Selective Control Assessment in Cerebral Palsy (Lower Limbs) A Clinical Approach

VIVIAN CHAN HELENA LI

S.R.P . M.H .K.P.A. S.R.P.

Summary Traditionally, assessment for cerebral palsy patients is often based on their ability to perform motor functions. It has been discovered, through clinical situations, that assessments of this type tends to underestimate the true abilities of the patient, and hence a new method of assessment is needed. The method proposed is to assess the selective joint control of individual joints, based on the reasoning that control ofjoints is the basis of movement, and purposeful movement is the basis of different functions . In this article, the method is used only for lower limbs. It is developed through the understanding that selective control of individual joints becomes easier if positions are altered to facilitate the movement. A chart is included for the purpose ofassessment.

Introduction Traditionally, the assessment of ability of a patient with a control problem is often done by assessing the quality and level of functional skills the patient demonstrates in the assessment (Levitt 1979) . This is often thought to be a true reflection of the ability and hence an indication of the potential as far as treatment is concerned . However, this is often to be the case in clinical situations. The ability displayed in functional skills is often influenced by factors such as: insufficient control over abnormal tone due to incorrect or poor treatment, lack of proper sensory-motor experience during development, presence of joint contractures and deformities, and associated handicaps etc. Therefore, the ability displayed is often not the true ability as limited by the severity of the brain lesion . In order to assess this true ability, a different approach is needed . As all functions are composed of movements and movements are build up from the control of different joints, as elaborated in this article, it is reasonable to presume that in order to assess the true ability of a patient, a more fundamental way of assessment would be to assess the isolated control of individual joints . This is the theoretical basis of the chart. It is thus reasonable to deduce that if a patient can perform good isolated movements, he should be able to use the control to improve movements and thus function. From the practical point of view, this chart has other advantages. Firstly, it acts as a good baseline for comparison of patient's ability before and after treatment, thus noting the patient's progress and value of treatment . Secondly, it is a simple chart which does not require special technical skill or equipment which makes it convenient in a wider range of clinical situations. 2

Development of Selective Control Selective Control is the ability to move any single joint of the body at any one time independently or in combination with other joints of the body, either sequentially or simultaneously (Perry 1975) . A newborn baby is born with a great variability of primitive motor patterns. Normal selective control evolves through the continuous process of the breaking up of these patterns into tiny specialised movements (Samilson & Perry 1975). As part of this process, extension and flexion abilities develop, gradually replacing the flexor dominance of the neonatal period . These abilities form the basis of control against gravity in both prone and supine positions (Bobath 1980) . The ability to rotate within the body axis develops as a consequence of the developing righting mechanisms, Rotation, combined with modified extension and flexion, allows movement to occur in different parts of the body and in different positions. Righting reactions are then modified and progressively integrated with the development of equilibrium . The perfection of equilibrium reactions gives rise to a stable trunk which frees arms and hands for manipulative activity. During this process, proximal fixation and stability of body parts develop, allowing fine distal control of joints (Cash 1974). This control is an important element of manipulative skill. Selectivity of any movement depends on the acquisition of the above abilities during development . Selectivity, Control and Function Good selectivity in any movement is an important basis for assessing the degree of voluntary motor control in Cerebral Palsy patients. When treatment is aimed at improving the gait of a patient with a control problem, the potential of the
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MUSCLE GROUP Hip Flexors Grade 6 : full range 0 - 90 Grade 5 - 3 : mid-range 20-70

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GRADE 5 4 3 2 1 Reflex Action

Hip Extensors Grade 6 : full range 0 - 30 Grade 5 - 3 : mid-range I0 - 20

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1

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Hip Abductors Grade 6 : full range : 0 - 45 Grade 5 - 3 : mid-range I5 - 30

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Hip Adductors Grade 6 : full range : 0 - 45 Grade 5 3 : mid-range I0-20

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being supported

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Knee Extensors Grade 6 : full range : I35 - 0 Grade 5 - 3 : mid-range 90 - 40

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Knee Flexors Grade 6 : full range : 0 - I35 Grade 5 - 3 : mid-range 40 - 90

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Ankle Dorsiflexors Grade 6 : full range : 0 - 20 Grade 5-3 : mid- range I0 note : Ankle Plantarflexors Grade 6 : full range : 0 - 45 Grade 5 - 3 : mid-range I5 - 30 note :

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* Dorsiflexion and Plantarflexion should be done with foot in neutral only - no inversion or eversion . Volume 7, 1985.

patient for treatments can often be revealed by the level of voluntary control demonstrated in the lower limbs during clinical assessment . If the patient can perform good isolated movements in the lower limbs, it is reasonable to expect this control to be utilised to improve the function of the lower limbs and thus improve the gait. That is to say, if the control can be further improved by treatment, it can be anticipated that the function should likewise be improved and that the gait should become easier and better . Grading System With this in mind, a grading system for selective control of the lower limbs is important, not only for revealing the patient's potential so that a realistic treatment goal can be established, but it also serves as an important baseline for comparison of patient progress and treatment value . This grading system is developed, based on the hypothesis that movement can be facilitated through different positionings in brain damaged patients (Bobath 1980). A scoring system of 6 to 1 is used to designate the degree of maximal control in different positions . The maximum grade (6) is given to maximal selective control in the most natural position where anatomical movement can take place. The subsequent position is modified to allow facilitated movement, where control becomes less difficult . The minimum grade (1) is given to a reflex action. Standing position is not chosen as a testing position because it requires good balance and postural reactions . These factors will influence the performance of a movement and makes judgement of motor control of that movement difficult . The quality of performance in any particular position is the criterion for scoring. This means that the degree of isolation and the accuracy of the movement performed will be the chief concerns . In order to standardise the test conditions, the Mid Range of a movement is chosen (A.A .O.S. 1965) (except for Grade 6) because it is the most functional range and the easiest one for a group of muscles to work in (as we do not concern ourselves with the power of muscles). Also, where possible, the chosen position requires the patient to lift the weight of the tested limb, as this will indicate whether there is sufficient muscle power for function in an antigravity position. The grading scale is as follows : Grade 6 Movements can be performed in full range in Positions of Maximal Selective Control with no contra-lateral or unilateral associations, mass or primitive movements . Grade 5 In the same Position as Grade 6, movements can be performed in the prescribed range with no or minimal contralateral or unilateral association, mass or primitive movements . Grade 4 Movements can be performed in the Facilitated Position in the prescribed range and there is no or minimal contralateral or unilateral association, mass or primitive movements, except at the end range . 4

Grade 3 In the, same Facilitated Position as in Grade 4, movement can be performed over a limited range, allowing some contralateral or unilateral associationmass or primitive movements. Grade 2 Movement can be performed when placed in Mass Pattern. (Quality of performance becomes insignificant) . Grade 1 Movement can only be a reflex action .

Conclusion This grading system has been in use in clinical situations for about a year. It has proven to be clinically sound and easy to apply . Work is in hand to test the consistency for the chart between assessors, and reviews are in progress .

References American Academy of Orthopaedic Surgeons Joint Motion, Method of Measuring and Recording. (American Academy of Orthopaedic Surgeons) 1965 Bobath, K. A Neupophysiological Basis fop the Treatment of Cerebral Palsy. (Heinemann - London) 1980 Cash, J. Neurology for Physiotherapists. (Faber & Faber - London) I974 Fiorentino, M.R . Reflex Testing Methods fop Evaluating C.N .S . Development (2nd Edition) . (Charles C. Thomas) Levitt, S. Treatment of Cerebral Palsy and Motor Delay. (Blackwell - Oxford) I979 (reprint) Perry, J. Orthopaedic Aspects of Cerebral Palsy. ed . Samilson, R.L . (Heinemann - London) I975 Peppy, J. & Samilson, R.L . Orthopaedic Aspects of Cerebral Palsy. ed . Samilson, R.L ., (Heinemann - London) I975

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