Chapter 2
Evaluation of Cerebral Palsy
Copyright 2005 Lippincott Williams & Wilkins
 Definition of Cerebral palsy:
 It is neurodevelopmental disorder caused by non
progressive lesion in single or multiple location
of immature)before2 years) leading to persistent
disorder in posture and environment in early
infant life.
 Etiology:
Prenatal (from conception to birth)
a- Trauma
b- Toxoplasma
c- Radiation
d- Drugs
e- Pollution
f- diabetics
g- Viral infection
h- German mdesis
Perinatal (during delivery)
a- Forceps causes brain damage
b- Anoxia(No o2 in blood)
- c- Hypoxia( decrease o2 in blood)
d- pralopard umbilical
cord
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 3 – postnatal causes:
Jaundice ,Fever, Malnutrient, Trauma , Meningitis
Types of Cerebral Palsy:
1- According muscle tone distribution (Topographic):
a- Monopegia: one limb
b- diaplegia: 4 limbs (Lower limbs more than upper limbs)
c- Hemiplegia: half of the body
d- Quadriplegia: 4 limbs
e – Triplegia: 3 limbs
f- Double Hemiplegia
2- According muscle tone disturbance:
a- Spastic type: Quadriplegia
b- Stegmus type ataxic type (rare)
c- Dyskinesia type: involuntary movement affect basal ganglia due to jaundice
D- Hypotonia : central forever Transient for certain period
E- mixed type
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 Assessment:
 Factors affecting the assessment:
 1- Age
2- Developmental level
 3- Degree of involvement(Severity) 4- Surrounding environment
Main aim of evaluation to put proper program of treatment
Team worker in assessment of C.P
1- pediatrition
2- neurologist 3- physical therapist 4- Occupational
Therapist
5- Social Worker
6- Nutritionist
7- Dentist
Defintion of evaluation :
It is a process of collecting and organizing information to plan proper treatment
POMR have 4 areas:
1- Data base
3- Initial Plane
2- problem list
4- Progress note
1- Data base
All subjective and objective information collected on child
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 Source: patient file
Include a- Diagnosis title, type
b- Referred from physician
c- Frequency of session
2- History Talking;
Personal History: Name Age by months Sex
Present history
Chief complain in wards of mother
Past History Any disease or surgery not related to CP
Family History: Consanguinity, Arrangement of child to his brothers
Parents attitude about child, Any familiar cases
Medical history: Anti epileptic drugs, muscle relaxant
3-Physical evaluation:
Informal evaluation (general overview at patient)
Formal evaluation (Functional test)
Standardized evaluation (objective test like MRI, CT)
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• a- Informal evaluation
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1-posture to determine
Tone (ex: flexion in upper limb indicate flexor hypertonia)
persistent primitive reflex ASTNR
2- Movement or spontaneous motility of child:
a- Initiation of movement: like hemiplegia initiate movement by non affected
limb then affected limb
b- Speed of movement: : like hemiplegia cerebral palsy have long latency of
response due to lack of understanding directions
3- Asymmetry of movement: between up& low Limb, RT & LT Side
4- Associated movements or mirror of movement: When make action in one
side other side make same action -----------inhabit isolated movemen 5- S
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5- Associated disorder:
a- Vision---- tested by attractive toy and he
follow it by his head
b- Hearing------ tested by attractive sound
or startle reflex
stimulus: sudden noise beside his ear
Response: flexion in elbow and fist hand Age birth and continue
c- Deformities and contracture
Determine direction of deformity
Determine degree of deformity:
First degree : can be corrected actively Second: can be corrected passively
Third: corrected only by surgery
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• Formal evaluation
• 1- Muscle tone assessment:
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Slight resistance or amount of tension that you feel when move muscle
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Methods of assessment: 1- passive movement
2- Shaking to distal part in all direction
3- Postural fixation(sudden release of limb)
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Passive movement performed in all 4 directions, constant speed, Rhythmic
Determine : body part examined(upper limb, lower limb)
Type of muscle tone (hypertonia, hypotonia)
Distribution (flexor, extensor. Abductor, adductor)
Spasticity has clasp knife phenomena increase resistance then suddenly
release
Factors affecting evaluation of muscle tone;
1-laughing 2- excitement 3- Surface 4- light 5- Sleeping 6- head
position
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2)- Assessment of reflexive maturation
3)- Assessment of development by using Denver developmental
Screening Test (DDST):include 4 components:
1- Gross Motor: the ability of the child to maintain and assume certain
position such as sitting, rolling creeping
2- Fine Motor: hand manipulation, hand coordination, reaching,
grasping
3- Language: lolling , pepping
4- Personal- social : How the child interact with environment
DDST consists of 105 tasks in 4 areas
Used for children from 1 month to 6 years
Each task divide to 25, 50,75,90 %
25% of population able to perform this task in this month
90% not 100% because 10% of population are hanedicap
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• How to use DDST:
• 1- Ask the mother about chronological age
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2- Ask the mother if he can do the task or not
3-Mark the task whenever make it 25, 50,75,90
CP child have scattering milestone that means he can do task before
another task standing before sitting this is due to:
a- The organization or systemic myelination of CNS
b- Habits the child like to stand on toes by +ve suuporting not sitting
How to measure scattering of milestone?
put marks on last task he can do it and other mark on scattered task
Summate both then divide them on two.
• 4- Musculoskeletal assessment: determine degree of tightness
by flexibility test
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1- soleus: put knee in flexion and make dorsiflexion if he
cannot so he have tightness
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2- Gastrocnemius: put knee in extension and make dorsiflexion if he cannot so
he have tightness
3- Iliopsoas: make flexion hip and knee in one side if flexion hip occur on
opposite side ------------tightness of Iliopsoas muscle
4- Hamstring Muscle
Degree of deformities:
1st grade---------- Child can correct it actively
2nd grade----------Child can correct it passively
3rd grade----------- Child cannot correct it need surgical interference
Assessment of gait in CP: Common types of gait in CP
Spastic diaplegia:
a- Mild or moderate type: Couch gait
Description: Semi flexion in hip, adduction ,internal rotation hip and
plantar flexion of ankle in both lower limb, slight bending in neck, trunk
forward high guard in upper limb(abduction in upper limb with flexion
elbow posterior pelvic tilt and very quick steps
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Cause of gait: sitting position (W shape) sitting on his feet because of
always working of hip extensors(gluteus Maximus and hamstring)
Happits: he wants to lower himself to BOS.
b- In sever type : scissor gait ( extension, adduction , internal rotation)
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Because of sever extensor spasticity will stimulate +ve supporting reaction
• 2- Spastic hemiplegia:
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Circumduction gait by quadratus lambrum hike pelvis
upward to clear foot from ground
Patient will take long step by affected limb and short step by non affected limb to
decrease time of bearing on affected limb
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3- Athetosis: Athetoid dance confliction between two reflexes : Flexor
withdrawal and toe grasping reflex
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4- Ataxic: drunken gait wide BOS due to poor balance
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