What are the key components to assess when describing cerebral palsy (CP) at a physical exam?

Physical Examination of Cerebral Palsy

When examining a patient with cerebral palsy, systematically assess motor function, tone abnormalities, topographical distribution, and associated impairments using standardized neurological and functional assessments to accurately characterize the motor subtype, severity, and comorbidities.

Essential Components of the Physical Examination

Motor Type Classification (Primary Assessment)

The motor examination must identify the predominant motor syndrome 1:

• Spastic CP (85-91% of cases): Assess for velocity-dependent increased resistance to passive movement, hyperreflexia, clonus, and pathological reflexes 2, 1
• Dyskinetic CP (4-7%): Look for involuntary movements including dystonia (sustained muscle contractions causing twisting postures) and athetosis (slow, writhing movements) 2, 1
• Ataxic CP (4-6%): Evaluate for impaired coordination, intention tremor, and wide-based gait 2
• Hypotonic CP (2%): Document persistently decreased muscle tone beyond infancy 2

Topographical Distribution

Critical to document the anatomical pattern of involvement 3:

• Unilateral/Hemiplegia (38%): Asymmetric involvement of one side of the body; test symmetry of movement, tone, and strength comparing right versus left 2
• Bilateral Diplegia (37%): Lower extremities affected more than upper extremities; assess leg tone and function more severely impaired than arms 2
• Quadriplegia (24%): All four limbs and trunk affected; document global motor impairment 2

Detailed Neurological Assessment

Muscle Tone Evaluation 4:

• Test passive range of motion at multiple joints (shoulders, elbows, wrists, hips, knees, ankles) noting velocity-dependent resistance 1
• Document presence of clonus (sustained rhythmic contractions with rapid dorsiflexion) 1
• Assess for contractures and fixed deformities at each joint 4

Reflex Examination 4:

• Deep tendon reflexes: Document hyperreflexia (increased reflexes) typical of spasticity 1
• Pathological reflexes: Test for Babinski sign (upgoing toes), which persists beyond infancy in CP 1
• Primitive reflexes: Note persistence of reflexes that should have been suppressed (e.g., asymmetric tonic neck reflex) 4

Motor Strength and Control 4:

• Assess antigravity strength in all extremities using age-appropriate testing 4
• Evaluate selective motor control (ability to isolate joint movements) versus mass flexion/extension patterns 4
• Document presence of involuntary movements at rest and with voluntary movement 5

Coordination and Balance 4:

• Finger-to-nose testing for upper extremity coordination 4
• Heel-to-shin testing for lower extremity coordination 4
• Sitting and standing balance assessment 4

Functional Motor Classification

Use the Gross Motor Function Classification System (GMFCS) to standardize severity 6:

• Level I: Walks without limitations 6
• Level II: Walks with limitations (difficulty with uneven surfaces, inclines) 6
• Level III: Walks using hand-held mobility device 6
• Level IV: Self-mobility with limitations; may use powered mobility 6
• Level V: Transported in manual wheelchair 6

Note: In children under 2 years, GMFCS classification may change as motor patterns evolve, so predictions should be made cautiously using standardized tools like the Hammersmith Infant Neurological Examination 3, 7.

Assessment of Associated Impairments

Systematically screen for common comorbidities 3, 2:

• Vision (11% affected): Test visual acuity, visual fields by confrontation, extraocular movements, and pupillary responses 3, 2
• Hearing (4% affected): Document response to sound stimuli; refer for formal audiometry 2
• Speech and Communication: Assess language comprehension and expression; note dysarthria (slurred speech from motor impairment) 6
• Cognitive Function: Evaluate age-appropriate responsiveness to environment and developmental milestones (49% have intellectual disability) 2
• Seizure Activity: Document any history or observed seizure activity (35% have epilepsy) 2
• Feeding and Swallowing: Observe for drooling, choking, or aspiration risk (assess eating and drinking ability) 6

Musculoskeletal Examination

Document secondary orthopedic complications 2, 4:

• Hip Assessment: Perform Galeazzi test and assess hip abduction (28% develop hip displacement) 2, 4
• Spine: Examine for scoliosis, which commonly develops in non-ambulatory patients 4
• Extremities: Measure limb lengths, document contractures, assess for limb deformities consistent with chronic spasticity 3, 4
• Gait Pattern (if ambulatory): Observe walking pattern noting toe-walking, scissoring, crouched gait, or asymmetric patterns 4

Growth Parameters

Measure and plot 3:

• Length/height, weight, and occipitofrontal circumference (head circumference) 3
• Many children with CP have growth impairment requiring nutritional intervention 2

Skin and General Examination

Inspect for 3:

• Pressure areas or skin breakdown (especially in non-ambulatory patients) 3
• Evidence of injury or bruising that might suggest falls or abuse 3
• Skin color and perfusion 3

Critical Clinical Pitfalls

Never assume symptoms are static: CP is defined as non-progressive; any acute neurological deterioration (loss of motor milestones, new incontinence, sudden worsening of spasticity) requires urgent neuroimaging to exclude stroke, hemorrhage, spinal cord compression, or hydrocephalus 8.

Absence of spasticity does not exclude CP: Motor types can evolve during the first 2 years of life, and some children have dyskinetic or ataxic forms without spasticity 7.

Document functional abilities, not just impairments: Use standardized classification systems (GMFCS for mobility, MACS for manual ability, CFCS for communication, EDACS for eating/drinking) to enable clear communication between providers and track outcomes 6.

Screen for pain: 75% of individuals with CP experience chronic pain, which may manifest as irritability, sleep disturbance, or behavioral changes 2.