CEREBRAL PALSY ASSESSMENT FORM

Name: Date of Assessment:

Age:------- months/ years Address:

Gender:

Name of the Parent:

Source of information:

Parent Occupation:

Parent Education:

Primary Caregiver:

Parent/ care giver concern:

History: Vision

Hearing

Epilepsy – type, frequency, duration, under medication.

GMFCS Level:

CFCS Level:

MACS Level:

Developmental milestones:

Social/Emotional Language Cognitive(learning Hand function

communication thinking and problem  Walks alone
 Likes to hand  Say several solving)  Many walk up
things to others words  Knows what steps and run
as play  Says and ordinary things  Pulls toys while
 May have shakes head are for ex: walking
temper and ‘no’ telephone,  Can help
tantrums  Points to show brushes, spoon undress himself
 May be afraid of some1 what he  Points to one  Drinks from a
strangers wants body part cup
 Show affection  Shows interest  Eats with a
to familiar in a doll or spoon.
people stuffed animal
 Play simple by pretending to
pretend, such feed
as feeding a  Points to get the
doll attention of
 May cling to others
caregivers in  Scribbles on his
new situations own
 Points to show  Can follow 1
others step verbal
something commands with

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 CEREBRAL PALSY ASSESSMENT FORM

interesting out any

 Explores alone gestures for ex:
but with parent sits when you
close by say sit down

On Examination:

Deformity(If any)

All joint ROM

Limb Length Discrepancy: True limb length measurement:-

Apparent limb length measurement:-

Popliteal angle measurement:

Thomas test:

Dunken Ely’s test:

Silfverskiold test:

Tone assessment:

Tardieu scale

Energy expenditure Index

 Resting Heart rate: _____beats/minute

 Walking Heart rate: _____beats/minute
 Distance covered: _____meters
 Time: _____minutes
 Speed: ______ meters/minute

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ICF Format
Body structure Body Function

Activity Limitation

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Participation restriction

Contextual factors

Environmental factors Personal factors

Facilitator Barrier Facilitator Barrier

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ICF Domains and Core sets

ICF DOMAIN CORE SETS OUTCOME OUTCOME MEASURE

OF
INTEREST

Body Structure of upper Body  Muscle Length

Structure and lower extremity alignment  Spinal alignment and range of motion
measure (SAROMM)
 Leg Length
Other
musculoskeletal
structures related to
movement

Structure of trunk

Exercise tolerance Energy  Energy expenditure index

function efficiency

Function
Voluntary control Weakness  Selective control assessment of the lower
and neuro- extremity (SCALE)
musculoskeletal,  MMT
movement related  Hand held dynamometry
function  Functional strength grading
Gait pattern Gait  Edinburgh visual gait score
functions performance

Activity Walking and Activity  Gross motor function measure (GMFM)

mobility capacity and  Functional mobility scale(FMS)
performance

Participation Going to school Participation  Teacher and parent interview

and playing  Functional mobility scale(FMS 150 m)

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Spinal Alignment and Range of Motion Measure

(A Measure of Posture and Flexibility)

Spinal Alignment Subscale

1. Cervical Spine ____

2. Thoracic Spine ____

3. Lumbar Spine ____

4. Lateral Curve ____

Spinal Alignment Score ____

Mean score ____

Range of Motion and Muscle Extensibility Subscale

Right Left

5/6. Hip Extension ____ ____

7/8. Hip Flexion ____ ____

9/10. Hip Abduction ____ ____

11/12. Hip Adduction ____ ____

13/14. Hip ER ____ ____ Mean

15/16. Hip IR ____ ____ Hip score (add 5 to 16) ____ ……

17/18. Knee Extension ____ ____

19/20. Hamstrings ____ ____ Knee score (add 17 to 20) ____ …....

21/22. Ankle Dorsiflexion ____ ____

23/24. Ankle Plantarflexion ____ ____ Ankle score (add 21 to 24) ____ ……

25/26. Upper Extremities ____ ____ UE score (add 25 $ 26) ____ ……

Range of motion score _______

Total SAROMM Score_______

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Hand Held Dynamometry

Muscle group Left Right

Lever Arm Torque (lbs) Lever Arm Torque (lbs)

Hip flexors

Hip extensors

Abductors

Adductors

Medial rotators

Lateral rotators

Knee flexors

Knee extensors

Ankle dorsiflexors

Ankle plantarflexors

Functional strength grading

Activity Ability Capacity Quality

Kneel sit to kneeling
Kneeling to half keeling
Sit to stand
Stand to sit
Up on toes
Heel down
Step up(20 cm step)
Step down
Lateral step up
Seated push up
Prone push up
Sit ups

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Ability scoring

0- Unable
1- Completes with human assistance
2- Completes with walker/ 2 crutches/other device using both hands
3- Completes using a device with 1 hand
4- Independent. Requires supervision for safety
5- Independent and safe

If A is 2 or above 2 and capacity is 3 or more than rate quality under following phases

Preparation
Acceleration
Deceleration
Stabilization

Scoring:
1. Grossly altered
2. Display hesitancy/ occasionally/ mild compensation
3. Completes activity appropriately in Normal pattern
Thus score it as A: ,C: ,Q:
If C or Q is not relevant they will be marked as *
EVGS

LEFT RIGHT

Initial contact

Heel lift

Max ankle dorsi in stance

Hindfootvarus/valgus

Foot rotation

Clearance In swing

Max ankle dorsi in swing

Knee progression angle

Peak knee extn in stance

Knee extn in terminal swing

Peak knee flexion in swing

Peak hip extension in stance

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Peak hip flexn in swing

Max pelvic obliquity in midstance

Pelvic rotation in midstance

Peak saggital trunk position

Max lateral shift of trunk

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GMFM:

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Dimension Percentage

A. lying and rolling

B. Sitting

C. Crawling and kneeling

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D. Standing

E. Walking

FMS

Play assessment:

Play interest:

Length of play:

Investigations:

Provisional Diagnosis:

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SMART Goals:

Short term goal:

Relevant to findings and should be based on ICF domain

Long term goal:

Parent /Care givers education.

Home programme.

Assessment Clinical reasoning

Name For Social interaction and identification

Age To rule out any delay in milestone

development
Source of information To get the correct history
Limb length discrepancy To rule out shortening and to prescribe foot
wear.
Popliteal angle To assess hamstring
Dunken Ely’s test To assess rectus femoris spasticity or tightness

Thomas test To assess Ilioposas

Silfverskiold To determine the isolation of gastrocnimeus
and soleus function

Tardieu Scale To rule out static or dynamic tightness.

To refer for botox or tendon release.

GMFCS To know the current motor function.

Emphasis is on usual performance in home,
school and community settings (what they do)
rather than what they are known to be able to
do at their best (capability). It is therefore
important to classify current performance in
gross motor function.

CFCS To rule out communication disorders.

Tells how the information is expressed and
received.
MACS To classify how the children use their hands
while handling objects in daily activities(i.e)
quantity and quality of performance and need
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for assistance or adaptations to perform

manual tasks in daily activity.
EEI To determine energy requirements to rule out
their physical activity level.
GMFM To detect and tell about the transition changes
in gross motor function in children with CP
SAROM Spinal mal alignment and limited ROM are
correlated with decline in gross motor function
SAROM tells about the spinal alignment in CP
children for cervical,thoracic and lumbar region
and describe the pattern of restrictions in these
areas.

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