[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.

27]

Symposium - Cerebral Palsy

Clinical Examination of Children with Cerebral Palsy

Abstract Kailash Sarathy,

Cerebral palsy  (CP), a heterogeneous disorder of movement and posture, is one of the most Chintan Doshi,
important causes of disability affecting children. With a wide variability in the clinical presentation Alaric Aroojis
and a paucity of reliable diagnostic tests, decision-making in CP is fraught with difficulties and
Department of Paediatric
challenges. The plethora of musculoskeletal manifestations includes poor muscle function, spasticity,
Orthopaedics, Bai Jerbai Wadia
rigidity, muscle weakness, poor selective motor control, soft-tissue and joint contractures, torsional Hospital for Children, Mumbai,
malalignments, and lever arm dysfunctions. Children with CP are at a high risk of further worsening Maharashtra, India
and progression of these musculoskeletal abnormalities with the natural course of the disease.
A  comprehensive assessment that includes a combination of detailed medical history, functional
assessment, clinical examination, analysis of gait, and radiological assessment is required to provide
a favorable treatment outcome in these children. A close surveillance is essential so as to identify risk
factors for the development and progression of musculoskeletal problems so that early interventions
can be carried out to circumvent them. This review article is to highlight the importance of clinical
examination in the assessment of children with CP.

Keywords: Cerebral palsy, clinical examination, gait analysis

Introduction MEDLINE  (1956–2016); and PubMed.

Searches were also supplemented by hand
Cerebral palsy  (CP) is defined as a
searching. Interventions and keywords
qualitative motor disorder of movement
for investigation were identified using
and posture appearing before the age of
(1) contributing authors’ knowledge of the
3  years, due to non-progressive damage
field; (2) internationally recognized CP
of the brain, occurring before growth
websites such as the American Academy of
of the nervous system is complete.1 The
Cerebral Palsy and Developmental Medicine
effect of the nonprogressive damage may
(www.aacpdm.org); and  (3) the top twenty
however contribute to a misunderstanding
hits in Google using the search terms
of the secondary musculoskeletal pathology,
“cerebral palsy” and “Clinical Examination”
which is not static but is most definitely
as an indicator of popular subject matter.
progressive.2 The presentation of patients
The full search strategy is available from the
with CP is highly variable, ranging from
authors on request.
those with mild neurological deficit to those
with severe involvement. The diagnostic History
matrix to be followed in case of CP includes
a detailed history, gait analysis, physical The most important aspect in the initial
examination of lower limbs, examination of clinical evaluation of a child with CP is the Address for correspondence:
upper extremities and spine, and additional medical and surgical history of the child. Dr. Alaric Aroojis,
Department of Paediatric
tests for appropriate clinical evaluation. The The history includes information regarding
Orthopaedics, Bai Jerbai
above diagnostic matrix is an important the birth, developmental milestones, Wadia Hospital for Children,
pillar for decision-making in CP [Figure 1]. other associated medical problems, Parel, Mumbai - 400 012,
surgical history, ongoing medications, and Maharashtra, India.
Search criteria physiotherapy treatment. E-mail: [email protected]

The authors identified the relevant articles The birth history includes important details
using a protocol based on searching Cochrane about antenatal problems, perinatal history Access this article online
Database of Systematic Reviews (1993–2017; including whether child was preterm, full Website: www.ijoonline.com
www.cochrane.org); Google Scholar; term, or post-term, and whether there were DOI:
other associated factors leading to hypoxic 10.4103/ortho.IJOrtho_409_17

This is an open access journal, and articles are distributed injury to the brain such as prolonged labor, Quick Response Code:
under the terms of the Creative Commons Attribution- meconium aspiration. etc. Treatment of a
NonCommercial-ShareAlike 4.0 License, which allows others
to remix, tweak, and build upon the work non-commercially,
as long as appropriate credit is given and the new creations
are licensed under the identical terms. How to cite this article: Sarathy K, Doshi C,
Aroojis A. Clinical examination of children with
For reprints contact: [email protected] cerebral palsy. Indian J Orthop 2019;53:35-44.

© 2019 Indian Journal of Orthopaedics | Published by Wolters Kluwer - Medknow 35

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

child in the neonatal Intensive Care Unit after delivery is important as it indicates relative functional deviations
an important pointer in history. An immature or preterm rather than static physical examination. The first and
infant with periventricular leukomalacia typically presents most important part in the examination of a child with
with spastic diplegia, whereas a child with periventricular CP is observing the gait when the child walks into
hemorrhage is more likely to present with hemiplegia.3 A the consultation room. Gait analysis can be done with
full-term child with watershed ischemia may present with different techniques such as observational gait analysis,
quadriparesis and that with focal ischemia may present videographic gait analysis, and instrumented 3D gait
with hemiparesis. analysis.5-7 Observational gait analysis is performed by
observing the gait cycle in both sagittal and coronal planes
History of developmental milestones is important, as it
and observing joint angles at different stages of gait cycle
signifies the stages of physical development as the child
at different levels. Videographic gait analysis is performed
becomes more mature. The current functional activity level
by observing gait in slow-motion video and analyzing
of the child provides a good insight for treatment, future
the movements of different joints in both coronal and
prognosis, capacity, and goal setting. The earlier the child
sagittal planes. The most comprehensive gait analysis is
attains standing balance, the better is the outcome with
performed by instrumented 3D gait analysis with the use
respect to hip deformities. It is also important to acquire
of reflective markers in a gait laboratory. However, 3D
previous history of associated medical illness, physiotherapy
gait analysis requires a setup with a lot of infrastructure
records, and previous surgical records to accurately assess
expenditure, and often sufficient findings can be obtained
present deformities and compensations. Present functional
by observation and slow-motion videographic gait analysis
ability at home, school, and in community as well as
on a day-to-day basis.
other functional skills such as walking, running, and stair
climbing also affect treatment plans and outcome analysis. Gait patterns in cerebral palsy
Depending on the involvement of spasticity or contracture
Clinical Examination
of different muscles, there are different patterns of gait
Physical examination, especially in children with CP, has observed in children with CP. Gait pattern variations
limitations and benefits. The information collected during related to topographical type of CP are best seen in contrast
physical examination is based on static responses, whereas between unilateral spastic CP and bilateral spastic CP.8
functional activities, such as walking, are dynamic. The
In spastic hemiplegia, there is more involvement distally
independence of gait analysis and physical examination
and therefore true equinus is the basis of common patterns.
measures supports the notion that each provides information
Winters et al. described four gait patterns in spastic
that is important in the delineation of problems of children
hemiplegics based on sagittal kinematics.9
with CP.4 The method of assessment, the skill of the
• Type 1 hemiplegia gait – Drop foot type
examiner, and the participation of the child can all affect
• Type  2 hemiplegia gait  –  True equinus with or without
the usefulness of the examination.
recurvatum knee [Figure 2a and b]
Gait analysis • Type 3 hemiplegia gait – Stiff knee gait
Gait analysis is commonly ignored in the examination of • Type  4 hemiplegia gait  –  In sagittal plane, the ankle is
children with CP and is sometimes performed last in the in equinus, knee in flexion, hip in flexion and anterior
examination sequence. However, gait analysis is most

Clinical History – Birth history,

developmental history, presenting history

Gait analysis – Observational gait analysis/

Videographic gait analysis/ 3D Gait analysis

GMFCS AND FMS SCORING

Physical examination for patients with cerebral palsy

– Lower limb, upper limb, and spine

a b
Advanced imaging in the form of radiographs or MRI Figure 2: Type II hemiplegic gait. (a): Anteroposterior view showing right-
sided hemiplegia with ankle equinus in stance. (b): Lateral view showing
Figure 1: Diagnostic flowchart in cerebral palsy right-sided hemiplegia with ankle equinus in stance

36 Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

pelvic tilt is present. In coronal plane, there is hip wheelchairs, or canes/walking sticks; and to a much lesser
adduction and internal rotation. extent, the actual quality of movement. The various levels
that are described include:
Gait patterns in spastic diplegia
• Level I  – The child can walk indoors and outdoors and
In spastic diplegia, there is more proximal involvement climb stairs without using hands for support and can
and therefore apparent equinus and crouch gait are seen perform usual activities such as running and jumping
commonly.10 There are four common patterns of gait in but has decreased speed, balance, and coordination
spastic diplegia as described by Rodda et al.11 • Level II  –  The child can climb stairs with a railing
• Type 1 – True equinus but has difficulty with uneven surfaces, inclines, or in
• Type 2 – Jump gait [Figure 3a and b] crowds and has minimal ability to run or jump
• Type 3 – Apparent equinus • Level III  –  The child walks with assistive mobility
• Type 4 – Crouch gait [Figure 4a and b]. devices indoors and outdoors on level surfaces, able to
climb stairs using a railing, and may propel a manual
Physical Assessment wheelchair but needs assistance for long distances or
A standard, detailed physical examination is crucial in uneven surfaces
assessing children with movement disorders, especially • Level IV – Here, the walking ability is severely limited
CP. The four primary reasons for the need to classify even with assistive devices such as wheelchairs most
CP include  (1) to provide a detailed description that can of the time and may propel own power wheelchair,
standing transfers, with or without assistance
delineate the nature of the problem and its severity,  (2) to
• Level V  –  The child has physical impairments that
provide predictions of both current and future service needs
restrict voluntary control of movements, has very
for an individual, (3) to provide comparison so that groups
poor head, neck, and trunk control, has impairment
of patients with CP at one institution can be compared with
in all areas of motor function, and cannot sit or stand
those at another, and  (4) to evaluate change so that one
independently, even with adaptive equipment.
individual with CP can be evaluated at various times and
change can be documented.12 The physical examination itself can be categorized into the
following:
In CP, the Gross Motor Function Classification System,
developed by Palisano et al.,13 has been in use for over two Functional mobility assessment
decades. It is a five-level clinical classification system that Over the years, various simple categorical scales have
describes the gross motor function of people with CP on been developed for the assessment of functional ability and
the basis of self-initiated movement abilities. The purpose functional mobility of children with CP. These scales were
of this system is to classify the child’s present gross motor designed to be responsive to change and can be used to
function in a systematic and reliable manner and serves document the serial attainment of mobility and functional
as a useful matrix for identification of where a child is abilities, the deterioration or improvement in these skills
at a specific point in time in relation to its age and gross after intervention, or other changes consequent on growth
motor function. Distinctions between levels are based and development. The Functional Mobility Scale  (FMS)
on functional abilities; the need for walkers, crutches,

a b
a b Figure 4: Type IV diplegic gait. (a): Anteroposterior view showing crouch
Figure 3: Type II diplegic gait. (a): Anteroposterior view showing jump gait gait with bilateral hip and knee flexion and ankle dorsiflexion. (b): Lateral
with bilateral hip and knee flexion and ankle equinus. (b): Lateral view view showing crouch gait with bilateral hip and knee flexion and ankle
showing jump gait with bilateral hip and knee flexion and ankle equinus dorsiflexion

Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019 37

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

had been described by Graham et al.14 to classify the extent and the position in which the child is assessed. Hypertonia
of mobility in children, taking into account the range of in a CP child can be due to spasticity, dystonia, rigidity,
assistive devices a child might use for mobility. The scale or a combination of the above features. First, the muscle
is useful in documenting change over time following contracture at rest is assessed by manual palpation of the
interventions such as orthopedic surgery or selective dorsal muscle in testing. Second, the limb is moved slowly through
rhizotomy and was found to be highly sensitive to detect its passive range and later at various speeds or velocity and
changes after operative intervention.15 catch or the resistance to passive motion is assessed. The
spasticity assessment is commonly done using the Modified
The FMS rates walking ability at three specific distances
Ashworth scale18-20 and the Tardieu scale.21
such as 5, 50, and 500 m and is further graded from 1 to 6
depending on the level of mobility. The scoring represents Modified Ashworth scale
the child’s mobility in the home, at school, and in the
The Modified Ashworth scale, which is used to grade the
community setting. The walking ability of the child is rated
amount of spasticity, is one of the commonly performed
at each of the three distances according to the need for
tests as it does not need any equipment and can be
assistive devices such as crutches, walkers, or wheelchairs.
performed quickly, easily, and in a day-care clinic. The
The rating is from 1 to 6 which is described as follows: test is performed manually to determine the resistance of
muscle to passive stretching. This was initially described
1  –  The child mostly uses a wheelchair but may stand
as a measure of spasticity but depends on the speed at
for transfers and does some stepping supported by a
which the test is performed. In the original article, it was
caretaker or with the help of a walker; 2 – The child uses a
suggested that the movement of the limb segments should
walker or frame to ambulate; 3  –  The child independently
be performed through the full range of movement enough
walks but with the help of crutches; 4  –  The child walks
to be a test of spasticity during walking [Table 1].
independently but with the help of sticks  (one or two);
5  –  The child walks independently only on leveled Due to the potential shortcomings of this test regarding
surfaces; 6 – The child walks independently on all surfaces; reliability and chances of error in measurements,
C – The child crawls for mobility at home  (5 m); N  – Not assessments of spasticity using this scale should be
applicable (e.g., the child does not complete 500 m). interpreted with caution.19,20
Children with CP, despite having a similar diagnosis, vary Tardieu scale
in their abilities and level of functioning within and across
This is a scale for measuring spasticity that takes into
different environmental contexts such as home, school,
account the resistance to passive movement at both slow
or a community setting.16 Capacity (what a child can do
and fast speeds. As this test is simple and relatively easy
in standardized, controlled environment) may or may not
to perform and recorded as an angle measure, it can be
be the same as performance (what a child actually does
easily correlated with gait analysis, if required. The various
in his/her daily environment). The FMS is a performance
parameters include the following:
measure and it is important to rate what the child actually
• V1 – Velocity to stretch as slow as possible
does at the time of assessment and not what they can do
• V2 – Velocity to stretch with the speed of limb segment
or used to be able to do. The FMS has been found to be
falling with gravity
a reliable tool that can be used by clinicians to assess
• V3 – Velocity to stretch as fast as possible (> natural drop)
mobility in children with CP.17
• R1  –  Angle of catch seen at velocity V2 or V3
Muscle tone assessment [Figure 5a]
• R2  –  Full range of motion  (ROM) achieved when
Tone can be defined as resistance to passive stretch at
muscle is at rest and tested at V1 velocity [Figure 5b].
the relaxed state of muscle activity. It is difficult and
cumbersome to assess the tone in CP children, as this can A large difference between R1 and R2 in outer and middle
be influenced by apprehension and excitement in the child ROM indicates a larger dynamic component and a small

Table 1: Modified Ashworth scale

Grading Description
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
remainder (less than half) of the ROM
2 More marked increase in muscle tone through most of the ROM, but affected part(s) can be easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part(s) are rigid in flexion or extension
ROM=Range of motion

38 Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

difference between R1 and R2 in middle and inner ROM

indicates a predominant fixed contracture.
The Tardieu scale has an excellent intra-  and inter-rater
reliability when assessed at the elbow and ankle joints of
children with CP, with no difference noted between visual
and goniometric measurements.22 Training is associated
with a highly significant improvement in reliability.
a b
Although we use these scales routinely during the Figure 5: Tardieu scale. (a): Clinical photograph showing Tardieu score
assessment of the CP children, they have some at the ankle (R1). (b): Clinical photograph showing Tardieu score at the
disadvantages because they are not standardized, stimulus ankle (R2)

is not well controlled, and they lack reliability and validity

for all the muscle groups. They offer only qualitative and
subjective information in measuring spasticity.23
Analysis of range of motion and joint contractures
Assessing the muscle length and joint contractures
is an integral part of the physical examination.24 The
muscle length is indirectly measured by assessing the
ROM of the joint through which the muscle acts. These
have to be undertaken with appropriate precautions and
standardization, as abnormally false results and errors
commonly arise due to faulty technique of examination.
Reliability studies suggest that the standard error of
Figure 6: Clinical photograph showing measurement of hip flexion deformity
measurement of passive joint range is of the order of 5°.25 by the Thomas test
Although it is difficult to differentiate static and dynamic
deformities in nonanesthetized child, a comprehensive
static examination gives a good insight on the type of
contracture and in planning the management of the same.26
Hip joint
Hip deformity is one of the common presenting
abnormalities in CP. Although the hips per se are normal
at birth, late displacements occur due to abnormal balance,
loss of selective motor control, and tone abnormalities.
Thus, hip screening is an essential part of examination of a
CP child,27 especially in non-walkers and late walkers. The
components of hip examination include the following:
1. Thomas’ hip flexion test  [Figure 6] is commonly used
for measuring hip flexion contracture.28 The test is Figure 7: Clinical photograph showing Staheli prone extension test
performed with the patient in supine position and the
uninvolved limb is adequately flexed to eliminate On comparing the above tests, the Thomas’ test showed the
exaggerated lumbar lordosis. The angle formed between best results in normal population whereas the Staheli’s test
the horizontal axis of the thigh and horizontal line was shown to have accurate results in children with CP.32
parallel to the floor measures the hip flexion contracture.
The next part of assessment is to measure the amount
The reliability and repeatability of the test was reported
of adductor contracture. With the patient in supine
by Kilgour and McWhirk et al.29,30
position, passive abduction of the hip is performed
2. Staheli described a prone extension test  [Figure 7] to
with the knee in extension and with the knee in 90°
assess hip flexion contracture, especially for children
flexion  (Phelp’s Test) [Figure  8a and b]. If abduction
with CP and in bilateral hip pathologies.31 It is performed
improves on knee flexion, the primary pathology lies in
with the patient prone on the edge of the couch, one
the medial hamstring muscles and gracilis. If both the
hand of the examiner to stabilize the pelvis and the other
measurements are the same, the prime pathology is in
extends the thigh while observing the lumbar lordosis.
the adductor muscles.
The point at which the pelvis rises indicates the end
point and the angle between the long axis of thigh and It has been proposed that, with a significant hip flexion
the horizontal line measures the flexion contracture. contracture in combination with combined hip abduction

Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019 39

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

of  <80°, there is an increased risk of hip subluxation and hip flexion contracture or anterior pelvic tilt.34,35 The
chronic hip pain in the near future.33 bilateral popliteal angle test is more reliable for assessing
the hamstring tightness than its unilateral counterpart,
Knee joint
as the latter test gives false high values if there is an
The commonly presenting deformity in knee is that associated psoas muscle contracture.
of flexion contracture, which is more pronounced in a
nonambulatory child. The first step in assessment is to In ambulatory children, a crouch gait develops as a part
differentiate true joint contracture from contracture due to of the natural course of the disease, especially in diplegic
muscle spasticity or tightness. children, in which there is a failure of plantar flexion–knee
a. Joint contracture  – With the hip in extension and ankle extension couple.36 While contemplating crouch correction,
in gravity-assisted plantar flexion, the residual knee other abnormalities such as lever arm dysfunction due to
flexion measures true joint contracture [Figure 9] torsional malalignments, planovalgus feet, and muscle
b. Muscle  (hamstrings) contracture  – Also called popliteal imbalance have to be kept in mind to provide overall
angle test, it is performed with the hip joint in 90° of improvement in the outcome.37
flexion in supine position, the residual knee flexion Assessment of rectus femoris spasticity using
shows the amount of muscle tightness or contracture. In Duncan-Ely’s/Prone Rectus test  [Figure 11] is essential, as
a unilateral popliteal angle [Figure 10a], the tested leg this in conjunction with hamstring contracture can result
is kept in 90-90 position of knee and hip with the other
in a stiff knee gait pattern, which necessitates a different
limb extended, the knee of the tested limb is extended
approach to management.
until resistance and further loss of knee extension is
measured. In a bilateral popliteal angle test [Figure 10b], Ankle and foot
both the limbs are kept in 90-90 position of hip and
The most common deformities seen in CP include
knee joints, and the popliteal angle is measured one by
equino-varus and plano-valgus. Assessment of equinus
one with the other limb in identical position. Hamstring
(gastro-soleus spasticity/contracture) is done by passive
shift measures the difference between unilateral and
bilateral popliteal angles and gives a direct measure of

a b
Figure 8: Phelp’s test. (a): Clinical photograph showing passive hip
abduction with knees in extension. (b): Clinical photograph showing Figure 9: Clinical photograph showing knee flexion deformity
improved hip abduction with knee flexion

a b
Figure 10: Popliteal angle test for hamstring contracture. (a): Clinical
photograph showing unilateral popliteal angle. (b): Clinical photograph
showing bilateral popliteal angle. Difference between the two measurements Figure 11: Clinical photograph showing prone rectus test. Note the pelvic
is the “hamstring shift” rise on knee flexion indicating spasticity of the rectus femoris

40 Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

dorsiflexion of ankle with knee in extension and strength assessment. The typical scale for muscle group
then with knee joint in 90° flexion  (Silverskiold test) selectivity is given as follows:
[Figure 12a and b]. A difference of 20°–30° shows a spastic • Grade 0 – No ability/only patterned movement observed
gastrocnemius component. • Grade 1 – Partial ability/partially isolated movements
• Grade  2  –  Complete ability/completely isolated
Muscle strength analysis and selective motor control
movements.
Assessment of muscle strength and selective motor control
To assess the overactivity of tibialis anterior muscle
is an integral part of the examination protocol of children
(varus/supination), confusion test is used. Here, due to loss
with CP. As muscle strength is directly proportional to motor
of selective motor control, resistance to hip flexion causes
function, strength evaluation is necessary for providing optimal
the overactive tibialis anterior muscle to act and there is
functional outcomes. Muscle strength analysis is also required
dorsiflexion at the ankle and forefoot supination.
to assess the appropriateness for surgical interventions.
Recently, a newer assessment scheme has been put forth,
The Medical Research Council  (MRC) grading for
the Selective Control Assessment of Lower Extremities,
muscle strength assessment has been in use for decades.38
which gives a comprehensive scheme for the motor
The main disadvantage of this grading system is that it
function assessment.42
neither considers the ROM for which a movement can be
performed nor defines the strength of resistance against Torsional profile and concept of lever arm dysfunction
which a movement can be performed. The MRC grading
“Lever arm dysfunction” is a term originally coined
system consists of six grades  (scale of 0–5) in relation to
by Gage in 199143 to describe the particular orthopedic
the maximum range expected for that muscle [Table 2].
deformities that arise in an ambulatory child with CP.
In children with CP, who have poor comprehension and Lever arm dysfunction describes a general class of bone
in whom isolated muscle testing is cumbersome, manual modeling, remodeling, and or traumatic deformities
muscle testing using Kendall scale is used.39 It is a 10-point that include hip subluxation, torsional deformities of
scale which provides a simpler way to assess muscle long bones, and/or foot deformities. Since muscles and
strength or muscle imbalance [Table 3]. However, it relies ground reaction forces  (GRFs) must act on skeletal
heavily on the examiner’s judgment and experience, the levers to produce locomotion, abnormalities of these
amount of force generated, and the accuracy of patient
positioning. It is subjective and prone to have a significant
Table 2: Medical Research Council grading of muscle
examiner bias. Studies have shown that clinically small but
power
significant differences in strength may not be detected by Grade Description
this method. However, under strict evaluation protocols, 0 Complete paralysis
this method was still found to be useful.40 For children who 1 Flicker of contraction present
are under the age of 5, and who cannot follow complex 2 Movement possible if gravity eliminated
directions for maximal force production, the manual muscle 3 Movement against gravity but not against resistance
testing method, as well as any other method of strength 4 Movement possible against resistance but less than
assessment, is still a vague screening tool. In recent normal power
studies, use of a handheld dynamometer has been shown to 5 Normal power
provide more reliable results in assessing muscle strength,
especially the isometric strength.41
Table 3: Kendall Scale
Selective motor control Grade Description
In children with CP, the reduced ability to control and 10 Holds test position against strong pressure
isolate movements provides great hindrance in muscle 9 Holds test position against moderate-to-strong pressure
8 Holds test position against moderate pressure
7 Holds test position against slight-to-moderate pressure
6 Holds test position against slight pressure
5 Holds test position (no pressure)
4 Gradual release from test position
3 Holds against resistance through full ROM with
gravity eliminated or <100% ROM with against gravity
2 Moves through full ROM with gravity eliminated
a b 1 Moves through <100% ROM with gravity eliminated
Figure 12: Silverskiold test. (a): Clinical photograph showing degree of T Visible or palpable muscle contraction
ankle equinus with knee in extension. (b): Clinical photograph showing
correction of ankle equinus with knee flexion indicating predominantly 0 No muscle contraction possible
gastrocnemius contracture ROM=Range of motion

Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019 41

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

lever arm systems greatly interfere with the child’s Standing balance and equilibrium
ability to walk.
To conclude the physical examination, assessment of
In CP, the muscles and the GRFs are neither appropriate posture, trunk balance, and position of the pelvis and
nor adequate because of contractures, poor selective motor lower extremities in standing position (static) and during
control, and abnormality of the bony lever arms due to walking (dynamic) in both planes gives overall information
bony malalignments. Among the malalignments, excessive regarding motor control and compensatory mechanisms.
femoral anteversion  (FAV) and tibial torsion are the two Children with CP tend to have delayed and reduced
commonly described conditions in literature.44 Excessive posterior equilibrium responses. A  comprehensive analysis
FAV and coxavalga can produce intoeing gait and hip of equilibrium in all planes should be done before planning
instability.45 for any modality of treatment.
The Craig’s test/Trochanteric prominence test [Figure 13] Upper-limb Examination
has been used for the assessment of FAV. With the patient
in prone position and knee at 90° flexion, the angle The upper extremity examination includes an assessment of
between the vertical line and long axis of the leg at the tone, ROM of joints, strength of muscles, and assessment
greatest prominence of the greater trochanter palpated of upper-limb functions. Assessment of tone is by the
laterally measures the amount of FAV. In recent studies, Ashworth scale similar to that for lower extremity muscles.
it has been found that trochanteric prominence test in ROM is assessed at each of the joints at shoulder, elbow,
combination with hip internal rotation X-rays is a better forearm, wrist, and hand.
predictor of FAV and neck-shaft angle as compared with Assessment of upper-limb function
computed tomography.46
The Manual Ability Classification System describes how
Tibial torsion malalignment can be assessed clinically by
children with CP use their hands to manipulate relevant and
the following:
appropriate objects for activity of daily living, classifying
a. Thigh foot angle [Figure 14] – With the patient in prone
them into five levels48 [Table 4]. Other assessment scales
position, knee in 90° flexion, and neutral ankle and hind
for upper-limb evaluation are Assisting Hand Assessment
foot position, the angle between the thigh axis and foot
score, Quality of Upper Extremity Skills Test  (QUEST),
axis (axis between the 2nd and 3rd metatarsals) gives
Melbourne Assessment of Unilateral Upper limb Function,
tibial torsional measurement
and Shriners Hospital Upper Extremity Evaluation.
b. Bi-malleolar axis method  –  With the knee in full
extension, the leg is rotated to align the femur Spine Examination
bi-condylar axis horizontally. The angle between the
horizontal and bimalleolar axis measures the tibial Spine deformities are a common presentation in CP. They
torsion47 present in varied patterns  –  scoliosis, kyphosis, lordosis,
c. Second toe test  –  With the patient in prone position, pelvic obliquity, and a combination of these. Scoliosis is the
the leg is rotated so that the 2nd toe points vertically most common spinal deformity in patients with CP.49 The
down. Now with the thigh held and knee flexed, the incidence of scoliosis increases with increasing severity of
angle between the vertical line and the leg axis gives the disease. The classic curve pattern is a long C-shaped
the measure of tibial torsion. curve that is often kyphoscoliotic or lordoscoliotic. The
curve progression is gradual; however, it can become rapid

Figure 13: Clinical photograph showing Craig test to measure femoral Figure 14: Clinical photograph showing Thigh Foot Angle test to measure
anteversion tibial torsion

42 Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

5. Stuberg  WA, Colerick  VL, Blanke  DJ, Bruce  W. Comparison

Table 4: Manual Ability Classification System scoring
of a clinical gait analysis method using videography and
system temporal-distance measures with 16-mm cinematography. Phys
Level of Description Ther 1988;68:1221-5.
ability 6. Chambers HG, Sutherland DH. A practical guide to gait analysis.
Level I Handles objects easily and successfully. Atmost, J Am Acad Orthop Surg 2002;10:222-31.
limitations in the ease of performing manual tasks 7. Krebs  DE, Edelstein  JE, Fishman  S. Reliability of observational
requiring speed and accuracy kinematic gait analysis. Phys Ther 1985;65:1027-33.
Level II Handles most objects but with somewhat reduced 8. Rodda  J, Graham  HK. Classification of gait patterns in spastic
quality and/or speed of achievement. May avoid some hemiplegia and spastic diplegia: A basis for a management
tasks or use alternative ways of performance algorithm. Eur J Neurol 2001;8 Suppl 5:98-108.
Level III Handles objects with difficulty; needs help to prepare 9. Winters TF Jr. Gage  JR, Hicks  R. Gait patterns in spastic
and/or modify activities hemiplegia in children and young adults. J  Bone Joint Surg Am
Level IV Handles a limited selection of easily managed objects in 1987;69:437-41.
adapted situations. Requires continuous support 10. Sutherland  DH, Davids  JR. Common gait abnormalities of the
Level V Does not handle objects and has severely limited ability knee in cerebral palsy. Clin Orthop Relat Res 1993;288:139-47.
to perform even simple actions. Requires total assistance 11. Rodda  JM, Graham  HK, Carson  L, Galea  MP, Wolfe  R.
Sagittal gait patterns in spastic diplegia. J  Bone Joint Surg Br
2004;86:251-8.
with onset of puberty, deteriorating neurological function, 12. Bax  M, Goldstein  M, Rosenbaum  P, Leviton  A, Paneth  N,
or spending prolonged time in wheelchair. Scoliosis Dan  B, et al. Proposed definition and classification of cerebral
developing at a younger age  (<15  years of age) has a palsy, April 2005. Dev Med Child Neurol 2005;47:571-6.
higher risk for progression, and progression can be seen 13. Palisano  R, Rosenbaum  P, Walter  S, Russell  D, Wood  E,
Galuppi  B, et al. Development and reliability of a system to
even after skeletal maturity in severely affected children.50
classify gross motor function in children with cerebral palsy. Dev
Nonoperative management of spinal deformity can be Med Child Neurol 1997;39:214-23.
achieved by sitting modifications and bracing. However, 14. Graham  HK, Harvey  A, Rodda  J, Nattrass  GR, Pirpiris  M.
nonoperative management does not halt the progression of The functional mobility scale  (FMS). J  Pediatr Orthop
deformity. Surgical management depends on factors such 2004;24:514-20.
as patient’s age, functional capabilities, curve pattern, and 15. Rosenbaum  P, Stewart  D. The World Health Organization
other comorbidities. international classification of functioning, disability, and health:
A  model to guide clinical thinking, practice and research in the
Conclusions field of cerebral palsy. Semin Pediatr Neurol 2004;11:5-10.
16. Diwan  S, Diwan  J, Bansal  AB, Patel  PR. Changes in capacity
A detailed bi-annual examination of all children with CP is and performance in mobility across different environmental
essential. The frequency of examinations should be more if settings in children with cerebral palsy: An exploratory study.
the child is nonambulant, has deterioration on subsequent J Clin Diagn Res 2015;9:YC01-3.
examination, or undergoes any surgical management. 17. Harvey  AR, Morris  ME, Graham  HK, Wolfe  R, Baker  R.
Reliability of the functional mobility scale for children with
Although strict guidelines have not been established for
cerebral palsy. Phys Occup Ther Pediatr 2010;30:139-49.
a streamlined physical assessment of children with CP, a
18. Bohannon  RW, Smith  MB. Interrater reliability of a modified
comprehensive clinical examination using the described Ashworth scale of muscle spasticity. Phys Ther 1987;67:206-7.
diagnostic matrix should be undertaken by every clinician 19. Gregson  JM, Leathley  M, Moore  AP, Sharma  AK, Smith  TL,
before contemplating the management of these children. Watkins  CL, et al. Reliability of the tone assessment scale
and the modified Ashworth scale as clinical tools for assessing
Financial support and sponsorship poststroke spasticity. Arch Phys Med Rehabil 1999;80:1013-6.
Nil. 20. Clopton  N, Dutton  J, Featherston  T, Grigsby  A, Mobley  J,
Melvin J, et al. Interrater and intrarater reliability of the modified
Conflicts of interest Ashworth scale in children with hypertonia. Pediatr Phys Ther
2005;17:268-74.
There are no conflicts of interest.
21. Haugh  AB, Pandyan  AD, Johnson  GR. A  systematic review
of the Tardieu scale for the measurement of spasticity. Disabil
References Rehabil 2006;28:899-907.
1. MacKeith RC, Polani PE. Cerebral palsy. Lancet 1958;1:61. 22. Yam WK, Leung MS. Interrater reliability of modified Ashworth
2. Boyd  RN, Graham  HK. Botulinum toxin A in the management scale and modified Tardieu scale in children with spastic cerebral
of children with cerebral palsy-indications and outcome. Eur J palsy. J Child Neurol 2006;21:1031-5.
Neurol 1997;4:15-22. 23. Damiano  DL, Quinlivan  JM, Owen  BF, Payne  P, Nelson  KC,
3. Volpe  JJ. Neurology of the Newborn. 5th  ed., Philadelphia: Abel  MF, et al. What does the Ashworth scale really measure
Elsevier; 2008. and are instrumented measures more valid and precise? Dev Med
4. Desloovere K, Molenaers G, Feys H, Huenaerts C, Callewaert B, Child Neurol 2002;44:112-8.
Van de Walle  P, et al. Do dynamic and static clinical 24. Cusick  BD, editor. Progressive Casting & Splinting.
measurements correlate with gait analysis parameters in children Tucson (AZ): Therapy Skill Builders; 1990.
with cerebral palsy? Gait Posture 2006;24:302-13. 25. McDowell  BC, Hewitt  V, Nurse  A, Weston  T, Baker  R. The

Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019 43

[Downloaded free from http://www.ijoonline.com on Friday, July 26, 2019, IP: 223.238.51.27]

Sarathy, et al.: Clinical examination of children with cerebral palsy

variability of goniometric measurements in ambulatory children testing muscle strength in patients with radial palsy. J  Rehabil
with spastic cerebral palsy. Gait Posture 2000;12:114-21. Med 2008;40:665-71.
26. Thomason  P, Rodda  J, Willoughby  K, Graham  HK. Orthopaedic 39. Kendall HO, Kendall FP, Wadsworth GE, editors. Muscle Testing
assessment in cerebral palsy and clinical practice. In: Dan  B, and Function. 2nd ed. London: Williams and Wilkins; 1971.
Mayston  M, Paneth  N, Rosenbloom  L, editors. Cerebral Palsy: 40. Wadsworth  CT, Krishnan  R, Sear  M, Harrold  J, Nielsen  DH.
Science and Clinical Practice. London: Mac Keith Press; 2014. Intrarater reliability of manual muscle testing and hand-held
27. Dobson  F, Boyd  RN, Parrott  J, Nattrass  GR, Graham  HK. Hip dynametric muscle testing. Phys Ther 1987;67:1342-7.
surveillance in children with cerebral palsy. Impact on the 41. Berry  ET, Giuliani  CA, Damiano  DL. Intrasession and
surgical management of spastic hip disease. J Bone Joint Surg Br intersession reliability of handheld dynamometry in children with
2002;84:720-6. cerebral palsy. Pediatr Phys Ther 2004;16:191-8.
28. Thomas HO. Diseases of Hip, Knee, and Ankle Joints, with their
42. Fowler  EG, Staudt  LA, Greenberg  MB, Oppenheim  WL.
Deformities, Treated by New and Efficient Method. Liverpool:
Selective control assessment of the lower extremity  (SCALE):
Dobb; 1876.
Development, validation, and interrater reliability of a clinical
29. Kilgour  G, McNair  P, Stott  NS. Intrarater reliability of lower tool for patients with cerebral palsy. Dev Med Child Neurol
limb sagittal range-of-motion measures in children with spastic 2009;51:607-14.
diplegia. Dev Med Child Neurol 2003;45:391-9.
43. Gage  JR. Gait Analysis in Cerebral Palsy. London: Mac Keith
30. McWhirk  LB, Glanzman  AM. Within-session inter-rater
Press; 1991.
realiability of goniometric measures in patients with spastic
cerebral palsy. Pediatr Phys Ther 2006;18:262-5. 44. Laplaza  FJ, Root  L, Tassanawipas  A, Glasser  DB. Femoral
torsion and neck-shaft angles in cerebral palsy. J  Pediatr Orthop
31. Staheli LT. The prone hip extension test: A method of measuring
1993;13:192-9.
hip flexion deformity. Clin Orthop Relat Res 1977;123:12-5.
32. Lee  KM, Chung  CY, Kwon  DG, Han  HS, Choi  IH, Park  MS, 45. Bobroff  ED, Chambers  HG, Sartoris  DJ, Wyatt  MP,
et al. Reliability of physical examination in the measurement of Sutherland  DH. Femoral anteversion and neck-shaft angle
hip flexion contracture and correlation with gait parameters in in children with cerebral palsy. Clin Orthop Relat Res
cerebral palsy. J Bone Joint Surg Am 2011;93:150-8. 1999;364:194-204.
33. Valencia  FG. Management of hip deformities in cerebral palsy. 46. Chung  CY, Lee  KM, Park  MS, Lee  SH, Choi  IH, Cho TJ, et al.
Orthop Clin North Am 2010;41:549-59. Validity and reliability of measuring femoral anteversion and
34. Gage  JR, Schwartz  MH, Koop  SE, Novacheck  TF. The neck-shaft angle in patients with cerebral palsy. J  Bone Joint
Identification and Treatment of Gait Problems in Cerebral Palsy. Surg Am 2010;92:1195-205.
London: Mac Keith Press; 2009. 47. Schwartz MH, Rozumalski A. A new method for estimating joint
35. Hoffinger  SA, Rab  GT, Abou-Ghaida  H. Hamstrings in cerebral parameters from motion data. J Biomech 2005;38:107-16.
palsy crouch gait. J Pediatr Orthop 1993;13:722-6. 48. Eliasson  AC, Krumlinde-Sundholm  L, Rösblad B, Beckung  E,
36. Gage  JR. Surgical treatment of knee dysfunction in cerebral Arner  M, Ohrvall  AM, et al. The manual ability classification
palsy. Clin Orthop Relat Res 1990;253:45-54. system  (MACS) for children with cerebral palsy: Scale
37. Rodda  JM, Graham  HK, Nattrass  GR, Galea  MP, Baker  R, development and evidence of validity and reliability. Dev Med
Wolfe  R, et al. Correction of severe crouch gait in patients Child Neurol 2006;48:549-54.
with spastic diplegia with use of multilevel orthopaedic surgery. 49. Koop  SE. Scoliosis in cerebral palsy. Dev Med Child Neurol
J Bone Joint Surg Am 2006;88:2653-64. 2009;51 Suppl 4:92-8.
38. Paternostro-Sluga  T, Grim-Stieger  M, Posch  M, Schuhfried  O, 50. Saito  N, Ebara  S, Ohotsuka  K, Kumeta  H, Takaoka  K.
Vacariu  G, Mittermaier  C, et al. Reliability and validity of the Natural history of scoliosis in spastic cerebral palsy. Lancet
medical research council  (MRC) scale and a modified scale for 1998;351:1687-92.

44 Indian Journal of Orthopaedics | Volume 53 | Issue 1 | January-February 2019