Cerebral Palsy: Physiotherapy Assessment and Management

Introduction

1. A disorder of movement and/or posture (weakness, spasticity, dystonia, ataxia, or choreoathetosis) with onset before age 1-2 years
2. Reliable evidence of a fetal or infant brain disturbance
3. No evidence of progression over time
4. Significant functional limitation in activities
5. Reasonable expectation the disorder persists lifelong

Epidemiology and Causes

• Prematurity (strongest single risk; incidence 8.7% in <32 weeks gestation vs. 0.6% in 34-37 weeks)
• Very low birth weight (<1,500 g)
• Periventricular/intraventricular hemorrhage
• TORCH infections (Toxoplasmosis, Other, Rubella, CMV, Herpes)
• Perinatal hypoxic-ischemic injury
• Multiple gestations (largely mediated through prematurity)

Classification

By Motor Type

By Topography (Spastic CP)

• Monoplegia - one limb affected
• Hemiplegia - one side (arm + leg), usually arm more than leg
• Diplegia - legs predominantly, arms less so (classic in periventricular leukomalacia)
• Triplegia - both legs and one arm
• Quadriplegia - all four limbs plus trunk and face

Gross Motor Function Classification System (GMFCS)

• Level I: Walks without restrictions
• Level II: Walks with limitations outdoors
• Level III: Walks with assistive devices
• Level IV: Self-mobility limited, uses powered wheelchair
• Level V: Transported in manual wheelchair; no independent mobility

Clinical Features

Upper Motor Neuron Syndrome

• Spasticity
• Clonus
• Hyperreflexia with radiation
• Extensor/flexor spasms
• Positive Babinski sign
• Involuntary activation of remote muscles

• Muscle weakness
• Loss of selective motor control
• Loss of dexterity
• Fatigability
• Cognitive, communication, and behavioral changes

Characteristic Postures and Gait Patterns

• Upper limb: elbow flexion, wrist/finger flexion, shoulder internal rotation, forearm pronation
• Lower limb: hip flexion and adduction, knee flexion, toe walking
• Gait patterns: toe-walking, crouched gait, jump gait, scissor gait (hip adduction)

Associated Conditions

• Epilepsy (30-50%)
• Intellectual disability
• Sensory impairments (vision, hearing)
• Communication/speech difficulties
• Feeding and swallowing dysfunction (sialorrhea common - may require physiotherapy measures, posture optimization, or botulinum toxin to submandibular ducts)
• Depression (prevalence up to double the general population in adults, correlating with functional disability)
• Cervical myelopathy in dyskinetic CP (onset typically 4th decade due to sustained involuntary movements causing degenerative changes)

Physiotherapy Assessment

History

• Pregnancy history: gestational age, birth weight, perinatal complications, NICU course
• Developmental trajectory: motor, language, visual-motor milestones
• Current functional abilities, assistive devices used
• Pain complaints and fatigue (very common in adults)
• Previous interventions: botulinum toxin, surgeries, orthoses

Physical Examination

• Modified Ashworth Scale (MAS) or Tardieu Scale for spasticity
• Distinguish spasticity (velocity-dependent) from dystonia (sustained abnormal postures) and rigidity

• Passive and active ROM of all joints
• Hip: Thomas test (hip flexion contracture), Ober test (IT band tightness), Staheli test (hip extension)
• Knee: popliteal angle for hamstring tightness
• Ankle: Silfverskiöld test (distinguishes gastrocnemius vs. soleus tightness)
• Foot: Coleman block test (hindfoot flexibility in cavovarus)

• Selective motor control (proximal and distal)
• Manual muscle testing (often limited by poor cooperation in younger children)
• Functional strength testing

• Persistent primitive reflexes (ATNR, STNR, Moro) beyond expected integration age
• Deep tendon reflexes: hyperreflexia typical
• Babinski sign

• Static and dynamic postural control
• Pelvic tilt, trunk alignment
• Hip surveillance (radiographic hip migration percentage monitored regularly)
• Spinal curves: scoliosis assessment (particularly GMFCS IV/V)

• Clinical observational gait analysis
• Instrumented 3D gait analysis (gold standard for surgical planning): assesses kinematics, kinetics, and EMG to identify pathological patterns and guide multi-level surgical decisions
• Common patterns: equinus, crouch gait, jump gait, stiff-knee gait (rectus femoris overactivity)

• GMFCS - functional mobility classification
• MACS (Manual Ability Classification System) - hand function
• CFCS (Communication Function Classification System)
• Gross Motor Function Measure (GMFM-66 or GMFM-88) - quantifies motor function and tracks change over time
• Pediatric Evaluation of Disability Inventory (PEDI)
• 6-Minute Walk Test - endurance in ambulatory patients

Physiotherapy Management

1. Physiotherapy Techniques

• Regular stretching to prevent/delay contracture formation
• Sustained (static) stretching preferred for spastic muscles
• Serial casting used for progressive contractures (commonly ankle, knee, elbow)

• Progressive resistance training - shown to improve strength without worsening spasticity
• Focus on weak antagonists (hip extensors/abductors, ankle dorsiflexors)
• Task-specific training improves motor learning

• Facilitates normal movement patterns; inhibits abnormal reflex activity
• Widely used but evidence base continues to evolve

• Used in hemiplegic CP: constrains unaffected limb to force use of affected arm
• Good evidence for improving upper limb function in hemiplegia

• Partial body-weight-supported treadmill training
• Robotics-assisted gait training (Lokomat) in non/low-ambulatory patients
• Improves walking speed, endurance, and GMFM scores

• Warm water reduces muscle tone temporarily, allowing improved ROM and movement
• Useful for strengthening in reduced gravity environment

• Peroneal nerve FES for foot drop/equinus
• Improves dorsiflexion during gait

2. Orthotic Management (PT co-managed)

• Ankle-Foot Orthoses (AFO) - most commonly used; prevents equinus, supports walking
  • Solid AFO, hinged AFO, ground reaction AFO (for crouch gait)
• Knee-Ankle-Foot Orthoses (KAFO) - for more proximal weakness
• Hip abduction orthoses - in early hip subluxation
• Upper limb splints - wrist/hand in hemiplegic CP

3. Pharmacological Management (PT works alongside)

• Baclofen (first-line) - GABA-B agonist
• Tizanidine, dantrolene, benzodiazepines (diazepam)
• Second-line: clonidine or gabapentin (dual benefit for tone and sleep, pain, dysautonomia)

• Botulinum Toxin A (BoNT-A) - gold standard for focal spasticity
  • Injections every 4-6 months (minimum 3 months to avoid resistance)
  • Targets specific overactive muscles (e.g., gastrocnemius, hip adductors, rectus femoris)
  • Maximally effective when combined with physiotherapy immediately post-injection
• Phenol / Ethyl alcohol - nerve blocks for larger muscle groups

• For severe, widespread spasticity not adequately controlled with oral baclofen
• Delivers baclofen directly to CSF at a fraction of the oral dose
• Avoids systemic side effects (sedation, weakness, GI symptoms)
• Reversible (unlike SDR)
• Requires test dose before pump implantation

4. Surgical Management (PT role: pre/post-op rehab)

• Tendon lengthening/release (gastrocnemius-soleus, hamstrings, hip flexors, adductors)
• Tendon transfers (e.g., split anterior tibialis transfer - SPLATT - for spastic varus)
• Rectus femoris transfer/release for stiff-knee gait

• Femoral/tibial derotation osteotomies for rotational malalignment
• Hip reconstruction (varus derotation osteotomy + acetabuloplasty) for subluxation/dislocation

• Surgical sectioning of sensory nerve rootlets (L1-S1) reducing spastic input
• Best candidates: spastic diplegia, GMFCS II-III, age 4-8 years, no fixed contractures
• Produces permanent, significant spasticity reduction
• Intensive post-operative PT for 12-24 months is mandatory

• Indicated for curves >50 degrees in skeletally immature or progressive curves
• Posterior instrumentation with pedicle screws; pelvic fixation preferred for pelvic obliquity
• Complication rates reported up to 81% (infection 15-19%); pulmonary management is critical perioperatively

Adult Considerations in CP

• Gait and self-care worsen in a substantial proportion of adults
• Pain and fatigue are frequent complaints (multifactorial: hypertonia, musculoskeletal changes, reduced rehabilitation access)
• Dyskinetic CP is complicated by cervical spine degeneration and myelopathy (onset ~4th decade)
• Depression prevalence up to double the general population
• Orthopedic interventions become less important once the skeleton matures; tone management and seizure management remain lifelong priorities

Summary Table: Physiotherapy Framework