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Cerebral palsy Assessment

Assessment of the child gives a baseline to appropriate treatment and management aims and techniques. Reassessment 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 motordevelopment and abnormal motor patterns. It is very essential for the therapist to explain, what he is going to do before handlingthe 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 aswell 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 orfrom relatives and through casesheet. 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: Behavior 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 releaser 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 midpositions of the bodyIn 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 ParametersHeight Until 24 to 36 months of age, length in recumbency is measured using an Infant-meter After the age of 2 years standing height is recorded by a stadiometer Height At birth At 1 year 2 to 12 years centimeters 50 75 (Age in years × 6) + 77 Inches 20 30 (Age in years × 2) + 30

Weight At birth 3 to 12 months 1 to 6 years 7 to 12 years

Weight of the child kilograms 3.25 (Age in months + 9) / 2 (Age in years × 2) + 8 [(Age in years × 7) + 5] / 2

Pounds 7 Age in months + 11 (Age in years × 5) + 17 (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 At birth 3 months 1 year 2 years 12 years Centimeters 35 40 45 48 52

Developmental Assessment Age 4 to 6 weeks 3 months 6 months 7 months 5 to 6 months 6 to 7 months 6 to 7 months 8 to 10 months 10 to 11 months 9 months 12 months 10 to 11 months 12 months 13 months 13 months 15 to 18 months 13 months 15 to 18 months 15 to 18 months 24 months 24 months 3 to 4 years 2 years 3 years 3 years 3 years

Developmental Milestones Social smile Head holding Sits with support Sits without support Reaches out for a bright object & gets it Transfers object from one hand to other Starts imitating cough Crawls Creeps Standing holding furniture Walks holding furniture Stands without support Says one word with meaning Walks without much of a support Says three words with meaning Joints 2 or 3 words into sentence Feeds self with spoon Climbs stair Takes shoes and socks off Puts shoes and socks on Takes some clothes off Dresses self fully Dry by day Dry by night Knows full name and sex 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 channelsActive shoulder elevation, abduction, rotation, flexion and extension movements are observed during the functional examination of creeping, reaching and other arm movementsActive elbow flexion and extension observed during child’s reach to parts of body or toysActive wrist and hand movements will be observed during function developmentActive hip flexion and extension will be observed during all functionsActive knee flexion and extension seen with active hip flexion extensionFoot movements are also check during functional development Reactions, Responses and ReflexesSucking 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 calledpositive signs. If reflexes, which are supposed to be, present during particular age but areabsent are known as negative signs.

Muscle tone ReflexesSuperficial ReflexesDeep Tendon Reflexes Limb Length DiscrepancyApparent (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, plays and hand function Ambulation (dependent or independent) Cognitive Assessment (if applicable) Response to external environment & Behavior Sense of color, size, shape Sense of common dangers as fire Toilet training Sense of household articles