Courtesy: Michael Sussmanand www.global-help.org

 

Physical Examination in Ambulatory Cerebral Palsy Patients with Gait Abnormalities

---

Overview

• Before gait analysis, clinicians must perform:
  • Detailed history
  • Focused lower limb examination
  • Specific clinical tests

---

Purpose

• Identify:
  • Structural deformities
  • Muscle tone abnormalities
  • Functional limitations

---

Initial Observation

---

First Step

• Observe the patient walking

---

Assess

• Strength
• Stamina
• Balance
• Major deformities

---

Key Observations

• Symmetry of gait
• Arm positioning (used for balance)
• Presence of deformities

---

Clinical Insight

• Arms held out — may indicate:
  • Balance impairment
  • Compensation for deformity

---

Classification of Severity in Cerebral Palsy

---

Gross Motor Function Classification System (GMFCS)

---

Purpose

• Classifies severity of motor impairment

---

Levels

---

Important Note

• GMFCS is not an outcome measure

---

Outcome Assessment

---

Gross Motor Function Measure (GMFM)

---

• Used to:
  • Quantify improvement
  • Track progress over time

---

Detailed Physical Examination

---

Structured Assessment Includes

• Joint range of motion
• Muscle strength
• Spasticity
• Special clinical tests

---

Documentation

• Use structured examination charts
• Enables:
  • Follow-up comparison
  • Outcome evaluation

---

Range of Motion Assessment

---

• Use goniometer for accuracy
• Avoid visual estimation

---

Muscle Tone Abnormalities

---

1. Spasticity

---

Definition

• Velocity-dependent increase in tone

---

Features

• Increased resistance with rapid stretch
• “Catch” during movement

---

2. Contracture

---

• Permanent restriction of movement
• Not velocity-dependent

---

Causes

• Muscle shortening
• Joint capsule tightening

---

3. Rigidity

---

• Constant resistance throughout movement
• Not dependent on speed

---

Quantification of Spasticity

---

Modified Ashworth Scale

---

---

Special Clinical Tests

---

1. Popliteal Angle Test

---

Purpose

• Assess hamstring tightness

---

Method

• Hip flexed to 90°
• Knee extended
• Measure angle

---

Interpretation

• Larger angle — hamstring tightness

---

2. Tardieu Test

---

Purpose

• Differentiate:
  • Spasticity
  • Contracture

---

Principle

• Compare:
  • Fast stretch
  • Slow stretch

---

Interpretation

• Large difference — spasticity

---

3. Duncan–Ely Test

---

Purpose

• Detect rectus femoris spasticity

---

Method

• Patient prone
• Rapid knee flexion

---

Positive Test

• Pelvic elevation

---

Clinical Significance

• Suggests stiff-knee gait

---

4. Silfverskiöld Test

---

Purpose

• Differentiate:
  • Gastrocnemius vs soleus tightness

---

Method

• Measure ankle dorsiflexion:
  • Knee flexed
  • Knee extended

---

Interpretation

---

Video Recording in Gait Assessment

---

Recommended Views

• Sagittal (side)
• Coronal (front/back)

---

Advantages

• Slow-motion analysis
• Frame-by-frame review
• Long-term comparison

---

Limitation

• Cannot assess rotational deformities well

---

Walking Speed Assessment

---

10-Meter Walk Test

---

Method

• Measure time over 10 meters
• Patient walks beyond start and end lines

---

Importance

• Reflects functional ability
• Important for:
  • Daily activity
  • Peer comparison

---

Key Points

---

• Start with:
  • History + physical examination

---

• GMFCS:
  • Classifies severity

---

• Differentiate:
  • Spasticity vs contracture vs rigidity

---

• Essential tests:
  • Popliteal angle
  • Tardieu
  • Duncan-Ely
  • Silfverskiöld

---

• Use:
  • Video analysis
  • Walking speed