What are the key components of a cerebral palsy (CP) physical exam?

How to Write a Cerebral Palsy Physical Exam

The physical examination for cerebral palsy must systematically document motor function, tone abnormalities, topographical distribution, functional severity using the GMFCS, and screen for associated impairments that affect 75% or more of patients. 1

Core Motor Assessment Components

Motor Type Classification

Document the predominant motor pattern, as this determines intervention strategies and prognosis:

• Spasticity (85-91% of cases): velocity-dependent increased muscle tone with resistance to passive movement 2, 1
• Dyskinesia (4-7%): includes dystonia and athetosis 2
• Ataxia (4-6%): cerebellar signs with coordination difficulties 2
• Hypotonia (2%): decreased muscle tone, though this may evolve into other types 2

Topographical Distribution

The anatomical pattern must be explicitly documented, as it dictates surveillance needs and early intervention strategies:

• Unilateral/hemiplegia (38%): one side of body affected 2, 1
• Bilateral diplegia (37%): lower limbs affected more than upper limbs 2, 1
• Quadriplegia (24%): all four limbs and trunk involved 2, 1

Early identification of unilateral versus bilateral involvement is critical because interventions like constraint-induced movement therapy and hip surveillance protocols differ substantially 2

Functional Severity Using GMFCS

The Gross Motor Function Classification System must be applied to standardize severity assessment, with levels I through V 1:

• Level I: walks without limitations
• Level II: walks with limitations (cannot run or jump normally)
• Level III: walks using hand-held mobility device
• Level IV: self-mobility with limitations; may use powered mobility
• Level V: transported in manual wheelchair

In children under 2 years, GMFCS predictions should be made cautiously using standardized tools, as motor skills are still developing and approximately half will have their classification change 2, 3

Standardized Neurological Assessment

For infants 5-24 months with risk factors, use the Hammersmith Infant Neurological Examination (HINE) 2:

• HINE score <73 at 6,9, or 12 months: indicates high risk of CP
• HINE score <40: indicates abnormal outcome, usually CP
• HINE score 50-73: likely unilateral CP (95-99% will walk)
• HINE score <50: likely bilateral CP
• HINE score 40-60 at 3-6 months: likely GMFCS I-II
• HINE score <40 at 3-6 months: likely GMFCS III-V

Tone and Reflex Examination

Document specific findings in each limb:

• Passive range of motion: assess for contractures and velocity-dependent resistance 1
• Deep tendon reflexes: typically hyperreflexic in spastic forms 1
• Babinski sign: assess plantar responses bilaterally 2
• Clonus: document presence and sustainability 1

Musculoskeletal Complications

Systematic examination for secondary complications is mandatory, as 28% develop hip displacement 2, 1:

• Hip examination: assess range of motion, abduction limitations, and asymmetry requiring surveillance imaging 2, 1
• Scoliosis screening: inspect spine alignment and measure curves if present 1
• Limb deformities: document contractures, foot deformities, and limb length discrepancies 1

Mandatory Screening for Associated Impairments

The examination must include systematic screening for comorbidities, as these profoundly impact quality of life 2:

Sensory Function

• Vision assessment (11% have functional blindness): check visual tracking, acuity, and strabismus 2, 1
• Hearing evaluation (4% have hearing impairment): assess response to sound and refer for formal audiometry 2, 1

Neurological Comorbidities

• Seizure history and signs (35% have epilepsy): document seizure types, frequency, and current control 2, 1, 3
• Cognitive function (49% have intellectual disability): assess developmental milestones and refer for formal testing 2, 1, 3

Communication and Feeding

• Speech and language: assess expressive and receptive abilities, as 3 in 4 will talk 2, 1
• Feeding and swallowing: observe for dysphagia, choking, prolonged feeding times 1

Pain Assessment

Screen for pain in every encounter, as 75% experience chronic pain that may manifest as irritability, sleep disturbance, or behavioral changes rather than verbal complaints 1, 3

Growth Parameters

Measure and plot on growth charts 1:

• Length/height: many have growth impairment requiring nutritional intervention
• Weight: assess for under- or overnutrition
• Head circumference: document microcephaly or macrocephaly

Skin and General Examination

• Pressure areas: inspect for breakdown, particularly over bony prominences 1
• Bruising or injury: document any concerning findings 1
• Perfusion: assess skin color and capillary refill 1

Critical Clinical Pitfalls

Never assume new symptoms are "just the cerebral palsy"—CP is non-progressive by definition, and any acute neurological deterioration requires urgent neuroimaging to exclude stroke, hemorrhage, spinal cord compression, or hydrocephalus. 1, 4 New onset incontinence, increased spasticity, or altered consciousness warrant immediate investigation for urinary tract infection (affects 15-60% of neurological patients), acute structural lesions, or other reversible causes 4

The absence of spasticity does not exclude cerebral palsy, as motor types can evolve during the first 2 years and some children have dyskinetic or ataxic forms without spasticity 1

Document functional abilities, not just impairments, as prognosis in high-income countries shows 2 in 3 will walk, 3 in 4 will talk, and 1 in 2 will have normal intelligence 2, 3