Topic: Cerebral Palsy Assessment Ideal for: BPT and BOT students Level: Beginner

1. CEREBRAL PALSY
ASSESSMENT

2. DEFINITION :-
• Cerebral palsy is a group of disorders of development
of movement and posture .
• It is an umbrella term covering a group of non
progressive but changing motor impairments due to
lesions or anomalies of brain.
• It includes various kinds of disabilities like difficulty in
coordinated movements, difficulty in maintaining an
upright posture against gravity .

3. DEMOGRAPHIC DATA
• NAME :- def
• AGE :- 4 year
• GENDER :- male
• D.O.B. :- dd/mm/yyyy
• RELIGION :- Muslim
• ADDRESS :- xyz
• HEIGHT :-
• WEIGHT :-
• DATE OF ASSESSMENT :-

4. CHIEF COMPLAINTS :-
PATIENT AT AGE OF 12 OR 18 MONTHS
• He is not able to hold the toys
• He is not able to sit with his own
• He also looks like a lazy child
• His head lag behind the body or no head
control
• No head movements
• He keep his eyes at one point
• He does not respond to any voice or
command

5. PATIENT AT AGE OF 4 AND ABOVE
• Unable to walk
• Frequent falls
• Feeding difficulty
• Does not respond to commands
• Dental caries

6. HISTORY OF PRESENT ILLNESS:-
• At 8th month of pregnancy the mother falls, due to
slipped in bathroom. Immediately a caesarian
delivery was done. The child did not cry and blue
in colour. Child also got epileptic attack. During the
course of 6 month the child not develop head
control, eye control.
• Initially the child did not make any movement and
don’t crawl. Then parents feel tightness in the
lower extremities of the baby.

7. HISTORY OF PRESENT ILLNESS :-
•PRE-NATAL HISTORY
•PERI-NATAL HISTORY
•POST-NATAL HISTORY

8. PRENATAL HISTORY
• Trauma occurs during first trimester of pregnancy,
vascular events like middle cerebral artery infarcts
• Genetic abnormalities occuring due to early
marriage

9. AGE OF MOTHER IS AN IMPORTANT
CAUSE :-
• When mother is too young {age below 18 years} or
too old {above 40 years}
• Down’s syndrome and Turner’s syndrome are
common
•AGE OF FATHER :-predisposes the child to
congenital defects due to chromosomal
abnormalities
•SMOKING:-leads to intrauterine growth
retardation , low birth weight infants and
mental retardations

10. •NUTRITION OF MOTHER :-malnourished
leads to CNS abnormalities
• EVALUATION OF MOTHER:- for cancer,
diabetes, leukemia …. if mother is suffering
with diabetes child may be large for
gestational age, can suffer for respiratory
distress syndrome.
• Multiple pregnancies, twins, triplets suffer
from cerebral palsy

11. •DRUGS LIKE:-
 Thalidomide leads to absence of limbs
 Warfarin leads to atrophy of optic nerve
and agenesis of corpus callosum
Anticonvulsants/ antiepileptics leads to
mental retardation
Streptomycin leads to deafness due to 8th
cranial nerve affection
Alcohol consumption leads to craniofacial
abnormalities and growth retardations

12. •INFECTIONS:-
Herpes simplex, rubella, cytomegalo virus,
HIV, syphilis leads to hydrocephalus , mental
retardation and cerebral calcificataion
Environmental intake of chemicals like
Mercury ( slow storage in body leads to CNS
abnormalities)

13. PERI-NATAL HISTORY:-Full time normal
delivery . If not check for the risk factor
• Duration of labor, whether the child cried
immediately after the birth or not, umbilical cord
entraigulation, brachial plexus injury or Erb’s palsy
.
• Hypoxic –ischemic encephalopathy, untreated
jaundice or severe neonatal infections.

14. POST-NATAL HISTORY :-
• INJURIES :-
cererebrovascular accident, trauma, infections, severe jaundice after
the birth

15. History of past illness :none
Medical history:- none
Surgical history:- none
Parental history:- none
SOCIAL HISTORY:-
 living environment ( chemical factory )
Education status of parents
Care taker of child
Economic status

16. PERSONAL HISTORY:-
Age of parents
Smoking or drinking habit of mother during
pregnancy
Nutritional status of the child

17. DEVELOPMENTAL MILESTONES:-
• Children develop from being totally dependent newborns to
independent individuals by the acquisition of skills
• Range of normality in the acquisition of skills
• Development follows an orderly process in a cephalic to caudal
direction

18. Routine Child Surveillance:-
• New born
• Supine (6-8wks)
• Sitting (6- 9 months)
• Mobile toddler (18-24mths)
• Communicating child (3-4yrs)

19. • Birth:-prone: pelvis high, knees under abdomen
• 6-8 weeks :-smiles to maternal overtures fixes & follows
• prone: pelvis flat, hips extended ventral: briefly holds head
up, goodeye hold turns
• 3 months:- contact rattle in hand to sound ear level

22. • 4-5 months :- able to reach out for object
• 6 months :- transfers hand to hand chews babbles
, sits with hand forward lifts head spont from
supine
• 10 months :- index finger approach finger thumb
apposition waves bye bye
• 13 months :- casting object walks without support
single words
• 15 months :- feeds self from cup domestic mimicry
• 18 months :- casting stops , tower of 3 walking
scribbles

23. • 2 years :- joins 2-3 words, 50 words , Runs well,
climbs stair, cubes tower 6 or 7
• 3 years :-mainly dry by day/night dresses and
undresses fully
stairs :- alternate feet , rides tricycle

24. milestone Present/absent At what age it come
Visual fixation 1 month
Recognition of mother 1.5 month
Neck control 4 months
Turning over 5-6 months
creeping 7-8 months
crawling 7-8 months
sitting 8-9 months
standing 9-10 months
Walking 11-12 months
Speech monosyllable 1 year

25. PHYSICAL HISTORY OF CHILD
• Birth weight : normal 5 pound
• Birth height
• Head circumference
• Proportion of upper limb and lower limb
• Brachial plexus injury

26. OBSERVATION:-
• Built :-
• Attitude of patient – irritated or silent
• Head size and shape
• Posture :- lying
sitting
standing

27. LYING :-
•SUPINE
 Squint , starring , at one point
Head lag
Frog position
Movement of one arm/leg than other

28. LYING :-
• PRONE
Immobile
Frog position (flexed)
Unable to brings arms from under the body
Arching of back
Overextension
Head control

29. SITTING :-
On floor
W-sitting on floor
On chair
Difficulty in independent sitting
Fall on side or back
Flexed posture of upper limb
Tremors on picking any object

30. STANDING:-
• Child may fall
• Flexed neck
• Flexed hip and knee
• Heel of the ground
• Fear of fall

31. ANY DEVICES:-
• Any splint
• Any orthosis : commanly AFO
• Any catheter like urinary

32. Local observation:-
• Scar or soft tissue release
• Any bruises , haematoma , Clots
•Examination:- VITALS
Heart rate:- new born:-120-160beats/min
1-12months:-80-140beats/min
1-2 years:-80-130beats/min
2-6 years:-75-120beats/min
7-12years:-75-110beats/min

33. • Respiratory rate :-
birth to 6 weeks :- 30-60 breaths/min
6 months :- 25-40 breaths/min
3 years :- 20-30 breaths/min
6 years :- 18-25 breaths/min
10 years :- 15-20 breaths/min
adults :- 12-20 breaths/min
 Blood pressure:-normal systolic :-100-140 mmhg
normal diastolic :-65-90 mmhg

34. PALPATION :-
• Temperature :- normal 37*c
• Edema :- pitting or non pitting
• Tenderness
• Tightness
• Tone
• Spasm

35. Higher mental function :-
Can be observed during play therapy
 Behavior – whether the child is alert , irritable ,
or fearful during activities
- child become fatigue easily
 Communication – how the child communicates
with the parents , uses words of speech
 Attention – for how much time child’s attention
is maintained on particular thing

36. • For example :-
• Question :- what’s u r name ?
Ans.- my name is xyz
This answer gives knowledge that the patients
hearing , speech and oriented knowledge
regarding ques. Is present , so we can have an idea
of age appropriate higher functions present or
absent . If not these things should be concentrated
while addressing protocol .

37. Checking IQ level :-
• IQ = mental age X 100 / chronological age
For mental age = social maturity test
color progressive metriasis
Normal IQ = >90
Borderline IQ = 70-80
Mild IQ = 60-70
Moderate IQ = 50-60
Severe IQ = < 50

38. CRANIAL NERVE EXAMINATION :-
• Unable to recognize smell – olfactory nerve involvement
• Visual problem - optic nerve involvement
• Squint or gaze – occulomotor , trochlear , abducent nerve
involvement
• Sensory impairment on face – trigeminal nerve involvement
• Asymmetry on face – facial nerve involvement

39. • Hearing impairments – vestibulocochlear nerve involvement
• Dysarthria – hypoglossal nerve involvement

40. Respiratory examination :-
• Chest expansion at all level
At axillary level :-
At nipple level :-
At xiphisternum level :-

41. Sensory examination :-
•Superficial :-
Pain
Touch , light or pin prick
Temperature
Deep :-
Pressure
Proprioception
Kinesthesia , vibration

42. •Cortical :-
 Sterognosis
 Barognosis
 Graphesthesia
 Two point discrimination by
asthesiometer
 Check for hearing , vision and smell

43. Sensory evaluation :-
• Fine and crude touch
• Cold and hot temperature
• Deep and superficial pain
• Proprioception
• Kinesthetic sensation

44. Reflex examination :
Superficial reflexes :Abdominal
• Babinski
• Chaddock
Deep tendon reflexes : Biceps
• Triceps
• Brachioradialis
• Knee
• Ankle
Increased in case of spasticity

45. Neo-natal reflexes :-
• Moro reflex
• Palmar grasp
• Rooting reflex
• Sucking reflex
• Planter grasp
• ATNR
• STNR

46. Motor assessment :-
• 1 ) Tone :-
0 :- absent
1+ :- hypotonia
2+ :- normotonia
3+ :- hypertonia
Examination :- ask the patient to relax
- Flex and extend the patient’s finger , wrist , elbow
- Flex and extend the patients ankle and knee

47. - There is normally a small , continuous resistance
to passive movements
- Observe for decreased or increased tone
2) Muscle girth :- compare with normal limb
Check through the help of enchitape
3) Range of motion :-
Active
Passive
End feels and MMT

48. 4) Manual muscle testing :-
• When muscle is flaccid then do
• 5 :- maximum resistance
• 4 :- minimal resistance
• 3 :- against gravity
• 2 :- gravity eliminated
• 1 :- flickers
• 0 :- no contraction

49. • If tone is higher then use modified ASHWORTH SCALE
is used :-
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
ROM
1+ - slight increase in muscle tone , manifested by a
catch , followed by minimal resistance throughout the
ROM
2 – more increase in muscle tone throughout the ROM

50. 3 – considerable increase in muscle tone , passive
movement is difficult
4 - rigid in flexion or extension
After assessing ROM certain muscle tightness are
generally common they are
Hip – flexors ,adductors, internal rotators
Knee – flexors
Elbow – flexors
Wrist and finger - flexors
Spine – lateral rotators

51. 5) Deformity :-
• Scoliosis ( functional or structural )
• Upper and lower limb deformity due to contracture
6 ) limb length discripancy
7 ) synergy / voluntary muscle control

52. Balance test :-
• Static balance – standing with feet together , toe standing , tandem
standing ,romberg test , nudge standing
• Dynamic balance – rotatory chair test
• Functional balance – functional reach test , timed up and go test

53. Coordination :-
• Equilibrium – finger to nose , finger to finger , finger to therapist
finger , heel to toe test
Non equilibrium - standing comfortable with normal BOS , standing in
tandem , standing with toe, march on place , walk in circle

54. Gait examination :-
Temporal parameters :- velocity and cadence
Spatial parameters :- stride length , step length , degree of toe out
Observational and subjective examination :-
Step length
Base of support
Walking velocity
C.P child have SCISSORING gait

55. SCISSORING GAIT
Inward pointed toes while walking
Leg cross over each other while walking
MISSING MOVEMENT :-
Hip extension & external rotation
Knee extension
Ankle dorsiflexion
No heel contact is there

56. Bladder & bowel examination:
Types of bladder
1- flaccid
2 – spastic
C.P child mainly have urine incontinence

57. Investigations :-
• APGAR score : after 5 min of birth generally low
• CSF study : shows perinatal asphyxia
• EEG
• ULTRASONOGRAPHY : for scanning the brain
• CT Scan
• MRI : done with in 2 or 3 weeks for determining the extent of brain
damage

58. APGAR SCORING :-
• Scores 7 and above = normal
• Between 4-6 = fairly low
• 3 and below = critically ill
This test is administered during the 1st 5 min of delivery and may be
repeated if the scores are low .

59. • A = APPEARANCE
• P = PULSE
• G = GRIMMACE
• A = ACTIVITY
• R = RESPIRATION

60. APGAR score :-
0 1 2
A Blue , pale allover Blue at the extremities
,body is pink
No cyanosis , body and
extremities are pink
P absent Less> 100 More than 100
G No response to
stimulation
Feeble cry on
stimulation
Cry or pull away when
stimulation
A none Some flexion is there Flexed arms & leg that
resist ext.
R absent Weak or irregular
gusping
Strong & lustine cry

61. Differential diagnosis :-
• BRAIN TUMOR
• MOTOR DELAY
• HEMIPARESIS
• SUBDURAL HAEMATOMA
• MENTAL RETARDATION
• MUSCULAR DYSTROPHY