Cerebral palsy physical examination: Difference between revisions

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{{Cerebral palsy}}
{{Cerebral palsy}}


{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{IQ}}


==Overview==
==Overview==
Patients with cerebral palsy usually have abnormal neck or truncal tone, asymmetric posture, abnormal strength, gait and coordination. Physical examination of patients with cerebral palsy is usually remarkable for neuromuscular findings such as tremors or involuntary movements, athetosis, chorea, muscle rigidity, sensory loss, diplegia/hemiplegia/quadriplegia, intellectual disability, dystonia, normal/increased/decreased tone, persistent or asymmetric fisting, abnormal oromotor patterns, tongue retraction and thrust, tonic bite, oral hypersensitivity, grimacing, poor head control and spastic cerebral palsy presents with features of upper motor neuron lesion.
Patients with cerebral palsy usually have abnormal neck or truncal tone, asymmetric [[posture]], abnormal strength, [[Ataxia|gait]] and coordination. Physical examination of patients with cerebral palsy is usually remarkable for [[neuromuscular]] findings such as [[tremors]] or involuntary movements, [[athetosis]], [[chorea]], muscle [[rigidity]], [[sensory loss]], [[diplegia]]/[[hemiplegia]]/[[quadriplegia]], [[intellectual disability]], [[dystonia]], normal/increased/decreased tone, persistent or asymmetric fisting, abnormal oromotor patterns, tongue retraction and thrust, tonic bite, oral hypersensitivity, grimacing, poor head control and spastic cerebral palsy presents with features of [[upper motor neuron]] lesion.


==Physical Examination==
==Physical Examination==
CP: cerebral palsy; PVL: periventricular leukomalacia; SGA: small for gestational age.
<small> CP: Cerebral palsy; PVL: [[Periventricular leukomalacia]]; SGA: [[Small for gestational age]]. </small>
{| class="wikitable"
{| class="wikitable"
! colspan="2" |Type of motor dysfunction
! colspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Type of motor dysfunction
!Common causes
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Common causes
!Percentage of CP cases
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Percentage of CP cases
!Age at which infants affected
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Age at which infants affected
!Clinical findings
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Clinical findings
|-
|-
| rowspan="3" |'''Spastic'''
! style="background: #DCDCDC; padding: 5px; text-align: center;" rowspan="3" |'''[[Spastic]]'''
'''(Pyramidal) subtypes'''
'''(Pyramidal) subtypes'''
|'''Spastic diplegia'''
! style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Spastic diplegia'''
|
|
* Most commonly associated with PVL
* Most commonly associated with PVL
|13 to 25%
| 13 to 25%
|
|
* Preterm infants
* [[Preterm]] infants
* Risk increases with decreasing gestational age
* Risk increases with decreasing [[gestational age]]
|
|
* Lower limbs are more affected than the upper limbs
* [[Lower limbs]] are more affected than the [[upper limbs]]
* Affected patients have flexion, adduction, and internal rotation of the hips with contractures of the hip flexors and hamstring muscles
* Affected patients have [[flexion]], [[adduction]], and [[internal rotation]] of the [[hips]] with [[contractures]] of the [[hip]] flexors and hamstring muscles
* Variable degrees of flexion at the elbows and knees
* Variable degrees of flexion at the [[elbows]] and [[knees]]
* Reduced limb length and muscle bulk in lower extremities
* Reduced limb length and muscle bulk in [[lower extremities]]
|-
|-
|'''Spastic hemiplegia'''
! style="background: #DCDCDC; padding: 5px; text-align: center;"  |'''Spastic [[hemiplegia]]'''
|
|
* Neonatal stroke
* [[Neonatal stroke]]
* Prenatal circulatory disturbances
* Prenatal circulatory disturbances
* Brain maldevelopment
* Brain development problems
|21 to 40%
| 21 to 40%
|
|
* Term infants of normal birth weight
* Term infants of normal [[birth weight]]
|
|
* One side of the body is affected
* One side of the body is affected
* The arm typically is more affected than the leg
* The arm typically is more affected than the leg
* The arm is adducted at the shoulder and flexed at the elbow, the forearm is pronated, and the wrist and fingers are flexed with the hand closed
* The arm is [[Adduction|adducted]] at the [[shoulder]] and flexed at the [[elbow]], the [[forearm]] is pronated, and the [[wrist]] and fingers are [[Flexion|flexed]] with the hand closed
* The hip is partially flexed and adducted, and the knee and ankle are flexed; the foot may remain in the equinovarus or calcaneovalgus position
* The [[hip]] is partially [[Flexion|flexed]] and [[Adduction|adducted]], and the [[knee]] and [[ankle]] are [[Flexion|flexed]]; the foot may remain in the [[equinovarus]] or calcaneovalgus position
* Most children also have sensory deficits
* Most children also have sensory deficits
* In mildly affected patients, postural abnormalities are more apparent during walking or running; however, unless severe intellectual disability is present, independent walking usually occurs at the appropriate age or is only slightly delayed
* In mildly affected patients, postural abnormalities are more apparent during walking or running; however, unless severe [[intellectual disability]] is present, independent walking usually occurs at the appropriate age or is only slightly delayed
|-
|-
|'''Spastic quadriplegia'''
! style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Spastic [[quadriplegia]]'''
|
|
* Congenital infection
* [[|TORCH|Congenital infection]]
* Cerebral dysgenesis
* Cerebral dysgenesis
* Perinatal or postnatal events
* Perinatal or postnatal events
Line 57: Line 57:
|
|
* All limbs are affected
* All limbs are affected
* Upper limbs may be equally or more involved than lower limbs
* [[Upper limbs]] may be equally or more involved than [[lower limbs]]
* Children often are severely handicapped
* Children often are severely handicapped
* Feeding difficulties, chronic respiratory insufficiency, and seizure disorder are common
* Feeding difficulties, chronic respiratory insufficiency, and [[seizure]] are common
|-
|-
| colspan="2" rowspan="2" |'''Dyskinetic (Extra-pyramidal) subtypes'''
! colspan="2" rowspan="2" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Dyskinetic (extra-pyramidal) subtypes'''
| rowspan="2" |
| rowspan="2" |
* Most cases are caused by severe perinatal asphyxia resulting in injury to the thalamus, basal ganglia, hippocampus, reticular formation, and/or cerebellum
* Most cases are caused by severe perinatal [[asphyxia]] resulting in injury to the [[thalamus]], [[basal ganglia]], [[hippocampus]], [[reticular formation]], and/or [[cerebellum]]
* Severe hyperbilirubinemia (kernicterus) can cause choreoathetotic CP
* Severe [[hyperbilirubinemia]] ([[kernicterus]]) can cause choreoathetotic CP
| rowspan="2" |12 to 14%
| rowspan="2" |12 to 14%
| rowspan="2" |
| rowspan="2" |
* Predominantly term infants
* Predominantly term infants
|'''Choreoathetotic CP''':
|'''Choreoathetotic CP''':
*Chorea consists of rapid, irregular, unpredictable contractions of individual muscles or small muscle groups that involve the face, bulbar muscles, proximal extremities, and fingers and toes
* [[Chorea]] consists of rapid, irregular, unpredictable contractions of individual muscles or small muscle groups that involve the face, bulbar muscles, proximal extremities, and fingers and toes
*Athetosis consists of slow, smooth, writhing movements that involve distal muscles
* [[Athetosis]] consists of slow, smooth, writhing movements that involve distal muscles
*Movements may be induced or accentuated by emotion or change in posture
* Movements may be induced or accentuated by emotion or change in posture
*Athetosis is most apparent during reaching
* [[Athetosis]] is most apparent during reaching
*Stress, excitement, or fever may exacerbate chorea
* [[Stress]], excitement, or [[fever]] may exacerbate [[chorea]]
*Primitive reflexes often are retained
* [[Primitive reflexes]] often are retained
*Oropharyngeal difficulties occur commonly
* Oropharyngeal difficulties occur commonly
|-
|-
|'''Dystonic CP''':
|'''Dystonic CP''':
*Repetitive, patterned, twisting, and sustained movements of the trunk and limbs that may be either slow or rapid
* Repetitive, patterned, twisting, and sustained movements of the trunk and limbs that may be either slow or rapid
*Pyramidal signs and anarthria may occur
* Pyramidal signs and [[anarthria]] may occur
*"Tension", a sudden involuntary increase in tone affecting both flexor and extensor muscles, may occur during attempted movement or with emotion
* "Tension", a sudden involuntary increase in tone affecting both flexor and extensor muscles, may occur during attempted movement or with emotion
*Tendon reflexes are normal or may be difficult to elicit
* Tendon reflexes are normal or may be difficult to elicit
*Clonus and extensor plantar responses are absent
* Clonus and extensor plantar responses are absent
|-
|-
| colspan="2" |'''Ataxic CP'''
! colspan="2" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Ataxic CP'''
|
|
* Most cases are caused by early prenatal events
* Most cases are caused by early [[prenatal]] events
* Etiology is frequently unknown
* Etiology is frequently unknown
* Some cases have genetic causes, including:
* Some cases have genetic causes, including:
** Cerebellar hypoplasia
** [[Cerebellar hypoplasia]]
** Granule cell deficiency
** Granule cell deficiency
** Joubert syndrome
** Joubert syndrome
* Rarely associated with congenital hypoplasia of the cerebellum
* Rarely associated with congenital [[hypoplasia]] of the [[cerebellum]]
|4 to 13%
|4 to 13%
|
|
*Term infants
*Term infants
|
|
*Ataxic movements
* Ataxic movements
*Widespread disorder of motor function
* Widespread disorder of motor function
*Ataxia usually improves with time
* [[Ataxia]] usually improves with time
*Speech typically is slow, jerky, and explosive
* [[Speech]] typically is slow, jerky, and explosive
|}
|}


==== Developmental milestones: ====
==== Developmental milestones: ====
*The most common delayed motor milestones are
*The most common delayed motor milestones are:
**Unable to sit by 8 months
**Unable to sit by 8 months
**Unable to walk by 18 months
**Unable to walk by 18 months
**Hand preference  at < 1yr age
**Hand preference  at < 1yr age
===Appearance of the Patient===
===Appearance of the Patient===
*General physical examination may show  
*General physical examination may show:
**Abnormal neck or truncal tone
** Abnormal neck or truncal tone
**Asymmetric posture
** Asymmetric posture
**Abnormal strength
** Abnormal strength
**Abnormal gait
** Abnormal gait
**Abnormal coordination
** Abnormal coordination
*Cerebral palsy involves a non-progressive motor dysfunction affecting muscle tone, posture and movement. On physical examination, following findings may be observed:<ref name="pmid2304976">{{cite journal |vauthors=Myklebust BM |title=A review of myotatic reflexes and the development of motor control and gait in infants and children: a special communication |journal=Phys Ther |volume=70 |issue=3 |pages=188–203 |year=1990 |pmid=2304976 |doi= |url=}}</ref><ref name="pmid17370483">{{cite journal |vauthors=Rosenbloom L |title=Definition and classification of cerebral palsy. Definition, classification, and the clinician |journal=Dev Med Child Neurol Suppl |volume=109 |issue= |pages=43 |year=2007 |pmid=17370483 |doi= |url=}}</ref><ref name="pmid17370477">{{cite journal |vauthors=Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, Dan B, Jacobsson B |title=A report: the definition and classification of cerebral palsy April 2006 |journal=Dev Med Child Neurol Suppl |volume=109 |issue= |pages=8–14 |year=2007 |pmid=17370477 |doi= |url=}}</ref><ref name="pmid11132255">{{cite journal |vauthors= |title=Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE) |journal=Dev Med Child Neurol |volume=42 |issue=12 |pages=816–24 |year=2000 |pmid=11132255 |doi= |url=}}</ref><ref name="pmid492783">{{cite journal |vauthors=Capute AJ |title=Identifying cerebral palsy in infancy through study of primitive-reflex profiles |journal=Pediatr Ann |volume=8 |issue=10 |pages=589–95 |year=1979 |pmid=492783 |doi= |url=}}</ref><ref name="pmid8534280">{{cite journal |vauthors=Zafeiriou DI, Tsikoulas IG, Kremenopoulos GM |title=Prospective follow-up of primitive reflex profiles in high-risk infants: clues to an early diagnosis of cerebral palsy |journal=Pediatr. Neurol. |volume=13 |issue=2 |pages=148–52 |year=1995 |pmid=8534280 |doi= |url=}}</ref><ref name="pmid23713113">{{cite journal |vauthors=Noritz GH, Murphy NA |title=Motor delays: early identification and evaluation |journal=Pediatrics |volume=131 |issue=6 |pages=e2016–27 |year=2013 |pmid=23713113 |doi=10.1542/peds.2013-1056 |url=}}</ref><ref name="pmid9003724">{{cite journal |vauthors=Allen MC, Alexander GR |title=Using motor milestones as a multistep process to screen preterm infants for cerebral palsy |journal=Dev Med Child Neurol |volume=39 |issue=1 |pages=12–6 |year=1997 |pmid=9003724 |doi= |url=}}</ref>
*Cerebral palsy involves a non-progressive motor dysfunction affecting muscle tone, posture and movement. On physical examination, following findings may be observed:<ref name="pmid2304976">{{cite journal |vauthors=Myklebust BM |title=A review of myotatic reflexes and the development of motor control and gait in infants and children: a special communication |journal=Phys Ther |volume=70 |issue=3 |pages=188–203 |year=1990 |pmid=2304976 |doi= |url=}}</ref><ref name="pmid17370483">{{cite journal |vauthors=Rosenbloom L |title=Definition and classification of cerebral palsy. Definition, classification, and the clinician |journal=Dev Med Child Neurol Suppl |volume=109 |issue= |pages=43 |year=2007 |pmid=17370483 |doi= |url=}}</ref><ref name="pmid17370477">{{cite journal |vauthors=Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, Dan B, Jacobsson B |title=A report: the definition and classification of cerebral palsy April 2006 |journal=Dev Med Child Neurol Suppl |volume=109 |issue= |pages=8–14 |year=2007 |pmid=17370477 |doi= |url=}}</ref><ref name="pmid11132255">{{cite journal |vauthors= |title=Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE) |journal=Dev Med Child Neurol |volume=42 |issue=12 |pages=816–24 |year=2000 |pmid=11132255 |doi= |url=}}</ref><ref name="pmid492783">{{cite journal |vauthors=Capute AJ |title=Identifying cerebral palsy in infancy through study of primitive-reflex profiles |journal=Pediatr Ann |volume=8 |issue=10 |pages=589–95 |year=1979 |pmid=492783 |doi= |url=}}</ref><ref name="pmid8534280">{{cite journal |vauthors=Zafeiriou DI, Tsikoulas IG, Kremenopoulos GM |title=Prospective follow-up of primitive reflex profiles in high-risk infants: clues to an early diagnosis of cerebral palsy |journal=Pediatr. Neurol. |volume=13 |issue=2 |pages=148–52 |year=1995 |pmid=8534280 |doi= |url=}}</ref><ref name="pmid23713113">{{cite journal |vauthors=Noritz GH, Murphy NA |title=Motor delays: early identification and evaluation |journal=Pediatrics |volume=131 |issue=6 |pages=e2016–27 |year=2013 |pmid=23713113 |doi=10.1542/peds.2013-1056 |url=}}</ref><ref name="pmid9003724">{{cite journal |vauthors=Allen MC, Alexander GR |title=Using motor milestones as a multistep process to screen preterm infants for cerebral palsy |journal=Dev Med Child Neurol |volume=39 |issue=1 |pages=12–6 |year=1997 |pmid=9003724 |doi= |url=}}</ref>
*Serial examinations are required to make a definitive diagnosis as the maturation of nervous system continues even after birth resulting in evolvement of neurological function and functioning ability.
**Serial examinations are required to make a definitive diagnosis as the maturation of nervous system continues even after birth resulting in evolvement of neurological function and functioning ability.


===HEENT===
===HEENT===
*Dysarthria
* [[Dysarthria]]
*Abnormal hearing tests  
* Abnormal hearing tests  
*Visual abnormalities
* Visual abnormalities


===Lungs===
===Lungs===
* Decreased chest expansion
* Decreased [[chest expansion]]
*Fine/coarse [[crackles]] upon auscultation of the lung bases unilaterally/bilaterally
* Fine/coarse [[crackles]] upon [[auscultation]] of the lung bases unilaterally/bilaterally
*Rhonchi
* [[Rhonchi]]
*[[Wheezing]] may be present
* [[Wheezing]] may be present


===Heart===
===Heart===
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
* [[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
* [[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]


===Abdomen===
===Abdomen===
*Guarding may be present
* [[Guarding]] may be present


===Back===
===Back===
*Scoliosis
* [[Scoliosis]]


===Neuromuscular===
===Neuromuscular===
* Tremors or involuntary movements
* [[Tremors]] or involuntary movements
* Athetosis -slow, writhing movements
* [[Athetosis]] -slow, writhing movements
*Chorea<ref name="pmid2002202">{{cite journal |vauthors=Harbord MG, Kobayashi JS |title=Fever producing ballismus in patients with choreoathetosis |journal=J. Child Neurol. |volume=6 |issue=1 |pages=49–52 |year=1991 |pmid=2002202 |doi=10.1177/088307389100600111 |url=}}</ref>
* [[Chorea]]<ref name="pmid2002202">{{cite journal |vauthors=Harbord MG, Kobayashi JS |title=Fever producing ballismus in patients with choreoathetosis |journal=J. Child Neurol. |volume=6 |issue=1 |pages=49–52 |year=1991 |pmid=2002202 |doi=10.1177/088307389100600111 |url=}}</ref>
* Muscle rigidity
* Muscle rigidity
*Sensory loss
* [[Sensory loss]]
*Diplegia/hemiplegia/quadriplegia<ref name="pmid16700930">{{cite journal |vauthors=Himmelmann K, Beckung E, Hagberg G, Uvebrant P |title=Gross and fine motor function and accompanying impairments in cerebral palsy |journal=Dev Med Child Neurol |volume=48 |issue=6 |pages=417–23 |year=2006 |pmid=16700930 |doi=10.1017/S0012162206000922 |url=}}</ref><ref name="pmid16467053">{{cite journal |vauthors=Odding E, Roebroeck ME, Stam HJ |title=The epidemiology of cerebral palsy: incidence, impairments and risk factors |journal=Disabil Rehabil |volume=28 |issue=4 |pages=183–91 |year=2006 |pmid=16467053 |doi=10.1080/09638280500158422 |url=}}</ref>
* [[Diplegia]]/[[hemiplegia]]/[[quadriplegia]]<ref name="pmid16700930">{{cite journal |vauthors=Himmelmann K, Beckung E, Hagberg G, Uvebrant P |title=Gross and fine motor function and accompanying impairments in cerebral palsy |journal=Dev Med Child Neurol |volume=48 |issue=6 |pages=417–23 |year=2006 |pmid=16700930 |doi=10.1017/S0012162206000922 |url=}}</ref><ref name="pmid16467053">{{cite journal |vauthors=Odding E, Roebroeck ME, Stam HJ |title=The epidemiology of cerebral palsy: incidence, impairments and risk factors |journal=Disabil Rehabil |volume=28 |issue=4 |pages=183–91 |year=2006 |pmid=16467053 |doi=10.1080/09638280500158422 |url=}}</ref>
*Intellectual disability
*[[Intellectual disability]]
*Dystonia<ref name="pmid20589866">{{cite journal |vauthors=Sanger TD, Chen D, Fehlings DL, Hallett M, Lang AE, Mink JW, Singer HS, Alter K, Ben-Pazi H, Butler EE, Chen R, Collins A, Dayanidhi S, Forssberg H, Fowler E, Gilbert DL, Gorman SL, Gormley ME, Jinnah HA, Kornblau B, Krosschell KJ, Lehman RK, MacKinnon C, Malanga CJ, Mesterman R, Michaels MB, Pearson TS, Rose J, Russman BS, Sternad D, Swoboda KJ, Valero-Cuevas F |title=Definition and classification of hyperkinetic movements in childhood |journal=Mov. Disord. |volume=25 |issue=11 |pages=1538–49 |year=2010 |pmid=20589866 |pmc=2929378 |doi=10.1002/mds.23088 |url=}}</ref>
*[[Dystonia]]<ref name="pmid20589866">{{cite journal |vauthors=Sanger TD, Chen D, Fehlings DL, Hallett M, Lang AE, Mink JW, Singer HS, Alter K, Ben-Pazi H, Butler EE, Chen R, Collins A, Dayanidhi S, Forssberg H, Fowler E, Gilbert DL, Gorman SL, Gormley ME, Jinnah HA, Kornblau B, Krosschell KJ, Lehman RK, MacKinnon C, Malanga CJ, Mesterman R, Michaels MB, Pearson TS, Rose J, Russman BS, Sternad D, Swoboda KJ, Valero-Cuevas F |title=Definition and classification of hyperkinetic movements in childhood |journal=Mov. Disord. |volume=25 |issue=11 |pages=1538–49 |year=2010 |pmid=20589866 |pmc=2929378 |doi=10.1002/mds.23088 |url=}}</ref>
* Tone may be normal/increased/decreased
* Tone may be normal/increased/decreased
**Persistent or asymmetric fisting
** Persistent or asymmetric fisting
**Abnormal oromotor patterns
** Abnormal oromotor patterns
***Tongue retraction and thrust
*** Tongue retraction and thrust
***Tonic bite
*** Tonic bite
***Oral hypersensitivity
*** Oral hypersensitivity
***Grimacing
*** Grimacing
**Poor head control  
** Poor head control  
* Spastic Cerebral palsy presents with features of upper motor neuron lesion that includes:<ref name="pmid2304976">{{cite journal |vauthors=Myklebust BM |title=A review of myotatic reflexes and the development of motor control and gait in infants and children: a special communication |journal=Phys Ther |volume=70 |issue=3 |pages=188–203 |year=1990 |pmid=2304976 |doi= |url=}}</ref><ref name="pmid3278524">{{cite journal |vauthors=Burke D |title=Spasticity as an adaptation to pyramidal tract injury |journal=Adv Neurol |volume=47 |issue= |pages=401–23 |year=1988 |pmid=3278524 |doi= |url=}}</ref><ref name="pmid3412602">{{cite journal |vauthors=Landau WM |title=Clinical neuromythology II. Parables of palsy pills and PT pedagogy: a spastic dialectic |journal=Neurology |volume=38 |issue=9 |pages=1496–9 |year=1988 |pmid=3412602 |doi= |url=}}</ref>
* Spastic cerebral palsy presents with features of [[upper motor neuron lesion]] that includes:<ref name="pmid2304976">{{cite journal |vauthors=Myklebust BM |title=A review of myotatic reflexes and the development of motor control and gait in infants and children: a special communication |journal=Phys Ther |volume=70 |issue=3 |pages=188–203 |year=1990 |pmid=2304976 |doi= |url=}}</ref><ref name="pmid3278524">{{cite journal |vauthors=Burke D |title=Spasticity as an adaptation to pyramidal tract injury |journal=Adv Neurol |volume=47 |issue= |pages=401–23 |year=1988 |pmid=3278524 |doi= |url=}}</ref><ref name="pmid3412602">{{cite journal |vauthors=Landau WM |title=Clinical neuromythology II. Parables of palsy pills and PT pedagogy: a spastic dialectic |journal=Neurology |volume=38 |issue=9 |pages=1496–9 |year=1988 |pmid=3412602 |doi= |url=}}</ref>
**Positive signs
** Positive signs:
***Muscle spasticity
*** [[Muscle spasticity]]
***Clonus may be present
*** Clonus may be present
***Hyperreflexia
*** [[Hyperreflexia]]
***Extensor muscle response
*** Extensor muscle response
**Negative signs such as
** Negative signs such as:
***Fatigability
*** [[Fatigue]]
***Weakness
*** [[Weakness]]
***Slow, effortful voluntary movements
*** Slow, effortful voluntary movements
***Impaired fine-motor function
*** Impaired fine-motor function
***Difficulty in isolating individual movement
*** Difficulty in isolating individual movement
*Abnormal gait: walking on toes/ a crouched gait/ a scissors-like gait with knees crossing/ a wide gait or an asymmetrical gait
* Abnormal gait: Walking on toes/ a crouched gait/ a scissors-like gait with knees crossing/ a wide gait or an asymmetrical gait
*Persistence or exaggeration of primitive reflexes such as
* Persistence or exaggeration of primitive reflexes such as:
**Moro reflex (startle reflex)  
** [[Moro reflex]] (startle reflex)  
**Asymmetric tonic neck reflexes (fencing posture with neck turned in same direction when one arm is extended and the other is flexed)
** Asymmetric tonic neck reflexes (fencing posture with neck turned in same direction when one arm is extended and the other is [[Flexion|flexed]])
*Other reflexes that might be noticed include:
* Other reflexes that might be noticed include:
**Symmetric tonic neck reflex
** Symmetric tonic neck reflex
**Palmar grasp reflex
** [[Grasp reflex|Palmar grasp reflex]]
**Tonic labyrinthine reflex  
** [[Tonic labyrinthine reflex]]
**Foot placement reflex
** Foot placement reflex
**Underdevelopment/disappearance/absence of postural or protective reflexes (extending arm when sitting up)
** Underdevelopment/disappearance/absence of postural or protective reflexes (extending arm when sitting up)
*In patients with cerebral palsy (CP) functional motor impairment can be categorized by:
***Gross Motor Function Classification System (GMFCS)
***Manual Ability Classification System (MACS)
***Communication Function Classification System (CFCS)
*Neurobehavioral signs may include excessive docility or irritability


===Extremities===
===Extremities===
*Common findings seen in cerebral palsy on hip, knee and foot joint are as follows:
*Common findings seen in cerebral palsy on hip, knee and foot joint are as follows:
**Hip
**Hip
***Excessive flexion
***Excessive [[flexion]]
***Adduction
***Adduction
***Femoral anteversion  
***Femoral anteversion  
**Knee
**Knee
***Flexion and extension with valgus or varus stress
***[[flexion]] and extension with valgus or varus stress
**Foot
**Foot
***Equinus or toe walking
***Equinus or toe walking
***Varus or valgus of the hindfoot
***Varus or valgus of the hindfoot
*Spastic diplegia may involve  
*Spastic diplegia may involve  
**Flexion at the elbows and knees
**[[flexion]] at the elbows and knees
**Flexion, adduction, and internal rotation of the hips
**[[flexion]], adduction, and internal rotation of the hips
**Equinovalgus or calcaneovarus deformity of the foot
**Equinovalgus or calcaneovarus deformity of the foot
**Atrophy below the waist<ref name="pmid8495821">{{cite journal |vauthors=Lesný I, Stehlík A, Tomásek J, Tománková A, Havlícek I |title=Sensory disorders in cerebral palsy: two-point discrimination |journal=Dev Med Child Neurol |volume=35 |issue=5 |pages=402–5 |year=1993 |pmid=8495821 |doi= |url=}}</ref>
**Atrophy below the waist<ref name="pmid8495821">{{cite journal |vauthors=Lesný I, Stehlík A, Tomásek J, Tománková A, Havlícek I |title=Sensory disorders in cerebral palsy: two-point discrimination |journal=Dev Med Child Neurol |volume=35 |issue=5 |pages=402–5 |year=1993 |pmid=8495821 |doi= |url=}}</ref>
*Spastic hemiplegia
*Spastic hemiplegia
**Shoulder retraction and flexion of fingers with adduction of the thumb
**Shoulder retraction and [[flexion]] of fingers with adduction of the thumb
**Hip is partially flexed and adducted with flexed ankle and knee<ref name="pmid7594266">{{cite journal |vauthors=Cooper J, Majnemer A, Rosenblatt B, Birnbaum R |title=The determination of sensory deficits in children with hemiplegic cerebral palsy |journal=J. Child Neurol. |volume=10 |issue=4 |pages=300–9 |year=1995 |pmid=7594266 |doi=10.1177/088307389501000412 |url=}}</ref>
**Hip is partially [[Flexion|flexed]] and adducted with [[Flexion|flexed]] ankle and knee<ref name="pmid7594266">{{cite journal |vauthors=Cooper J, Majnemer A, Rosenblatt B, Birnbaum R |title=The determination of sensory deficits in children with hemiplegic cerebral palsy |journal=J. Child Neurol. |volume=10 |issue=4 |pages=300–9 |year=1995 |pmid=7594266 |doi=10.1177/088307389501000412 |url=}}</ref>
*Chorea
*Chorea
*Athetosis
*Athetosis

Latest revision as of 16:47, 6 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Overview

Patients with cerebral palsy usually have abnormal neck or truncal tone, asymmetric posture, abnormal strength, gait and coordination. Physical examination of patients with cerebral palsy is usually remarkable for neuromuscular findings such as tremors or involuntary movements, athetosis, chorea, muscle rigidity, sensory loss, diplegia/hemiplegia/quadriplegia, intellectual disability, dystonia, normal/increased/decreased tone, persistent or asymmetric fisting, abnormal oromotor patterns, tongue retraction and thrust, tonic bite, oral hypersensitivity, grimacing, poor head control and spastic cerebral palsy presents with features of upper motor neuron lesion.

Physical Examination

CP: Cerebral palsy; PVL: Periventricular leukomalacia; SGA: Small for gestational age.

Type of motor dysfunction Common causes Percentage of CP cases Age at which infants affected Clinical findings
Spastic

(Pyramidal) subtypes

Spastic diplegia
  • Most commonly associated with PVL
 13 to 25%
Spastic hemiplegia
  • Neonatal stroke
  • Prenatal circulatory disturbances
  • Brain development problems
 21 to 40%
  • One side of the body is affected
  • The arm typically is more affected than the leg
  • The arm is adducted at the shoulder and flexed at the elbow, the forearm is pronated, and the wrist and fingers are flexed with the hand closed
  • The hip is partially flexed and adducted, and the knee and ankle are flexed; the foot may remain in the equinovarus or calcaneovalgus position
  • Most children also have sensory deficits
  • In mildly affected patients, postural abnormalities are more apparent during walking or running; however, unless severe intellectual disability is present, independent walking usually occurs at the appropriate age or is only slightly delayed
Spastic quadriplegia
  • [[|TORCH|Congenital infection]]
  • Cerebral dysgenesis
  • Perinatal or postnatal events
 20 to 43%
  • Most commonly term SGA infants, but can also occur in preterm infants
  • All limbs are affected
  • Upper limbs may be equally or more involved than lower limbs
  • Children often are severely handicapped
  • Feeding difficulties, chronic respiratory insufficiency, and seizure are common
Dyskinetic (extra-pyramidal) subtypes 12 to 14%
  • Predominantly term infants
 Choreoathetotic CP:
  • Chorea consists of rapid, irregular, unpredictable contractions of individual muscles or small muscle groups that involve the face, bulbar muscles, proximal extremities, and fingers and toes
  • Athetosis consists of slow, smooth, writhing movements that involve distal muscles
  • Movements may be induced or accentuated by emotion or change in posture
  • Athetosis is most apparent during reaching
  • Stress, excitement, or fever may exacerbate chorea
  • Primitive reflexes often are retained
  • Oropharyngeal difficulties occur commonly
Dystonic CP:
  • Repetitive, patterned, twisting, and sustained movements of the trunk and limbs that may be either slow or rapid
  • Pyramidal signs and anarthria may occur
  • "Tension", a sudden involuntary increase in tone affecting both flexor and extensor muscles, may occur during attempted movement or with emotion
  • Tendon reflexes are normal or may be difficult to elicit
  • Clonus and extensor plantar responses are absent
Ataxic CP
  • Most cases are caused by early prenatal events
  • Etiology is frequently unknown
  • Some cases have genetic causes, including:
  • Rarely associated with congenital hypoplasia of the cerebellum
 4 to 13%
  • Term infants
  • Ataxic movements
  • Widespread disorder of motor function
  • Ataxia usually improves with time
  • Speech typically is slow, jerky, and explosive

Developmental milestones:

  • The most common delayed motor milestones are:
    • Unable to sit by 8 months
    • Unable to walk by 18 months
    • Hand preference at < 1yr age

Appearance of the Patient

  • General physical examination may show:
    • Abnormal neck or truncal tone
    • Asymmetric posture
    • Abnormal strength
    • Abnormal gait
    • Abnormal coordination
  • Cerebral palsy involves a non-progressive motor dysfunction affecting muscle tone, posture and movement. On physical examination, following findings may be observed:[1][2][3][4][5][6][7][8]
    • Serial examinations are required to make a definitive diagnosis as the maturation of nervous system continues even after birth resulting in evolvement of neurological function and functioning ability.

HEENT

  • Dysarthria
  • Abnormal hearing tests
  • Visual abnormalities

Lungs

Heart

Abdomen

Back

Neuromuscular

  • Tremors or involuntary movements
  • Athetosis -slow, writhing movements
  • Chorea[9]
  • Muscle rigidity
  • Sensory loss
  • Diplegia/hemiplegia/quadriplegia[10][11]
  • Intellectual disability
  • Dystonia[12]
  • Tone may be normal/increased/decreased
    • Persistent or asymmetric fisting
    • Abnormal oromotor patterns
      • Tongue retraction and thrust
      • Tonic bite
      • Oral hypersensitivity
      • Grimacing
    • Poor head control
  • Spastic cerebral palsy presents with features of upper motor neuron lesion that includes:[1][13][14]
    • Positive signs:
    • Negative signs such as:
      • Fatigue
      • Weakness
      • Slow, effortful voluntary movements
      • Impaired fine-motor function
      • Difficulty in isolating individual movement
  • Abnormal gait: Walking on toes/ a crouched gait/ a scissors-like gait with knees crossing/ a wide gait or an asymmetrical gait
  • Persistence or exaggeration of primitive reflexes such as:
    • Moro reflex (startle reflex)
    • Asymmetric tonic neck reflexes (fencing posture with neck turned in same direction when one arm is extended and the other is flexed)
  • Other reflexes that might be noticed include:

Extremities

  • Common findings seen in cerebral palsy on hip, knee and foot joint are as follows:
    • Hip
      • Excessive flexion
      • Adduction
      • Femoral anteversion
    • Knee
      • flexion and extension with valgus or varus stress
    • Foot
      • Equinus or toe walking
      • Varus or valgus of the hindfoot
  • Spastic diplegia may involve
    • flexion at the elbows and knees
    • flexion, adduction, and internal rotation of the hips
    • Equinovalgus or calcaneovarus deformity of the foot
    • Atrophy below the waist[15]
  • Spastic hemiplegia
    • Shoulder retraction and flexion of fingers with adduction of the thumb
    • Hip is partially flexed and adducted with flexed ankle and knee[16]
  • Chorea
  • Athetosis
  • Ataxia[17]

References

  1. ↑ 1.0 1.1 Myklebust BM (1990). "A review of myotatic reflexes and the development of motor control and gait in infants and children: a special communication". Phys Ther. 70 (3): 188–203. PMID 2304976.
  2. ↑ Rosenbloom L (2007). "Definition and classification of cerebral palsy. Definition, classification, and the clinician". Dev Med Child Neurol Suppl. 109: 43. PMID 17370483.
  3. ↑ Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, Dan B, Jacobsson B (2007). "A report: the definition and classification of cerebral palsy April 2006". Dev Med Child Neurol Suppl. 109: 8–14. PMID 17370477.
  4. ↑ "Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE)". Dev Med Child Neurol. 42 (12): 816–24. 2000. PMID 11132255.
  5. ↑ Capute AJ (1979). "Identifying cerebral palsy in infancy through study of primitive-reflex profiles". Pediatr Ann. 8 (10): 589–95. PMID 492783.
  6. ↑ Zafeiriou DI, Tsikoulas IG, Kremenopoulos GM (1995). "Prospective follow-up of primitive reflex profiles in high-risk infants: clues to an early diagnosis of cerebral palsy". Pediatr. Neurol. 13 (2): 148–52. PMID 8534280.
  7. ↑ Noritz GH, Murphy NA (2013). "Motor delays: early identification and evaluation". Pediatrics. 131 (6): e2016–27. doi:10.1542/peds.2013-1056. PMID 23713113.
  8. ↑ Allen MC, Alexander GR (1997). "Using motor milestones as a multistep process to screen preterm infants for cerebral palsy". Dev Med Child Neurol. 39 (1): 12–6. PMID 9003724.
  9. ↑ Harbord MG, Kobayashi JS (1991). "Fever producing ballismus in patients with choreoathetosis". J. Child Neurol. 6 (1): 49–52. doi:10.1177/088307389100600111. PMID 2002202.
  10. ↑ Himmelmann K, Beckung E, Hagberg G, Uvebrant P (2006). "Gross and fine motor function and accompanying impairments in cerebral palsy". Dev Med Child Neurol. 48 (6): 417–23. doi:10.1017/S0012162206000922. PMID 16700930.
  11. ↑ Odding E, Roebroeck ME, Stam HJ (2006). "The epidemiology of cerebral palsy: incidence, impairments and risk factors". Disabil Rehabil. 28 (4): 183–91. doi:10.1080/09638280500158422. PMID 16467053.
  12. ↑ Sanger TD, Chen D, Fehlings DL, Hallett M, Lang AE, Mink JW, Singer HS, Alter K, Ben-Pazi H, Butler EE, Chen R, Collins A, Dayanidhi S, Forssberg H, Fowler E, Gilbert DL, Gorman SL, Gormley ME, Jinnah HA, Kornblau B, Krosschell KJ, Lehman RK, MacKinnon C, Malanga CJ, Mesterman R, Michaels MB, Pearson TS, Rose J, Russman BS, Sternad D, Swoboda KJ, Valero-Cuevas F (2010). "Definition and classification of hyperkinetic movements in childhood". Mov. Disord. 25 (11): 1538–49. doi:10.1002/mds.23088. PMC 2929378. PMID 20589866.
  13. ↑ Burke D (1988). "Spasticity as an adaptation to pyramidal tract injury". Adv Neurol. 47: 401–23. PMID 3278524.
  14. ↑ Landau WM (1988). "Clinical neuromythology II. Parables of palsy pills and PT pedagogy: a spastic dialectic". Neurology. 38 (9): 1496–9. PMID 3412602.
  15. ↑ Lesný I, Stehlík A, Tomásek J, Tománková A, Havlícek I (1993). "Sensory disorders in cerebral palsy: two-point discrimination". Dev Med Child Neurol. 35 (5): 402–5. PMID 8495821.
  16. ↑ Cooper J, Majnemer A, Rosenblatt B, Birnbaum R (1995). "The determination of sensory deficits in children with hemiplegic cerebral palsy". J. Child Neurol. 10 (4): 300–9. doi:10.1177/088307389501000412. PMID 7594266.
  17. ↑ Miller G, Cala LA (1989). "Ataxic cerebral palsy--clinico-radiologic correlations". Neuropediatrics. 20 (2): 84–9. doi:10.1055/s-2008-1071271. PMID 2739880.

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