A Cerebral Palsy Assessment Chart

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1 A Cerebral Palsy Assessment Chart nstructions for Administration of the Test SARAH SEMANS, M.A., ROSALYN PHLLPS, B.A., MADELNE ROMANOL, R.N., RUTH MLLER, B.S. and MARY SKLLEN, B.A. SOURCE AND BASS OF SELECTON OF TEST TEMS The test items were selected and adapted from the Asssesment Chart developed by Karel Bobath, M.D., and Berta Bobath, F.C.S.P. The general arrangement follows that of the original tests. The decision to use the series of test postures From the Division of Physical Therapy, Stanford University School of Medicine, Palo Alto, California, and the Department of Public Health, Bureau of Crippled Children's Services, State of California, Berkeley. for assessment of motor ability was based on the following considerations. Movements, which evolve into functional activities, can serve no practical purpose unless they can be supported and controlled by the appropriate postures which render them effective. Lacking their underlying postural control, attempted movements are haphazard and cannot be sustained to reach their goal. Well-defined postural patterns appear in an orderly sequence as the child develops. By selecting characteristic postural patterns simple enough for accurate observation, the assessment can be reasonably objective. The progress sequence from hori- Downloaded from by guest on 3 October 208 JOURNAL OF THE AMERCAN PHYSCAL THERAPY ASSOCATON 463

2 TABLE CEREBRAL PALSY ASSESSMENT CHART BASC MOTOR CONTROL Name: Birthdate: Diagnosis:. Examiner: Name: Name: Name Test Postures and Movements Date Remarks Date Remarks Date Remarks Supine j \. Hips and knees fully flexed, j ^s~r\ arms crossed, palms on shoulders. 2. Hips and knees fully flexed, i v (a) Extend right leg. \ (b) Extend left leg. - 3S-J 3. Head raised. Prone 4. Arms extended beside head., Raise head in midposition. i ' 5. Arms extended beside body, palms down. 'r 6. (a) Flex right knee, hips ex- tended. - r~\ (b) Flex left knee, hips ex- ' T tended. 7. Trunk supported on forearms, upper trunk extended, face j vertical. j 8. Trunk supported on hands with elbows and hips extended. - ^ Sitting erect Q 9. Soles of feet together, hips j" " flexed and externally rotated to at least 45. \ ^ lr ~ Q Downloaded from by guest on 3 October Knees extended and legs ab-. A ducted; hips ^ 464 CEREBRAL PALSY ASSESSMENT CHART

3 TABLE Continued CEREBRAL PALSY ASSESSMENT CHART BASC MOTOR CONTROL Name: Diagnosis: Birthdate:. Examiner: Name: Name: Name: Test Postures and Movements Date Remarks Date Remarks Date Remarks. Legs hanging over edge of table.?! (a) Extend right knee. j v (b) Extend left knee. Kneeling ^ 2. Back and neck straight (not hyperextended). -yr (a) Weight on knees. ~ b (b) Weight on hands. T 3. Side sitting, upper trunk erect, \ arms relaxed: (a) On right hip. j J (b) On left hip. j ^ J 4. Kneeling upright, hips ex- tended, head in midposition, arms at sides. 5. (a) Half kneeling: weight on right knee. (b) Half kneeling: weight on i left knee. Squatting 6. Heels down, toes not clawed, ' knees pointing in same direc-! tion as toes, hips fully flexed, head in line with trunk. Standing and components of walking 7. Standing, correct alignment. % J c f 8. Pelvis and trunk aligned over j C forward leg. Both knees ex- i tended. (a) Right leg forward. (b) Left leg forward. 9. Bear weight on one leg in midstance. (a) Shift weight over right leg. i (b) Shift weight over left leg. 20. Heel strike. Rear leg extended and externally rotated, heel down. Both knees straight: S (a) Right heel strike. (b) Left heel strike. j J ) L. { > 9 h a a a b b L. L. A / o f L. L. L. Downloaded from by guest on 3 October 208 JOURNAL OF THE AMERCAN PHYSCAL THERAPY ASSOCATON 465

4 zontal to upright postures indicates how far the child has come in his development of postural control. nformation Yielded by the Test n cerebral palsy, the state of muscle tone and abnormal patterns of movement interfere with the orderly sequence of motor development. The test postures selected show the nature and extent of this interference. Ability to sustain a test posture not previously possible indicates a freedom from that pathological state which had prevented its achievement. The significance of such newly gained freedom is that it makes possible the learning of new skills. For example, when a child achieves postural support on the arms, indicating a freedom from hypertonia of the flexor muscles, he can learn hand skills which persistent flexion would not have permitted. Thus, the various items representing basic postural controls which underlie support and alignment of the body with respect to gravity, hand use, and locomotion indicate whether or not there is sufficient freedom from pathological influences to develop useful skills in each of these areas. n the early tests, attention is focused on control of proximal parts; in later tests, greater individuation and segregation from the total limb synergies is required. By noting limitations in range of motion which prevent passive positioning in the test postures, the assessment can also serve as a range-of-motion test. Ease and quality of movement are indicated by the numerical grade for the active movement when the child is asked to assume the test position. Since each of the test items has some developmental significance and since total scores were found to correlate closely with developmental test scores, the assessment yields information regarding developmental status of the child. The initial test serves as a guide in planning treatment procedures by indicating areas of needed emphasis. ncrease in total score may represent the effects of maturation, or treatment, or a combination of both factors. Changes in either a negative or positive direction in specific areas may reflect the relative effectiveness of treatment. Explanation of Testing Procedures Throughout the testing, the therapist should insure maximal freedom from emotional and physical tension through proper handling. n all tests, the therapist should first place the child in the test position. Physical manipulation to reduce tension should be used if this factor interferes with placement. f the therapist is unable to place the patient, inability to relax tension or the presence of contractures or structural deviations are indicated. Secondly, after being placed, the child is asked to stay in the test position. As a third step, he is asked to move into the test position independently. Grading Through Use of a Key A grading system with values from 0 to 5 is used as follows: 0 Cannot be placed in test posture. Can be placed in test posture, but the position cannot be held. 2 Can hold test posture momentarily after being placed. 3 Can assume an approximate test posture unaided, in any manner. 4 Can assume and sustain test posture in a near normal manner (note any abnormal detail). 5 Normal. nterpretation of Use of Key in Grading Grades 0 to 2 indicate the severity of the handicap as tested by resistance to passive motion, by limitation of joint range, or by ability to maintain posture. These are static tests. Grades 3 to 5 indicate the quality of movement when performed actively by the patient. Grades 3 to 5 would not be given when grades and 2 cannot be attained. f for any reason the child cannot be placed, he is given a grade of 0 and a note is made to explain, under appropriate REMARK column, why, e.g., a child with an elbow flexion contracture, even though he can assume a posture normally except for the use of the elbow, would be graded 0 on all test postures requiring complete elbow extension. For a grade of 2, it is only necessary to maintain the test posture momentarily. This indicates some control over the disabling factors. For grades of 3 to 5, it is important that the child understands what is expected of him when he is asked to move into the test position. Proper placing will usually be sufficient, but visual cues such as a demonstration by the therapist or the use of dolls or stick figures or assistance given preceding the test may be helpful. Grade 4 requires the child to assume and sustain the test position, but allows for slight abnormality of movement, or a lack of a very few degrees from the test posture into which he could be placed passively. For example, a spastic child may not be able to achieve the same degree of extension of the thoracic spine in the sitting position as he could in the supine or prone positions, or he may have slower than normal movement; the athetoid child may perform the complete movement, except for tension or extraneous movement in some distal part. To obtain a grade of 5, each test should be exactly as indicated. Downloaded from by guest on 3 October CEREBRAL PALSY ASSESSMENT CHART

n judging whether a movement is normal, the following qualities should be considered: normal movement smooth, easy, free, and in the line of movement; abnormal movement jerky, tremorous, sluggish,

5 n judging whether a movement is normal, the following qualities should be considered: normal movement smooth, easy, free, and in the line of movement; abnormal movement jerky, tremorous, sluggish, labored, or deviating from the line of movement. Testing Hemiplegia n hemiplegia, the primary consideration should be that of evaluating the affected side. SPECFC NSTRUCTONS FOR ADMNSTERNG THE TEST TEMS Each item in the test represents a necessary postural control for various functional activities. For instance, the arm position in Test is a prerequisite for engaging the hands in front of the body and for later self-help activities. Other test positions will be recognized as stages of postural control preparatory to creeping, sitting, standing, and walking. t is helpful to keep in mind the functional significance of each test while administering it in order to observe the most critical aspects contributing to the test score. The following groups are arranged in the approximate order of normal developmental sequence. Test Supine Purpose. To test freedom from extensor hypertonus in the supine position. Emphasis in this test is on proximal joints. Bring knees, one after the other, to chest with enough external rotation at hips to point knees toward axillae. This is needed to get complete flexion; if not attained, there is probably not full range of hip flexion. Steady knees in position with your body while placing child's arms as follows: Pull arms forward at shoulders, abducting the scapulae, and fold across chest so that open palms cup shoulders; arms should be up, away from chest wall; head should remain in a neutral position; feet should be relaxed in plantar flexion. f child assumes position except for dorsiflexed feet or incompletely relaxed hands, grade 4 should be given. Test 2 Purpose. To test ability to flex or extend one leg at a time through full range. Starting with hips and knees fully flexed, arms across chest or relaxed at side, bring right leg down to table in an extended position, avoiding internal rotation. Back should not arch. Return to starting position and repeat with left leg. Test 3 Purpose. To test ability to raise head. Place in a symmetrical supine position with legs extended and arms at sides. Raise head by flexing at the atlanto-occipital joint and in the cervical spine. The shoulders remain relaxed. f the child can raise the head but protracts the shoulder, a grade of 3 is given. Test 4 Prone Purpose. To test freedom from flexor hypertonus in prone position. Place prone, lift under shoulder to free arm; place arms overhead one after the other, elbows and wrists extended, palms down, legs extended and relaxed. Head is raised in midposition. Replace arms below shoulder level before asking child to move into test position. Test 5 Purpose. To test freedom of arms and shoulders from flexor hypertonus in prone position. Place prone, arms beside body, palms down. To extricate arms from under the body, lift the shoulder and externally rotate arm. Place hands out a short distance from the body so that arms are not pressed against the thorax. To assume position actively, start with arms at shoulder level or above. Note any change of tension resulting from turning head from one side to the other. Test 6 Purpose. To test selective control of hip and knee. Place prone, arms relaxed beside head or at sides. Flex right knee to 90 degrees without flexion at hip. The foot should not dorsiflex; other leg should remain relaxed. Repeat with left leg. For grade 4 or 5, there should be no appreciable motion in the hip. Test 7 Purpose. To test postural control in spinal extension. This is important for beginning locomotion (crawling), erect sitting, and beginning use of hands. Place prone, extend thoracic spine, and place arms one after the other in at least 90 degrees shoulder flexion and slight abduction, supported on forearms. Head is raised with face vertical. Arms point straight ahead and hands are open. Test 8 Purpose. To test ability to support weight on extended arms. Start from test position 7. Lift child's head giving gentle traction on cervical spine so that support is on extended arms and heel of open hand; entire spine and hips are fully extended. Alternate method: Lift under shoulders or under chest. This position is often difficult to attain but is necessary for creeping. Downloaded from by guest on 3 October 208 JOURNAL OF THE AMERCAN PHYSCAL THERAPY ASSOCATON 467

6 Test 9 Sitting Erect Purpose. To test control of hips in flexion, abduction, and external rotation. Place in erect sitting position with legs abducted, flexed, and externally rotated to at least 45 degrees; soles of feet together, arms relaxed. For grades 3 to 5, start in an}' sitting position on flat surface. Test 0 Purpose. To test erect sitting with legs straight. Place in erect sitting position with thighs abducted without internal rotation, and with knees extended; angle at hip should be 90 to 00 degrees, arms relaxed. Test Purpose. To test selective control of hip and knee. Place in erect sitting position, angle at hip 90 to 00 degrees, legs hanging vertically. Extend knee fully without further extension of hip. Other leg and arms should remain relaxed, (a) Right knee extended; (b) left knee extended. Test 2 Kneeling Purpose. To test weight-bearing and balance control on knees and heels of open hands. Start in four-point kneeling, back and neck straight (not hyperextended), legs parallel, elbows extended, hands pointing forward, (a) Weight predominantly on knees; (b) weight predominantly on hands. Test 3 Purpose. To test ability of trunk to adapt to gravitational changes. Place in side sitting from four-point or upright kneeling by lowering the hips to one side of feet. Head and upper trunk should be erect; arms free, (a) On right hip; (b) on left hip. Test 4 Purpose. To test anterior-posterior control of pelvis and trunk on thighs. Place in upright kneeling position, hips extended, legs parallel, trunk and head erect, head in midposition, arms relaxed. Test 5 Purpose. To test control of rotation at hip. Place in half-kneeling position from upright kneeling. The other foot is placed on floor in front and to the side for adequate supporting base. Hip, knee, and ankle of forward leg at 90 degrees, toes not clawed. Pelvis and trunk face forward, knee slightly outward. Test 6 Squatting Purpose. To test control of extensor spasticity. Place from squat sitting, i.e., legs and hips fully flexed and outwardly rotated, feet flat on floor, toes not clawed, knees pointing in same direction as toes, arms forward for balance. Shift weight forward over feet into squatting position. Older child can be placed from a low stool. t is easier to assume this position if the legs are spread wide apart. Standing and Components of Walking Test 7 Purpose. To test normal distribution of tone in standing. Place in standing position with body segments in normal alignment with relation to the line of gravity in midcoronal and midsagittal planes, i.e., weight evenly distributed over both feet, legs in midposition of rotation, and so on. Points of control might be the hip of one side and the knee of opposite side, or hip and opposite arm. A lift may be used to equalize leg length. Test 8 Purpose. To test the ability to shift weight forward onto stance leg with rear leg extended ready for push off. Place in forward step position. Shift weight over forward leg with trunk, pelvis, thigh, and leg correctly aligned over foot. Rear leg should be extended, outwardly rotated at hip, and resting on the normal roll-off point (the head of the first metatarsal); arms should be relaxed. For grades 2 to 5, the therapist may steady child by holding one hand. Test 9 Purpose. To test the ability to support the body over one leg (absence of Trendelenberg sign). From a symmetrical standing position, shift weight laterally over one leg and lift the other free of the floor, as for the swing phase of walking. Trunk should remain erect. For grades 2 to 5, therapist may steady child by holding one hand. Test 20 Purpose. To test heel strike. One foot is advanced in dorsiflexion and heel placed on the floor. Weight is supported mainly on rear leg, hip extended, both knees straight. Ankles remain at approximately 90 degrees. Arms should be relaxed. For grades 2 to 5, therapist may steady child by holding one hand. REFERENCE. Bobath, K.: The long-term results of treatment. n Child Neurology and Cerebral Palsy. Little Club Clinics in Developmental Medicine, No. 2. London: National Spastics Society, 960. Downloaded from by guest on 3 October CEREBRAL PALSY ASSESSMENT CHART

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Somatic Adaptation in Cerebral Palsy LINKING ASSESSMENT WITH TREATMENT: AN NDT PERSPECTIVE. By W. Michael Magrun, M.S., OTR/L

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