 10 months Crawls 10 to 11 months Creeps

9 months Standing holding furniture 12 months Walks holding furniture

10 to 11 months Stands without support 13 months Walks without much of a support 12 months Says one word with meaning 13 months Says three words with meaning

15 to 18 months Joints 2 or 3 words into sentence 13 months Feeds self with spoon

15 to 18 months Climbs stair 15 to 18 months Takes shoes and socks off

24 months Puts shoes and socks on 24 months Takes some clothes off 3 to 4 years Dresses self fully

2 years Dry by day 3 years Dry by night 3 years Knows full name and sex 3 years Rides tricycle

• Joint Range of Motion (active & passive) - Active head and trunk flexion, extension, rotation observed during head

raise in prone, supine, sitting, standing developmental channels - Active shoulder elevation, abduction, rotation, flexion and extension

movements are observed during the functional examination of creeping, reaching and other arm movements

- Active elbow flexion and extension observed during child’s reach to parts of body or toys

- Active wrist and hand movements will be observed during function development

- Active hip flexion and extension will be observed during all functions - Active knee flexion and extension seen with active hip flexion extension - Foot movements are also check during functional development

• Reactions, Responses and Reflexes - Sucking Reflex (3 months) - Rooting Reflex (3 months) - Grasp Reflex (3 months) - Reflex Stepping (2 months) - Galant’s Trunk Incurvation (2 months) - Moro Reflex (0-6 months) - Startle Reflex (remains) - Landau Reflex (3 months - 2½ years) - Flexor Withdrawal (2 months) - Extensor Thrust (2 months) - Asymmetric Tonic Neck Reflex (ATNR) (usually pathological) - Symmetrical Tonic Neck Reflex (STNR) (usually pathological) - Tonic Labyrinthine Supine (pathological) - Tonic Labyrinthine Prone (3 months) - Neck Righting (5 months) - Positive Supporting (3 months) - Negative Supporting (3-5 months) - Protective Reflexes If reflexes are persistent beyond the usual duration then they are called positive signs. If reflexes, which are supposed to be, present during particular age but are absent are known as negative signs.

• Muscle tone • Reflexes

- Superficial Reflexes - Deep Tendon Reflexes

• Limb Length Discrepancy - Apparent (umbilicus to lateral malleolus) - True (ASIS to medial malleolus)

• Contractures • Deformities

Gait (if applicable) Transfer activities (if applicable) Balance (if applicable) Assessment of daily activities • Assessment of feeding, dressing, washing, toileting, play and hand function • Ambulation (dependent or independent)

Cognitive Assessment (if applicable) • Response to external environment & Behaviour • Sense of colour, size, shape • Sense of common dangers as fire • Toilet training • Sense of household articles