Cerebral palsy physical examination

Cerebral palsy Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Cerebral Palsy from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Criteria
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography and Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Cerebral palsy physical examination On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Cerebral palsy physical examination All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Cerebral palsy physical examination
CDC on Cerebral palsy physical examination
Cerebral palsy physical examination in the news
Blogs on Cerebral palsy physical examination
Directions to Hospitals Treating Psoriasis
Risk calculators and risk factors for Cerebral palsy physical examination

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

Overview

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

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 subtypes	Spastic diplegia	Most commonly associated with PVL	13 to 25%	Preterm infants Risk increases with decreasing gestational age	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 Variable degrees of flexion at the elbows and knees Reduced limb length and muscle bulk in lower extremities
	Spastic hemiplegia	Neonatal stroke Prenatal circulatory disturbances Brain maldevelopment	21 to 40%	Term infants of normal birth weight	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	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 disorder are common
Dyskinetic subtypes		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	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: Cerebellar hypoplasia Granule cell deficiency Joubert syndrome 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

• Cerebral palsy involves a non-progressive motor dysfunction affecting muscle tone, posture and movement. On physical examination, following findings may be observed:
• 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.

Vital Signs

• High-grade / low-grade fever
• Hypothermia / hyperthermia may be present
• Tachycardia with regular pulse or (ir)regularly irregular pulse
• Bradycardia with regular pulse or (ir)regularly irregular pulse
• Tachypnea / bradypnea
• Kussmal respirations may be present in _____ (advanced disease state)
• Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
• High/low blood pressure with normal pulse pressure / wide pulse pressure / narrow pulse pressure

Skin

• Cyanosis
• Jaundice
• Pallor
• Bruises

HEENT

• Dysarthria
• Abnormal hearing tests
• Visual abnormalities

Lungs

• Asymmetric chest expansion / Decreased chest expansion
• Lungs are hypo/hyperresonant
• Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
• Rhonchi
• Vesicular breath sounds / Distant breath sounds
• Expiratory/inspiratory wheezing with normal / delayed expiratory phase
• Wheezing may be present
• Egophony present/absent
• Bronchophony present/absent
• Normal/reduced tactile fremitus

Heart

• Chest tenderness upon palpation
• PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
• Heave / thrill
• Friction rub
• S1
• S2
• S3
• S4
• Gallops
• A high/low grade early/late systolic murmur / diastolic murmur best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the otoscope

Abdomen

• Abdominal distention
• Abdominal tenderness in the right/left upper/lower abdominal quadrant
• Rebound tenderness (positive Blumberg sign)
• A palpable abdominal mass in the right/left upper/lower abdominal quadrant
• Guarding may be present
• Hepatomegaly / splenomegaly / hepatosplenomegaly
• Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test

Back

• Scoliosis

Neuromuscular

• Tremors or involuntary movements
• Athetosis -slow, writhing movements
• Chorea
• Muscle rigidity
• Sensory loss
• Diplegia/hemiplegia/quadriplegia
• Intellectual disability
• Dystonia
• 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 palsy that includes:
  • Positive signs
    • Muscle spasticity
    • Clonus may be present
    • Hyperreflexia
    • Extensor muscle response
  • Negative signs such as
    • Fatigability
    • 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
• Disappearance or exaggeration of developmental reflexes
• 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

• 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
• Spastic hemiplegia
  • Shoulder retraction and flexion of fingers with adduction of the thumb
  • Hip is partially flexed and adducted with flexed ankle and knee
• Chorea
• Athetosis
• Ataxia