Cerebral palsy physical examination

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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

• Physical examination of patients with [disease name] is usually remarkable for:[finding 1], [finding 2], and [finding 3].
• The presence of [finding(s)] on physical examination is diagnostic of [disease name].
• The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

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

• Patients with [disease name] usually appear [general appearance].

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

• Description (Adapted from Dermatology Atlas)

  Description (Adapted from Dermatology Atlas)

• 

  Description (Adapted from Dermatology Atlas)

HEENT

• Abnormalities of the head/hair may include ___
• Evidence of trauma
• Icteric sclera
• Nystagmus
• Extra-ocular movements may be abnormal
• Pupils non-reactive to light / non-reactive to accomodation / non-reactive to neither light nor accomodation
• Ophthalmoscopic exam may be abnormal with findings of ___
• Hearing acuity may be reduced
• Weber test may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
• Rinne test may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
• Exudate from the ear canal
• Tenderness upon palpation of the ear pinnae / tragus (anterior to ear canal)
• Inflamed nares / congested nares
• Purulent exudate from the nares
• Facial tenderness
• Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae

Neck

• Jugular venous distension
• Carotid bruits may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
• Lymphadenopathy (describe location, size, tenderness, mobility, and symmetry)
• Thyromegaly / thyroid nodules
• Hepatojugular reflux

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

• Point tenderness over __ vertebrae (e.g. L3-L4)
• Sacral edema
• Costovertebral angle tenderness bilaterally/unilaterally
• Buffalo hump

Genitourinary

• A pelvic/adnexal mass may be palpated
• Inflamed mucosa
• Clear/(color), foul-smelling/odorless penile/vaginal discharge

Neuromuscular

• Tremors or involuntary movements
• Athetosis -slow, writhing movements
• Muscle rigidity
• 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

• Clubbing
• Cyanosis
• Pitting/non-pitting edema of the upper/lower extremities
• Muscle atrophy
• Fasciculations in the upper/lower extremity