- A total of at least six items from (1), (2) and (3), with at least two from (1) and one each from (2) and (3):
- Qualitative impairment in social interaction as manifested by at least two of the following :
- marked impairment in the use of multiple nonverbal behaviors, such as eye to eye gaze, facial expression, body postures, and gestures to regulate social interaction
- failure to develop peer relationships appropriate to developmental level
- lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by a lack of showing, bringing, or pointing out objects of interest)
- lack of social or emotional reciprocity
- Qualitative impairments in communication as manifested by at least one of the following :
- delay in, or total lack of the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
- in individuals with adequate speech, marked impairment in the ability to initiate or stereotyped and repetitive use of language or idiosyncratic language
- lack of varied spontaneous make-believe play or social imitative ply, appropriate to developmental level
- Restricted, repetitive, and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
- encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
- apparently inflexible adherence to specific, nonfunctional routines or rituals
- stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting or complex whole body movements)
- persistent preoccupation with parts of objects
- Delays or abnormal functioning in at least one of the following areas, with onset prior to age three years:
- social interaction
- language as used in social communication or
- symbolic or imaginative play
- Not better accounted for by Rett disorder or childhood disintegrative disorder.
Onset before 3 years of qrs.
|Clinical Protocols for Spasticity|
|The Modified Tardieu Scale (MTS)
- Assesses spasticity as distinct from muscle tone.
- Offers a scale to delineate between dynamic and static muscle contracture.
- Useful for patient groups where spasticity is predominant feature being assessed eg. CP, SDR's ITB's.
- The test is dependent upon the velocity at which it is performed. A such the angle of spasticity may change according to the speed of the test, affecting reliability.
- May not directly correlate with the angle of spasticity demonstrated in gait kinematics (eg equinus). This may be due to speed adjustments the patient with spasticity may perform.
- As currently used, the scale does not provide a qualitative measure of spasticity (this can be included if the equality of muscle reaction (X) is utilised.
- In a study investigating measures of lower limb muscle and joint performance in children with cerebral palsy, Fosang et al, 2003 found that the inter-rater reliability (ICC+95% CI) of the MTS to be acceptable, ranging between 0.55 (0.33-0.77) and 0.74 (0.55-0.88) in the calf, hamstrings and hip adductors. However, a higher SEM was present for the hamstrings in the order of 9.0-9.6 on the first and second occasions of testing respectively and a fairly high SEM of 7.1 for the calf on the first occasion of testing
This translated to repeated measures over time with different raters for the MTS varying by 10 18 . Test re-test reliability ICC results demonstrated a wide range of variability among raters (varying between 4 - 19); sufficient time for training and practice were recommended.
- The joint to be assessed should be moved as fast as is possible (faster than the rate of the natural drop of the limb segment under gravity) through its range of motion over 3 consecutive trials. Velocity of test to be performed as consistently as possible across these trials.
- Patient to be assessed in supine with the neck in a consistent position (preferably straight with head on one pillow) and joints to be moved in the following ways:
- Hamstrings: Hip held at 90 flexion, knee then extended. Test to be performed on legs small enough to test reliably and consistently (at therapist's discretion).
- Calf (gastrocnemius): Ankle dorsiflexion using the forefoot (keeping the subtalar joint as neutral as possible).
- Hip adductors are not routinely assessed as they do not receive a quick stretch during gait.
Fosang AL, Galea MP, McCoy AT, Reddihough DS and Story I. 'Measures of muscle and joint performance in the lower limb of children with cerebral palsy' Developmental Medicine & Child Neurology 2003, 45 : 664-670
CLINICAL PROTOCOLS FOR SPASTICITY The Modified Ashworth Scale (MAS)
- Offers a scale to describe muscle tone.
- Useful for patient groups where spasticity is predominant feature being assessed eg. SDR's ITB's (to describe underlying muscle tone).
- The definition is blurred between the feel (resistance) of the visco-elastic properties of the muscle /tendon / joint versus a 'catch' and subsequent resistance assumed to be due to spasticity
- Velocity of testing not stated and assumed to be slow therefore is a measure of muscle tone as a distinct entity from spasticity (which is velocity dependent).
- May not directly contribute to gait function seen in 3DGA kinematics.
- In a study investigating measures of lower limb muscle and joint performance in children with cerebral palsy, Fosang et al 2003 found that the inter-rater reliability (ICC+95% CI) of the MAS to be poor, ranging between 0.27 (0.10-0.54) and 0.56 (0.33-0.78) in the calf, hamstrings and hip adductors. It was suggested that if used, only a single rater for the same patient should use this tool.
- To be used at Physiotherapists discretion regarding whether test is clinically meaningful.
- Rating scale to be applied to a slowly moving joint (to minimize spasticity being elicited).
- Patient to be assessed in supine and joints to be moved in the following ways:
|| Hip Adductors
||Hip to be moved between abduction and adduction
||Hip Internal Rotators
||Hip in neutral and rotated between IR and ER. Hip IR can also be assessed in prone ROM exam in further information is required
||Hamstrings and Quads
||Hip and knee to be flexed and extended (below 900 of hip flexion)
|| Ankle dorsiflexion with subtalar joint as neutral as possible
Fosang AL, Galea MP, McCoy AT, Reddihough DS and Story I. 'Measures of muscle and joint performance in the lower limb of children with cerebral palsy' Developmental Medicine & Child Neurology 2003, 450 : 664-670
|Clinical Exam Definitions|
|SELECTIVE MOTOR CONTROL
0 = No active dorsiflexion
1 = Predominantly EHL+/-EDL
2 = EHL, EDL with some Tib Ant
3 = DF achieved mainly by TA but accompanied by hip and /or knee flexion
4 = isolated selective DF with TA, no hip/knee flexion
5 = Assessor struggles to break or overcome maximal resistance against gravity, throughout the available range
4 + = Able to resist strong resistance against gravity throughout the available range
4 = Able to resist moderate resistance against gravity, throughout the available range
3 + = Able to resist slight resistance against gravity, throughout the available range
3 = Able to resist gravity only, throughout the available range
2 = Can move through available range with gravity eliminated
1 = Flickers of muscle activity only
0 = No muscle contraction detected
| LIGAMENTOUS LAXITY
|| SELECTIVITY SCALE
| Knee hyperextension
|| 0 = Only patterned movement
|DF> 45 0
|| 1 = Partially isolated movement
| Elbow hyperextension
|| Can initiate with some level of isolation
| Thumb to volar surface of forearm
|| but then uses patterned movement
| MCP Hyperextension parallel to forearm
||2 = Completely isolated movement |
MODIFIED ASHWORTH SCALE
0 = No increase in tone
1 = Slight increase in tone, manifested by a catch and release or by minimal resistance at the end of motion when affected part is moved in flexion or extension
1 + = Slight increase in tone, manifested by a catch and release or by minimal resistance at the end of motion when affected part is moved in flexion or extension
2 = More marked increase in muscle tone through most of the ROM, but affected part easily moved
3 = Considerable increase in muscle tine, passive movement difficult
4 = Affected parts rigid in flexion or extension
| OTHER QUALIFIERS || DUNCAN ELY |
| L = Strength range limited by strength deficit not ROM |
UA = Unable to assess F & U : Omit
| Mild, Moderate, or Severe |
|Clinical Protocols for Muscle Control|
|The Confusion Test
- Offers a quantitative tool to assess whether the tibialis anterior muscle is functioning, particularly when poor distal selective motor control is present. This may guide decisions regarding surgical transfer of tendons.
- May represent neurological maturation and be positive in the normal population also (see below).
- In a study by Davids et al 1993 comparing the confusion test between normal children and those with cerebral palsy, the unresisted confusion test was positive in 47% of the normal children (mean age 4 yrs; 6 mths) and the resisted confusion test positive in 97% of the normal children (mean age 8 yrs; mths).
The median age of those normal children who had both positive unresisted and resisted confusion tests was significantly younger than the children who had a positive resisted confusion test alone. It was suggested that the confusion test defines a normal primitive reflex or patterned response that is modified and controlled with age and neurological maturation.
In the group of children with cerebral palsy, a positive confusion test was not found to be predictive of swing phase ankle kinematics.
- Patient to be assessed in sitting with knees flexed.
- Patient asked to flex hip and lift thigh off the supporting surface.
- The foot is observed to see whether the ankle dorsiflexes during hip/ knee flexion. Dorsiflexion is rated as a +'ve response and further qualified by noting whether the foot remains neutral, or moves into inversions or eversion during the dorsiflexion movement (indicative of predominating muscles).
Davids JR, Holland WC and Sutherland DH. 'Significance of the Confusion Test in Cerebral Palsy'. Journal of Pediatric Orthopaedics 1993, 13 : 717-721
The Selective Motor Control Test
- Offers a quantitative tool a assess distal selective motor control for dorsiflexion at the ankle joint.
- A good SMC can predict outcome post calf spasticity management i.e dorsiflexion and foot clearance in swing.
- In a study by Boyd et al 1998, SMC was found to have a small but significant correlation with changes in active dorsiflexion during the swing phase of gait (r=0.4, P<[t] 0.05).
- Patient to be assessed in supine with head raised so a clear view of feet is possible. If possible, patient to be assessed in long sitting (if hamstrings length and good sitting balance available).
- Patient asked to dorsiflex the ankle and a score of 0-4 applied according to the activation of the muscles required to perform the movement (Boyd et al 1999.)
O = No active dorsiflexion
1 = Predominantly EHL +/- EDL
2 = EHL with some Tib Ant
3 = Dorsiflexion with effective Tib Ant (with knee+/- hip flexion)
4 = Isolated selective dorsiflexion (kn extended, use of Tib Ant)
Boyd RN, Pliatsios V and Graham HK. 'Use of clinical measures in predicting response to botulinum toxin A in children with cerebral palsy'. Developmental Medicine & Child Neurology 40 (suppl 78): 48
Boyd RN and Graham HK. 'Objective measurement of clinical findings in the use of Botulinum toxin type A for the management of children with cerebral palsy'. European Journal of Neurology 1999, Vol 6 (suppl 4): S23- S35
|Clinical Protocols for Ligamentous Laxity|
|Testing for Ligamentous Laxity
- Offers additional information regarding the stability skeletal system.
- Ruth Wynne-Davies' criteria for grading ligamentous laxity are listed below.
- There are 5 tests for ligamentous laxity of which 2 only are for the lower limb:
- Knee hyperextension
- Foot dorsiflexion> 45
- Elbow hyperextension
- Thumb can be bent back to touch the volar surface of the forearm
- MCP hyperextension to parallel the forearm.
- Both tests for knee hyperextension and excessive dorsiflexion will be covered in the routine clinical exam measuring joint range of motion. Other upper limb tests to be performed at the therapist's discretion.
- Knee hyperextensibility may also be assessed with rotation or varus / valgus forces as appropriate.
Wenger DR and Rang M. 1993. The Art and Practice of Children's Orthopaedics. Chapter : Assessing the Patient p 83. Raven Press New York.
|Strength Assessment Qualifiers|
| Generic definition of partial isolation
Can initiate movement with some level of isolation but then patterned movement occurs
| Hip Abduction
Patterned movement evident as hip flexion
Further qualification for hip abduction
Fully Isolated: No stabilization required
Partial Isolation: starts off isolated with stabilization but hip then comes fwd
No Isolation: Patterned movement evident from start of movement with and without stabilization
| Hip Extension: knee extended
|| Patterned movement evident as hip hitching / rotation
| Hip Extension: knee flexed
Patterned movement evident as hip abd/flex & /or knee extension
| Patterned movement can included ATNR
Ankle DF (supine)
| Patterned movement evident as knee flexion & /or rotation
| Ankle In/Eversion
Patterned movement evident as leg rotation &/or knee flexion with ankle inversion
| Ankle PF
Patterned movement evident as knee flexion prior to ankle PF
| Abdominals (arms crossed, no leg stabilization)
Head and shoulders
Head, shoulders and scapulae
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