Approach to assessment

The framework for all assessments is outlined to synthesise various approaches. This avoids use of assessment methods focused on any one therapy system.

The framework consists of the following assessments:

(1) The task(s) individuals want to achieve. Their choice may be a daily activity in self-care, play, social interaction or during recreation.

(2) The motor functions for the individual’s choosen task, for example sitting, standing, using a form of locomotion and using hands. The individual’s developmental level of motor functions is identified.

(3) The component abilities of each motor function needed for the chosen task. This includes specific postural mechanisms, relevant voluntary movements and perceptual motor abilities which may be present but abnormal or are absent.

(4) The impairments which may be preventing achievement or causing abnormal performance such as limited range of motion, weakness, abnormal reflex reactions, abnormal movement patterns, postural malalignments or limited repertoire of movements for the task. The impairments are primary and secondary. These impairments include any medical conditions such as pain, fatigue, poor nutrition, respiratory problems and general health in individuals.

(5) The constraints on motor functions and their components by other impairments and disabilities of vision, hearing, perception, understanding and communication.

(6) The abilities or residual abilities of these components of vision, hearing, perception, cognition and communication and general motivation which can reinforce the learning of motor functions.

This process of assessment is discussed in Chapters 2 and 6 to show how specific assessments of posture, movements and use of sensations are observed in the context of whole daily functions or tasks which individuals want to achieve and the family background which enables achievement. This chapter addresses the specific assessments and objective measures by a physiotherapist and occupational therapist, which grow out of the collaborative learning models in Chapters 2, 6 and 7.

Assessments of motor functions, their specific components and impairments, often take place in physiotherapy rooms in hospital units and special centres. Whenever possible, these daily functions are best observed in individuals’ natural environments most relevant to the tasks chosen by them and the specific people involved with individuals. Therefore, depending on a therapist’s workplace, appropriate organisation is made to include the important observations of individuals in their own environments. The therapist is then enabled to complement the clinical examinations and to have assessments of the following:

Which tasks, functions and component abilities are actually used and which are not being activated.

Which physical obstacles in the environment prevent use of a task, functions and component abilities or block further development. Assessment, both indoors and outdoors, shows, for example, whether access is available, ground is uneven or slippery, furniture is inappropriate or there are no stable objects or bars to grasp. Recommended special equipment needs to be assessed as useful in different environments.

Which attitudes and behaviours of people in the individual’s environments may influence a child’s motor or whole daily functions and the use of components or whole of a task.

Whether a child’s motivation and behaviour vary in different environments.

Occupational therapists in different places have expertise in environmental assessments and share their information with centre-based physiotherapists. Simultaneous visits of physiotherapists with occupational therapists to an individual’s environment are desirable whenever possible. Community paediatric physiotherapists and occupational therapists are well placed to obtain the broad perspective of a child’s function in home, school and community.

Purpose of assessment and outcomes

(1) To respond to the reason for referral, which may be for additional medical information, for educational placements, for parental needs or for social or legal considerations. Some adolescents or adults with cerebral palsy refer themselves and state their reasons. People paying for therapy will want assessments indicating the need for physiotherapy and reassessments of outcomes.

Therefore, the type of assessment varies according to the referral. Physiotherapy assessments need to relate to what information is wanted and how it will be used.

(2) To add to medical and other diagnostic information as specific assessments before and during therapy involve long periods of time and close contact with a child and his family. Information may be revealed to a therapist when not obvious in shorter consultations with different medical consultants. A therapist will also detect any unusual deterioration which needs referral to a neurologist in case a progressive neurological condition rather than cerebral palsy is becoming obvious. Deterioration in function due to neuromuscular, deformity, health or behavioural problems may be detected so that referral can be made to other professionals.

(3) To participate in screening and follow-up of children ‘at risk’ of developing cerebral palsy and to decide whether specialised physiotherapy or monitoring is indicated.

(4) To plan a specific physiotherapy and occupational therapy programme based on the child and parents’ needs. There are programmes of selected treatment methods focused on function and the component abilities and for impairments constraining function. Therapy includes a management programme with information and practical ideas for all involved with a child or older person.

(5) To evaluate progress (outcomes) in reassessments which may lead to continuation, modification, changes or periodical stopping of specific therapy methods and sometimes of specific therapy sessions. The evaluation also changes practical suggestions for others involved with an individual.

(6) To share assessments and evaluations with child, parents and families, and others involved with a child and to receive their reports and views.

(7) To contribute to research into the effectiveness of therapy by using standardised measures within a research study. Clinical assessments and measures discussed in this chapter also detect questions for research (see section ‘Research and clinical studies’ in Chapter 4).

Review of a therapist’s observations

Observations are made during joint assessments with a child and parents or with an older person. There will also be other joint assessments with another professional and with carers. They are continued during specialised ‘hands-on’ assessment and evaluation as well as during ongoing therapy and management. Observations need to be as unobtrusive as possible and must precede ‘hands-on’ examinations and measurements to gain rapport with child, parents and any family members present at assessments.

(1) Behaviour. Observe whether a child is alert, apathetic, irritable or fearful in a session or during particular activities. A child or older person may become fatigued easily, make undue effort, or show discomfort or fear during an activity. Find out what motivates any actions. Is it a particular situation, a person, special plaything or hobby? There may be fear of falling, of augmenting musculoskeletal pain or due to space perception problems. Behaviours are detailed in Chapters 2, 6, 7, 10 and 12.

(2) Communication. Observe how the child and parents interact (see Chapter 2). Find out whether a child initiates or responds with gestures, sounds, hand or finger pointing, eye pointing or uses words and speech.

(3) Attention span. What catches a child’s attention? How does a parent assist him to maintain attention and what distracts him? Distractibility is due to brain damage and/or environmental overstimulation.

(4) Understanding. Observe if a child follows suggestions to move or promptings to act. What does he appear to understand? (See section ‘Development of communication – brief summary’ in Chapter 10.)

(5) Position. Notice which position he chooses to be in and if he get into that position on his own or with help. Observe if a parent can place him in a position and if he participates in any way. His limbs and head may move more easily in some positions than in others. Involuntary movements may be decreased in some positions.

(6) Postural control and alignment. Observe how much parental support is given and check a child’s own ability in postural stabilization and counterpoising (postural adjustment) in all postures. Parental support may be excessive or reasonable. Check whether a child bears more weight on one side of his body, or on one hand or foot. A child may collapse to one side, twist to one side, or tilt and turn his head to one side. Observe any fears of falling in a child due to poor balance experience. Parental anxiety about falling may increase a child’s fears.

(7) Use of limbs and hands. Observe limb patterns in changing or going into a position as well as using them in a position. There may be excessive flexion, extension or rotation in one part of the range. Observe whether one or both hands are used, type of grasp and release. Inaccuracy of reach and hand actions also indicates a possible visual problem. Observe any involuntary movements, tremors or spasms which interfere with actions.

(8) Sensory aspects. Observe a child’s use of vision, hearing, touch, smell and temperature in relevant tasks. Does he enjoy particular sensations? Notice whether he enjoys being moved or having his position changed. He may show an increase in tension and apprehension on being touched and handled. Are his hands persistently fisted so sensation cannot be experienced?

(9) Form of locomotion. On entering the room, observe how a child is carried, if he uses a wheelchair or walking aids. During the session, create interest which motivates him to roll, creep, crawl, bottom shuffle or walk to where a daily activity is to be carried out. A child may have unusual ways of getting about, such as dragging himself along his stomach, along his back, bunny hopping on both knees, running headlong and a variety of abnormal gaits.

(10) Deformities. Observe any recurring positions of the whole child as well as of parts of his body in all postures and in the movements he uses in motor functions and daily living activities.

Impairment and function

The observations above are predominantly functional. The observation of impairments which constrain function will vary with age and any changes in diagnostic classifications (see Chapter 1).

There is a functional view of the impairments as subtypes of cerebral palsy. For example, hemiplegia tends to be less disabling in motor function than diplegia, and diplegia less than tetraplegia. Dyskinesia tends to be more severe than spastic hemiplegia, diplegia and ataxia (Ostensjo et al. 2004). However, other research studies with a large number of participants have a few subtypes of spastic tetraplegia and of dyskinesia present in milder levels of functional disability, and a few of spastic hemiplegia in more severe levels. Spastic diplegia can be present at any functional level (Beckung et al. 2007; Voorman et al. 2007).

Chapter 9 gives details of impairments linked with functional aspects so that they can be immediately related to simultaneous functional therapy with minimising of impairments which are constraining the specific function. The suggested therapy and management methods do not separate impairment from function but integrate them so that a quality of function may be gained as far as possible. However, in the very severe conditions, more attention is given to minimising deformities whilst activating whatever minimal function can be achieved.

Teamwork and the influence of other disabilities

The therapist will need a comprehensive assessment from a team (see Chapter 1; Thylefors et al. 2000). She will learn from the different professionals what modifications to make for specific visual, hearing and sensory impairments. She will adjust her communication with a child in relation to any speech and language difficulties and find out what communication systems are being used, for example Paget, Makaton, Bliss or electronic communication aids. If a child has perceptual problems (sensory processing difficulties) relating to body scheme, space, distance and timing, then adaptations will be recommended by specialists in the team.

Medical consultants inform therapists about a child’s or older person’s health, nutrition problems, fatigue, possible pain and other medical impairments which affect energy, motivation and attention span. The health problems of parents are also relevant to therapists’ home programmes for their child.

General points for assessments

Assessments need to be playful, interesting and non-threatening.

Assess a young child, as much as possible, on a parent’s lap.

Observe a child among the familiar toys as well as with selected toys to activate interest as well as reveal dormant abilities.

Keep sessions within the bounds of a child’s concentration.

Have an unhurried atmosphere.

Have easy, successful actions of a child interspersed with difficult tasks.

Avoid undressing a child, especially an adolescent, until he is happy about this.

Time is needed for a child who is unhappy about a new environment, new professional or new experience of being assessed in a different style.

An individual needs time to attempt new abilities in the assessment.

Consider a child’s state of health and energy.

Assessments can take from one to four sessions, depending on each child’s severity, mood, level of energy and cooperation. It is usual to create a final plan of therapy and management after a number of assessments, especially if a therapist meticulously checks her assessment findings with the variations in daily behaviour of a child. It is surprising that daily variations are rarely checked by some therapists as it is well known that a child has good and bad days in function. Assessments need to relate directly to therapy methods and evaluations so that parents appreciate the relevance of specific professional assessments. It is wise to select some home therapy on the first visit, so parents feel ‘something is given’ for them to do which will help their child.

Assessment and measurements

Clinical assessment includes both careful observations and measurements. There is a growing importance of measurements for evidence-based practice. However, in cerebral palsy there are still observations of unique abilities and difficulties discovered in careful clinical assessments of an individual. These are significant for therapy and for a child’s own strategies. The observations for clinical assessment cannot always be easily measured using current measurement tools (measures).

It is also recommended that a therapist’s assessments are not limited to existing measures. Although measures are important, they should not reduce her own innovative observations. In addition, current measures are based on values which may change in the light of research. For example, measures were focused on spasticity for many years and functional measures thought to be dependent on them (Bobath & Bobath 1984; Haas and Crow 1995; among others). In some references in Haas and Crow’s review (1995), in Levitt (1977, Physical Ability Chart) and in Shepherd (1995), spasticity was not given great significance and functional assessments and measures were valued much more.

As in previous editions, Chapter 9 continues to present clinical assessments of function in prone, supine, sitting and standing positions and use of hands so that treatment and management suggestions (sometimes called ‘tactics or strategies’) are immediately related. A developmental framework is used to show how the components of motor functions are normally developed and how an abnormal performance may be normal at an earlier age. For example, asymmetry is normal in a number of early actions and postures, and so weight bearing on one side of the body in lying is expected at the 0–3-month developmental stage. A person’s stepping in a walker giving full trunk support is similar to the manually supported stepping of an able-bodied baby at the developmental level of around 6 months. The normal gait of a toddler uses components such as co-contractions, wide base, flat foot contact and more double leg support, which are also seen in older children with cerebral palsy. A developmental framework also shows a therapist the degree of motor delay which has an effect on other areas of child development.

The examination of the individual in channels of prone development, supine development, sitting, standing and walking development, and hand function also shows any influence of impairments in the functions. Impairments which create deformities are treated within these developmental functions and also discussed in an additional Chapter 11 on specific problems of deformity in cerebral palsy.

Clinical progress is assessed when supports by equipment, walkers and orthoses are decreased or eliminated. Walkers can change from wheel-walkers to elbow crutches, quadripods or sticks.

Current measures used in cerebral palsy

The traditional therapy measures in physiotherapy and occupational therapy are for impairments and motor functions and participation in self-care skills such as eating, washing, toileting and dressing. These measures can be linked with the International Classification of Functioning, Disability and Health (ICF), World Health Organization (WHO 2001) aspects of body structure and function (impairments), with activity (daily functions and self-care skills) and with some aspects of participation. Participation and quality of life have received consideration in occupational therapy, social work and psychology. The teamwork with other professionals, families and others involved in the life of the young or older person with cerebral palsy adds information to the therapist’s assessments of environmental and personal factors which are stated in the ICF. There are parent or child questionnaires which are being increasingly used by therapists. There are also measures for environmental factors used by professions other than physiotherapists and are given below.

Measurements of impairments

When assessments of impairments are made, a therapist assumes which of the impairments appear to primarily constrain function. This assumption is studied by Ostensjo et al. (2003, 2004) and discussed in relation to the International Classification of Functioning, Disability and Health (WHO 2001). This study found that the measure of abnormal selective motor control links more with overall motor function than spasticity and range of motion. ‘Motor function is strongly related to accomplishment of essential tasks in daily life’ (Ostensjo et al. 2004). Voorman et al. (2007) support the view that selective motor control and strength are most important for gross motor function. However, in a study by Bartlett and Palisano (2002), spasticity, topographical distribution and range of motion (ROM) were listed by paediatric physiotherapists as the most important impairments which contributed to change in motor function. Selective motor control was not listed and weakness was not given emphasis.

There was no correlation of true spasticity with function at Gross Motor Function Classification System (GMFCS) Levels I to III (Palisano et al. 1997) in researches by Ross and Engsberg (2002, 2007). They used KinCom, an instrumented dynamometer, to measure spasticity and strength in the same subjects, and showed no relationship between strength and spasticity, nor between spasticity, motor function and gait. They pointed out that their research did not include children in more severe classifications.

A number of research studies now find that weakness rather than spasticity is particularly significant for functional disability in cerebral palsy (Damiano & Abel 1998; Damiano et al. 2002a,b; Ross & Engsberg 2002, 2007; Shortland et al. 2002; Mc-Nee et al. 2004).

Weakness

Strength is the ability to generate force to either move a body part or stabilise a body part and resist movement. These two aspects need assessment for physiotherapy exercises and functional activities. Strength may be measured isometrically (no change in muscle length), isotonically (shortening of muscle length) or isokinetically (concentric and eccentric work during a specific velocity of movement). Endurance is measured by the number of repetitions of a motor function. Cardiovascular measures of fitness relate to energy consumption and endurance. A child can be ‘weak’ when not fit (Miller 2007). Parker et al. (1993) found that aerobic power and anaerobic power of the legs, but not of the arms, were correlated with the total score and the scores for the standing and walking, and running and jumping subsections of the Gross Motor Function Measure (GMFM).

The isotonic (concentric) and isometric (eccentric) muscle actions are measured clinically and the isokinetic measure is tested with instrumented systems. Children with cerebral palsy cannot easily be measured with traditional manual muscle tests. Florence et al. (1992) give the Medical Research Council (MRC) manual strength test with the original 6-point scale as well as a modified 11-point scale. However, these isotonic assessments can be used as guides together with other measures. The hand-held dynamometer quantifies isometric strength or the force required to break the active position held by a person against resistance given by the examiner. The procedure and reliability of hand-held dynamometer are confirmed by various authors (Taylor et al. 2004; Crompton et al. 2007).

Children under 4 years do not cooperate with either of these measures because they cannot understand the procedure, nor do they have the ability to isolate muscles for testing because of lack of selective muscle control. Furthermore, excessive co-contraction and impaired selective motor control in any person may interfere with the ability to produce agonist force (Damiano et al. 2002a).

Wiley and Damiano (1998) have strength tests for children who are able-bodied and in cerebral palsy. Their subjects are frequently older and less severely affected and can be classified in GMFCS Levels I, II or III (Palisano et al. 1997). Manual muscle tests are very difficult in adults and children with severe cerebral palsy classified in Levels IV or V. These individuals often have cognitive impairments which prevent them following test procedures. Ohata et al. (2006, 2008) recently investigated ultrasound sonography which might measure muscle strength and activity in these severely involved adults or in children at all levels of severity. They related atrophy with weakness.

Clinical assessment of strength. The observations are usually of muscle actions in motor functions, whether this is a holding action for postural stability or a moving action in voluntary motion or in rising (righting) and saving reactions. Long and Toscano (2002) also use observation of muscles in anti-gravity positions and assumption of positions, symmetry and any compensatory patterns rather than muscle testing in very young children. It has been found that muscle tests on the couch can differ from muscle actions in function, which include the actions in synergies and the postural mechanisms. For example, shoulder girdle muscles may work well in crawl position but not in a muscle test on the couch. Back extensors may be well activated in prone but not in sitting or standing. Extension of the elbow is greater when a child reaches out for a desired object than when tested with the conventional ‘stretch your elbow’ in muscle tests. Static and dynamic measures of lower extremity range of motion in the clinical examination are inconsistent with instrumental measures of gait (McMulkin et al. 2000).

Functional assessments such as sit change to standing and return to sitting assess both concentric and eccentric muscle actions (Shepherd 1995). Rising onto toes and standing on toes assess both concentric and isometric muscle action of plantar flexors. Rising from lying to sitting, crawl to sitting, and crawl to standing reveals strength of arms in weight bearing. Records of strength have depended on a therapist’s judgement, such as a scale of: absent, present at initiation or throughout range or absent, trace, poor or strong. Such a scale indicates need for strengthening activities. But such scales can be questioned as being evidence-based physiotherapy. Voorman et al. (2007) within their research used a test of strength of legs by having children squat and stretch up eight times. Support for balance is allowed. The categories are:

good strength for eight or more times

moderate strength for fewer than eight or performed as part of the motion eight times

poor strength if not able to squat and stretch out at all.

This test apparently also includes endurance as well as strength in ranges of flexion and extension of limbs. ROM was measured with goniometry in supine and in other tests. However, their test is scoring for impairment within function. This should motivate therapists to develop better scoring for evidence-based muscle actions in functional assessments in the future.

Spasticity

Slow passive range of movement demonstrates the muscle length or extensibility of the muscles. The slow passive ROMs are measured by goniometry and limitations of range show stiffness of spastic muscles, mobility of joints and tightness of soft tissues. The measurements of length limitations in slow ROM are not the same as measurements of range limitation in velocity-dependent spasticity or reflex response to quick stretch. To challenge us further, joint range may be full in very young children with stiff, spastic muscles, but muscle actions are hypoextensible and limit range of active movement. Clinical reasoning is available to select treatment options.

Clinical measurements of spasticity. The frequently used Ashworth scale and Modified Ash-worth scales (MAS) have the examiner rate the amount of tone felt as a limb is passively stretched. In a scale from 0–5, there is an estimate of how soon in the motion and how much during the motion the resistance to stretch is felt (Bohannon and Smith 1987). It is also used in measurements for botulinum toxin A treatment of spasticity (see section ‘Botulinum toxin A’ in Chapter 11). However, it should not be the only measure.

There are questions about the objectivity of the MAS (Pandyan et al. 1999; Miller 2007). Damiano et al. (2002b) investigated the precision of the Ash-worth scale by using isokinetic dynamometer measures of passive stretch together with electromyog-raphy (EMG), which shows muscle activity in response to the quick passive stretch. They show that slow passive stretch without muscle activation on the EMG is stiffness due to muscle transformations and tight soft tissues. This ‘intrinsic’ muscle stiffness has higher correlation with the original Ashworth test rather than the magnitude of resistance to quick passive stretch. The children in the study by Damiano et al. (2002b) were in less severe classifications (GMFCS Levels I–III), with most at Levels II and III (Palisano et al. 1997). Ashworth scales are weakly correlated with function measures. Damiano et al. (2002b) hypothesise that in future studies, measures with instrumented isokinetic dynamometers used with cases of severe cerebral palsy may demonstrate an influence of spasticity on function.

Scholtes et al. (2006) reviewed 13 clinical instruments to measure spasticity, having identified validity criteria from 119 references. They report on a number of ‘Ashworth-like scales’, the Tardieu Scale, a Modified Tardieu Scale (MTS), the New York University Tone Scale and other lesser known scales. They found most instruments to assess spasticity did not comply with the physiological definition of spasticity as a velocity-dependent response to passive stretch. This definition was used only in the Tardieu measures (Tardieu et al. 1954). Tardieu tests measure increased muscle tone at three different velocities of stretch and the joint angle at which the ‘catch’ or increased tone appears. However, the original Tardieu scales are time-consuming in order to carry out a comprehensive assessment and the speed of the velocities are not standardised. This is questioned, particularly the time-consuming aspect, for use with children. From their detailed studies, Scholtes et al. (2006) advise that clinicians make a comparison of ‘the maximal ROM at a very slow passive stretch before and after treatment of spasticity and the joint angle of the catch at a fast velocity passive stretch before and after treatment’.

Table 8.1 Modified Ashworth Scale

Source: Modified by Hedberg et al., see Ostensjo et al. (2004).

Score	Description
0	Hypotonic: less than normal tone, floppy
1	Normal: no increase in muscle tone
2	Mild: slight increase in tone, ‘catch’ in limb movement or minimal resistance to movement through less than
	half of the range
3	Moderate: more marked increase in tone through most of the range of motion but affected part is easily moved
4	Severe: considerable increase in tone, passive movement difficult
5	Extreme: affected part rigid in flexion or extension

Boyd and Graham (1999) proposed a measurement of passive range by modifying the Tardieu Scale and calling it an MTS. They use goniome-try to measure R1, the joint angle of the ‘catch’ after fast stretch, and R2, the maximum joint angle after slow stretch. It is suggested that if there is a large difference between R1 and R2, then there is a greater dynamic component, whereas a smaller difference would indicate that muscle contracture is greater than spasticity. As these measurements were essentially devised to plan BTX A treatment, they found that BTX A was useful for the dynamic component.

Fosang et al. (2003) investigated the reliability of clinical measures of Passive Ranges of Motion (PROM), MAS and an MTS. They did not use the MTS by Boyd and Graham (1999) as its reliability had not been assessed. They found that PROM and MTS measures can be reliable, provided the examiners were sufficiently trained with enough time for practice. Large changes as a result of intervention are needed to overcome error margins in test–retest and inter-rater results. Because of poor reliability the MAS, if used, should only be carried out by single raters for the same participant (subject/client).

Table 8.1 is an up-to-date Swedish modification of the Ashworth scale used in a careful research study by Ostensjo et al. (2004).

The factors for reliable clinical assessments are as follows:

(1) Standardise the posture for testing, the position of the other limbs and midline head position.

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