Evaluating the Child with Cerebral Palsy

Introduction

Most of the information leading to a diagnosis of cerebral palsy is usually obtained through a thorough history and examination. The most important task for healthcare professionals is to identify potentially treatable causes of injuries in children. healthcare professionals Evaluation of a child for possible cerebral palsy should have experience with the neurologic examination and evaluation of impaired children and knowledge of the underlying causes of cerebral palsy. Usually, but not necessarily, this practitioner should be a pediatric neurologist. once the exam Complete Depending on the results of the examination, the practitioner may order laboratory tests to aid in the evaluation.

There is no single test that can diagnose cerebral palsy. But because cerebral palsy is the result of many different causes, tests are done to determine the specific cause when possible. Other tests will be done to assess the child’s condition (such as nutritional status) or Assess for other concomitant conditions your child may have.

Clinical Assessment

Evaluation of a walking child with CP requires a unified multidisciplinary team (MDT), usually consisting of a physician or pediatrician, rehabilitation consultant, neurologist, orthopedic consultant, physical therapist, occupational therapist, clinical scientist, and orthopedist. [1] MDT requires Maintain a close working relationship with parents or caregivers to ensure consent for the assessment or any proposed interventions is obtained and to ensure that treatment is integrated into daily life.

Observing the child’s movements is an initial and critical part of the examination. Observe before touching. If the child is young, worried or crying, have them sit on mom’s lap while you watch and talk to mom. As children acclimatize, place them in Stay close to the mother/carer on the examination table or floor and watch them move around. If the baby cries a lot and is uncooperative, continue by laying them on the mother’s lap. The tools needed for the inspection are very simple: small toy logs/blocks of different shapes and Objects with different textures.

A comprehensive physical and biomechanical assessment is necessary to identify the specific joint and segment level to target any intervention. The physical examination of children with cerebral palsy should evaluate:

• prone position supine sitting standing walking;
• Muscle tone of the deep tendon reflexes in the trunk and neck of the extremities;
• Muscle Strength; and
• Joint range of motion of the subtalar and midtarsal joints of the hip, knee, ankle. [1] [2]

Because cerebral palsy is a movement disorder often manifested by abnormal muscle tone, it is critical to assess muscle tone during the initial and any future physical evaluation. Hypertonia due to additional pyramidal brain damage is known as dystonia and presents as Involuntary intermittent muscle contractions that cause twisting or repetitive movements in abnormal postures. Hypertonia in the presence of pyramidal encephalopathy manifests as muscle spasms. Spasticity accounts for 80% of the manifestations of cerebral palsy in children and is defined as a movement disorder It is characterized by a velocity-dependent increase in tonic stretch reflex (muscle tone) with exaggerated tendon twitches. [3] It results from overexcitation of the stretch reflex as a component of upper motor neuron syndrome. Recognition and quantification of spasticity is critical When determining appropriate orthotic intervention. Identify joint angles during joint range of motion (ROM) testing at slow, medium, and fast speeds, when increased muscle tone is first felt and helps determine anatomical joint angles at the end of joint ROM Placed within any orthotics that may be prescribed. It also determines whether and what type of mechanical joints can be included in the orthotic design.

Tone 

Measurement tools used to assess muscle tone in children with cerebral palsy can be divided into two broad categories, based on the assessment technique and quantification method. The Tardieu Scale (TS) assesses spasticity by passively moving the joint at three specified speeds (slow) under gravity and fast), while the strength and duration (X) of the muscle response to stretching was rated on a 6-point scale (Table 1), and the joint angle (Y) was recorded at the location where the muscle response was first felt . [4]

VelocityDescriptionV1As slow as possible (slower than the natural falling speed of limb segments under gravity)V2Velocity of limb segments falling under gravityV3As fast as possible(faster than the natural falling speed of limb segments under gravity)GradeDecsription0No resistance throughout Passive movement 1 Slight resistance throughout, no apparent catch at precise angles 2 Clear catches at precise ankles followed by release 3 Fatigable clonus at precise angles (10 seconds) 5 Joint immobility

Table 1: Definition of velocity used in the assessment of spasticity using the Tardieu scale and the 6-point scale used to grade the quality of muscle response

Because of the substantial time required to administer the full Tardieu scale, the Modified Tardieu Scale (MTS) was developed. It only records joint angles during fast and slow. It uses the most clinically relevant part of the TS: the capture angle (R1) at maximum speed and the joint angle when the muscle length is at its maximum (R2), assessed by moving the joint to full ROM using slow passive movements. [5] MTS has been found to be a valid, reliable and sensitive abridged version of TS. [6] [7] [8] Angle difference between angles R2 and R1 is known as the dynamic component of spasticity and estimates the relative contribution of spasticity compared to muscle contractures. [6] [5] [9]

The Ashworth Scale (AS) grades muscle tension strength by joint ROM at an unspecified speed on a five-point scale. (Table 2) Modifications of the AS are referred to as the Modified Ashworth Scale (MAS). The literature also describes that the MAS includes a 6-point rating scalea Severity of muscle tone is graded and muscle tone is assessed at an unspecified “rapid” rate. [4]

Grade Description 0 No increase in muscle tone 1 Slight increase in muscle tone, manifested by grasping and release or minimal resistance at the end of the range of motion when the affected joint flexes or extends, or minimal resistance 1 Slightly increased muscle tone, manifested by grasping followed by minimal resistance Resistance throughout the rest of the ROM (less than half) 2 Significantly increased muscle tone in most ROM, but affected joint moves easily 3 Significantly increased muscle tone Difficulty with passive movement 4 Affected joint is stiff in flexion and extension

Table 2: Grading scale and description of the Ashworth Spasticity Assessment Scale [10]

As with any measurement tool, common sources of error are due to inaccuracies of the individual measuring instrument making the measurement and variability in the measured characteristic. [1] Studies on the reliability of TS and MTS show that both internal and external reliability are high Rater reliability when assessing children with cerebral palsy, given sufficient time for training and practice. [8][2] However, AS showed poor test and retest results in terms of inter-rater and intra-rater reliability. [4] [8]

Spasticity is defined as a velocity-dependent increase in muscle tone, which means that only the Tardieu scale is an appropriate assessment tool because it accounts for the velocity dependence of spasticity by passively stretching the muscle at three different velocities. [3] AS Assessment Tool Measuring passive resistance to movement at one speed leads to instability and overestimation in identifying spasticity, especially in the presence of muscle contractures. [3] Despite the widespread use of AS and its ability to identify general hypertonia, it is recommended that this The tool is no longer used and TS or MTS are used to assess muscle tone in children with cerebral palsy. [5]

Children with cerebral palsy who present with altered muscle tone often show signs of underlying muscle weakness, so it is important to assess lower extremity muscle strength in children with cerebral palsy. [4] [6] Muscular child with cerebral palsy Strength will be achieved at a higher level of motor function because muscle strength is more correlated with function than the presence of spasticity. [5] Muscle strength and children’s motor function walking speed energy expenditure and temporal space gait characteristics. [7] [8] As the difficulty of walking increases from GMFCS levels I to III, there is a gradual decrease in muscle strength in all muscle groups. [6]

Strength 

The presence of muscle weakness can cause muscle imbalances in other joints. This muscle imbalance is thought to be a factor in the development of muscle shortening, contributing to rotational deformity and further affecting motor function in children. [4] [6] So when executing Orthotic assessment in children with cerebral palsy A complete muscle strength profile of the lower extremities is critical. The Medical Research Council Scale (MRCS) for manual muscle testing is a widely accepted clinical assessment tool for grading muscle strength in children with cerebral palsy. [6] (Table 3) During the assessment, it is important to note if the child is uncooperative, unable to isolate the muscle being tested or understand what is being asked of them. If muscle strength needs to be further quantified, a hand-held dynamometer can be used. [6] [4]

Grade Description 0 No movement observed 1 Only flickering or traces of muscle movement seen or felt in the muscle, or fascicles observed in the muscle 2 Muscle moves only when resistance to gravity is removed 3 Muscle strength is further reduced, Allows joints to move only against resistance Gravity, examiner’s resistance is completely eliminated 4 Muscle strength is reduced, but muscle contraction can still move the joint against resistance 5 Muscle contracts normally against full resistance

Table 3: Medical Research Council Scale (MRCS) for assessment of muscle strength [9]

Range of Movement 

Muscle contractures and skeletal deformities are common secondary musculoskeletal problems that may occur in children with cerebral palsy. These secondary musculoskeletal problems result in a reduction in available lower extremity joint ROM in children. Therefore evaluate and quantify Passive and dynamic lower extremity joint ROM are important components of orthotic evaluation in any child with cerebral palsy. These findings aid in intervention evaluation of orthotic prescriptions and monitoring of growth changes.

The amount of passive and dynamic ROM available to the hip joint during flexion, extension, abduction, and adduction should be assessed. Hip flexion contractures are common in children with predominantly spastic cerebral palsy. primary flexion contracture of the hip Affects the kinematics of a child’s gait by:

• limit heel contact during initial contact;
• changing the position of the body weight line during the stance phase;
• Changing the inclination of the femur and tibia during the stance phase;
• Reducing the amount of hip extension may cause interruptions in the transfer through the second and third rockers of the stance phase.

The knee needs to be assessed for flexion and extension in passive and dynamic ROM. It is also important to assess range of motion for passive active and speed-specific knee extension with the child supine and the hip flexed to approximately 30°. this location Replicate the degree of hip flexion that occurs at initial contact of gait and determine the degree of possible knee extension during the early stance phase.

To determine plantar and dorsiflexion ROM of the ankle, it is important to maintain the subtalar joint in a neutral position, and it is best to test with the child in the supine position. Movement of the subtalar joint eversion or varus during dorsiflexion The ankle will affect the length of the gastrocnemius muscle and may produce false results for the available dorsiflexion ROM. [10] Plantar extensor patterns are often present in the lower extremities of children with spastic manifestations of cerebral palsy. This usually results in gastrocnemius or The soleus is affected by increased muscle tone. The gastrocnemius is a biarticular muscle that originates at the proximal femoral condyle and inserts at the base of the calcaneus. Bend the hips and knees to 90°, then bend the ankles back to eliminate The gastrocnemius muscle on the foot and ankle allows checking the available ROM and muscle tone specifically attributed to the soleus muscle. (Figure 1A)

AB

Figure 1: Physical assessment of ankle ROM induced by the soleus (A) and gastrocnemius (B) muscles [1]

Alternatively, establish a ROM of ankle dorsiflexion by placing the hip in 30° flexion, the knee in maximum achievable extension, the subtalar joint in neutral, and dorsiflex the foot, which can be attributed to due to changes in muscle tone or ankle contractures Gastrocnemius. (Fig. 1B) Assessment of ankle ROM due to gastrocnemius length can determine the child’s plantar flexion knee extension pair. This is used during AFO prescribing to determine the Ankle Angle in AFO (AAAFO) and is a measure of the dorsal aspect of the ankle or plantar The flexed ankle is inside the AFO. It is defined as the angle of the foot relative to the tibial crus when viewed in the sagittal plane. [2]

A walking child with cerebral palsy develops torsion deformity when the muscles are out of balance and the bones are loaded and grown abnormally due to increased tone or weakness. [3] Therefore, it is important to include the assessment of rotation of the lower extremity joints. Specific areas The assessment is hip medial/external rotation, degree of femoral anterior/posterior tilt, tibial torsion, subtalar varus/valgus and midtarsal abduction/adduction. Determining the torsional curve of a child’s lower extremity can help determine if a torsional moment arm defect is present and thus aid in corrective prescription current. [4]

Goniometry is the most widely used technique to assess passive or velocity-dependent lower extremity joint ROM in children with cerebral palsy. [6] Factors such as the number of assessors, patient compliance, and measurement methods can affect the reliability and reproducibility of the assessment measure. Several studies involving children with spastic cerebral palsy found that goniometric measurements showed high levels of intra- and intra-internal reliability and reproducibility to trained and experienced observers. [8] [5] [7] [8] Subject to strict measurement protocol arrive.