Cerebral Palsy Integrated Pathway Scotland (CPIPS) · This collaboration resulted in the Cerebral Palsy Integrated Pathway Scotland (CPIPS) programme, supported financially by the

Cerebral Palsy Integrated Pathway Scotland (CPIPS)

Origins and DevelopmentCore DatasetClinical Assessment

1

Cerebral Palsy Integrated Pathway Scotland (CPIPS)

Contents

Introduction .............................................................................................................................. 2

Core Database ........................................................................................................................... 3

Assessment for Hip Surveillance ................................................................................................ 9

The Traffic Lights System ......................................................................................................... 19

Glossary of Terms .................................................................................................................... 20

Updated 2017

Appendix 1 – CPIPS Assessments

Appendix 2 – CPIPS Flow chart

Appendix 3 – CPIPS Clinical Measure .

Appendix 4 – X-ray Protocol

Appendix 5 - Functional Mobility Scale

Appendix 6 – Consent Form .

Appendix 7 - Patient management system

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Introduction

After the Liverpool consensus meeting in 2010 on the management of the hip in children with cerebral palsy (CP) a group of clinicians met later that year to discuss the possibility of introducing a hip surveillance programme, based on the Swedish model, for children with CP in Scotland.

Those attending this first meeting were representatives from the Scottish Paediatric Orthopaedic Club (Miss Heather Read, Messrs Simon Barker, Donald Campbell, Jamie McLean, James Robb) Professor Gunnar Hagglund (Orthopaedic Surgeon, Lund, Sweden), Professor Peter Donnelly (Public Health, University of St Andrews) and Dr Paul Eunson (Paediatric Neurologist, Royal Hospital for Sick Children, Edinburgh). They agreed that a hip surveillance programme for children with CP was desirable for Scotland and basing it on the Swedish model was feasible. However, this was an opportunity to collect more than hip data and to include physical examination measures as well. Accordingly, meetings were then held with Physiotherapy representatives from all board areas in Scotland and non-nhs providers.

Protocols for physical and radiological examinations were agreed and a group established to develop resources to support implementation (Laura Wiggins, Lesley Harper, Nicola Tennant, Susan Quinn and Katie Kinch). Training for Physiotherapists for the physical examination of children with cerebral palsy was provided and supported by The Association of Paediatric Chartered Physiotherapists (APCP) Scotland. Audio-visual support was provided by NHS Greater Glasgow and Clyde Medical Illustration Services.

At the same time, two MRes postgraduate students, Madeleine Baines (2010-11) and Kimberly Stevenson (2011-12) investigated the organisation of resources in Scotland for children with cerebral palsy, the feasibility of introducing a hip surveillance programme and the likely input of Occupational Therapists into the programme. They were based at the University of St Andrews and supported by a grant from NHS Tayside.

This collaboration resulted in the Cerebral Palsy Integrated Pathway Scotland (CPIPS) programme, supported financially by the Robert Barr Trust, Brooke’s Dream and the Scottish Government for three years, 2013-2016.

In 2016 the CPIPS programme continued with the support of The Sick Kids Friends Foundation, a charity which supports and compliments the work of Edinburgh Royal Hospital for Sick Children as well as other children's healthcare settings across Scotland.

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Core database for children with a diagnosis of cerebral palsy aged two and aboveThis is the minimum data set, additional measures may be included in the assessment if clinically indicated. Other measures will not be recorded in the database

Frequency of examinations

• 6 monthly for children aged between 2-6 years

• Annually for children over 6 years

• More frequently if there are “red flag” signs

• Final examination between16-18 years

DEMOGRAPHICS

Chi Number

Name Forename

Surname

Date of birth

Responsible Health Board

Ayrshire and Arran One choice only

Borders

Dumfries and Galloway

Fife

Forth Valley

Grampian

Greater Glasgow and Clyde

Highland

Lanarkshire

Lothian

Orkney

Shetland

Tayside

Western Isles

ASSESSMENT

Date of first assessment Insert date

Date of this assessment Insert date

Assessor Forename Free text

Surname Free text

Physiotherapist Yes/no

Orthopaedic Surgeon Yes/no

Community Paediatrician Yes/no

Other Free text

Child's address Free text

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CLINICAL DETAILS

Dominant neurological condition

Spastic Yes/no

Dyskinetic Yes/no

Dystonic Yes/no

Ataxic Yes/no

Mixed Yes/no

Unclassified Yes/noDistribution of neurology Yes/no

Yes/no

Yes/no

Yes/no

Hemiplegia

• Hip involvement

Diplegia

Triplegia

Quadriplegia

Total Body Yes/no

Other relevant diagnosis(es)

Free text

GMFCS (E&R)www.canchild.ca/en/resources

Select level

1

23

5

Clinical Details continues on next page

Relevant to the appropriate GMFCS E&R age band

4

5

Clinical Details continued

FMS See also page 28 for question examples Insert values

5 metres

50 metres

500 metres

Spasticity reducing treatments since last assessment

Yes/no

Yes/no

Yes/no

Yes/no

Yes/no

Hip surgery since last assessment

Yes/no

None

Botulinum toxin

SDR

ITB

Oral antispasmodics

None

Adductor longus and

gracilis

Psoas tenotomy

Femoral osteotomy

Pelvic osteotomy

Open reduction

Other

Bony Surgery

Soft Tissue Surgery

Left/right/both

Left/right/both

Left/right/both

Left/right/both

Left/right/both

Left/right/both

Free text

Drop down

menu

28

Rating 6

Independent on all surfaces:

Does not use any walking aids or need any help from another person when walking over all surfaces including uneven ground, curbs et, and in a crowded environment.

Rating 5

Independent on level surfaces:

Does not use walking aids or need help from another person. *Requires a rail for stairs.

* If uses furniture, walls, fences, shop fronts for support, please use 4 as appropriate description.

Rating 4

Uses sticks (one or two):

Without help from another person.

Rating 3

Uses crutches:


Rating 1

Uses wheelchair:

May stand for transfers, may do some stepping supported by another person or using a walker / frame.

Rating 2

Uses a walker or frame:


Rating C

Crawling:

Child crawls for mobility at home (5m).

Rating N

N = does not apply:

For example, child does not complete the distance (500m).

Walking distance

Rating: select the number (from 1-6) which best describes current function

5 metres (yards)

50 metres (yards)

500 metres (yards)

Functional Mobility Scale

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EXAMINATION GMFCS IV, V

RANGE OF MOTION

Hip

Knee Popliteal angle (shank to vertical, hip flexed to 90º)

Insert value

Fixed flexion (hip extended as far as possible) No/Yes

Popliteal angle R1 Insert value

Ankle Dorsiflexion knee flexed Dorsiflexion

knee extended Dorsiflexion knee flexed

R1 optional Dorsiflexion knee extended

R1

Insert value DF/PF

Insert value DF/PF

Insert value DF/PF

Insert value DF/PF

Spine Scoliosis (sitting) Yes/no

Lumbar lordosis excessive Yes/no

Thoracic kyphosis excessive Yes/no

Scoliosis management

Yes/no

Yes/no

Yes/no

EXAMINATION GMFCS I-III

X-ray since last assessment

Orthosis since last assessment

Surgery since last assessment

RANGE OF MOTION

True leg length Right

Left

Insert value

Insert value

HipExternal rotation in extension prone

Internal rotation in extension prone

Insert value

Abduction (max) in 90º hip extension and knee flexion

Insert value

Abduction (max) in hip extension and knee flexion

Insert value

Duncan Ely Test Insert value

Examination GMFCS I-III – Hip, continues on next page

Unable to Test - add commentR1 measures are not colour coded, impact should be related to function

Unable to Test - add comment R1 measures are not colour coded, impact should be related to function

Hip flexion deformity No/Yes/Unable

Insert Value

Insert value

Insert value

No/Yes/Unable to test

Insert ValueInset ValueNo/Yes/Unable to Assess

External Rotation (max) in 90º hip flexion, knee flexed to 90º

Internal Rotation (max) in 90º hip flexion, knee flexed to 90º

Fixed flexion deformity (Thomas Test)

Abduction (max) in 90º hip neutral, knee flexed Duncan Ely TestPain on passive RoMAbduction R1

Adduction Contracture Insert value Yes/No

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Examination GMFCS I-III – Hip, continued

Yes/no

Insert value

Pain on passive RoM

Abduction (max) in hip and knee extension

RI Duncan Ely Test RI

Insert value

Knee Popliteal angle Insert value

Fixed Flexion Deformity Insert value

Popliteal angle R1 Insert value

Knee Hypertension Insert value

Ankle Dorsiflexion knee flexed Dorsiflexion

knee extended Dorsiflexion knee

flexed R1 Optional

Dorsiflexion knee extended R1

Insert value DF/PF

Insert value DF/PF

Insert value DF/PF

Insert value DF/PF

Foot – weight bearing

Hind foot varus Yes/no

Hind foot normal valgus Yes/no

Hind foot excessive valgus Yes/no

Midfoot break Yes/no/correctable

Spine Yes/no

Yes/no

Scoliosis sitting

Lumbar lordosis excessive

Thoracic kyphosis excessive Yes/no

Scoliosis management

Yes/no

Yes/no

X-ray since last assessment

Orthosis since last assessment

Surgery since last assessment Yes/no

HIP X-RAY

Insert value

Yes/no

Insert value

Insert value

FRACTURE SINCE LAST ASSESSMENT

If ‘Yes’ Free text

Yes/no

X-Ray not applicable Failed toAttend DeclinedDate of last x-ray

Technical quality satisfactory

Migration % Right - Head Shaft Angle Right- Head Shaft Angle LeftMigration % Left

Assesor detail Onward Referral Yes/No

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PHYSIOTHERAPY

Management programme

Active Yes/no

Review Yes/no

Discharged Yes/no

Postural management

Specialist seating Yes/no

Specialist seating in use Yes/no

Standing equipment Yes/no

Standing equipment in use Yes/no

Sleep system Yes/no

Sleep system in use Yes/no

Orthoses Yes/no

Orthoses in use-access drop down menu of orthosis Yes/no

Walking aids Yes/no

Walking aids in use Yes/no

Barriers to effectiveness of programme

Action plan

Activity

n

• Social Factors• Environmental factors• Learning difficulties• Barriers to communication• Emotional difficulties• Challenging behavior• Other health needs• Active Stretching• Passive Stretching• Muscle strengthening• Task focused active use• NDT• Wheelchair sports club• Wheelchair sports club number of sessions• CP football club• CP football number of sessions per week• Swimming club• Swimming club number of sessions per week• Atletics club• Athletics club number of sessions per week• Racerunning club• Racerunning number of sessions per week• Boccia club• Boccia club number of sessions per week• Activity -not in a club- number of sessions• Other activity-Comments - free text

Headings below should be discussed with child or family

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Assessment for Hip Surveillance

Optimal conditions: measures taken by two people who are familiar with these measures, utilising a plinth goniometer and tape measure.

Thomas Test

Supine - Hip

Start position: Supine, hip extended, knees relaxed. If there is a knee flexion contracture the patient should be moved to the end of the bed where legs are over the end and the knees are flexed. Flex the opposite hip as far as is necessary to bring the pelvis to neutral then press the thigh of the leg to be measured towards the plinth, measure the angle between the thigh and the bed.

The fulcrum of the goniometer is placed over the greater trochanter with the rigid arm in line with the plinth towards the pelvis and the movable arm follows the femur producing an angle between the femur and the plinth.

Hip flexion contracture - Thomas Test

Thomas Test accommodating knee flexion contracture Positive Thomas Test

Hip flexion contracture

Hip flexion contracture - Thomas Test

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Abduction

Starting position: Supine with hips extended, knees flexed and lower legs over the edge of the plinth. Knees are flexed to counteract Gracilis and Hamstrings. The hip is extended to include Iliopsoas.

An alternative position can be used If there is increased lumbar lordosis, the hip NOT being measured is flexed on the plinth.

The goniometer fulcrum is placed over the ASIS on the side to be measured, the fixed arm is placed along an imaginary line between both ASISs, the movable arm follows the femur. In order to avoid pelvic rotation both hips are abducted at the same time.

R1 should also be measured.

Hip, range of motion

Abduct hips bilaterally over the end of the plinth, knees flexed

Bilateral hip abduction Right hip abduction

Left hip abduction - Fast (R1)

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Internal /External Rotation (GMFCS IV-V)

Starting position: Supine with hip to be measured and knee flexed to 90°.The lower leg and foot is rotated towards the other leg to measure external rotation and out away from the other leg to measure internal rotation.

The fulcrum of the goniometer is placed on top of the knee, the rigid arm is stabilised in line with the trunk (a line bisecting at 90° a trans-verse line between the two ASISs) and the moving arm is aligned and moved with the anterior border of the tibia.

Beware instability of the knee which may lead to an erroneous increase in angles measured.

Hip external and internal rotation with hip flexed Hip external and internal rotation with hip flexed

Hip, range of motion

Internal rotation, knee flexed

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Popliteal Angle

Starting position: supine with leg to be measured flexed to 90° and contralateral limb lying passively on the plinth. Extend the limb to be measured to its maximum, the angle measured is between the shank and the vertical, if the leg extends so that the knee is straight the angle is 0°.

The fulcrum of the goniometer is placed over the lateral aspect of the knee joint with the fixed arm aligned with the femur towards the greater trochanter and the moving arm is placed along the fibula aligned with the lateral malleolus.

R1 should be measured.

Popliteal angle Fast popliteal angle (R1)

Hamstring length

Popliteal angle

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Knee Extension

Starting position: Supine with hip and knee extended. The fulcrum of the goniometer is placed over the lateral aspect of the knee joint, the fixed arm aligned with the femur towards the greater trochanter and the moving arm is placed along the fibula aligned with the lateral malleolus.

• If fixed flexion of the knee is present note FF.

• If knee hyperextension is present note HE.

Knee extension

Knee flexion contracture

Hypermobile knee

Knee joint range

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Ankle Dorsiflexion

With knee flexedStarting position: Hip and knee flexed to 90°, stabilise the subtalar joint by holding the calcaneus in neutral, supinate the forefoot to prevent movement of the intertarsal joints and dorsiflex the foot towards the vertical.

With knee extendedStarting position: Hip and knee extended, stabilise the subtalar joint by holding the calcaneus in neutral, supinate the forefoot to prevent movement of the intertarsal joints and dorsiflex the foot towards the vertical.The fulcrum of the goniometer should be placed inferior to the lateral malleolus towards the sole of the foot with the fixed arm aligned with the lateral malleolus and the fibula, the moving arm over the lateral border of the foot up to the base of the 5th metatarsal to prevent a mid-foot break producing an erroneous measure.Beware the subtalar joint slipping in to valgus to allow an increased measure of dorsiflexion.• A 90° angle is recorded as 0° of dorsiflexion.• If dorsiflexion is lacking e.g. -5° or note 5° PF.• R1 should be measured with knee extended.

Knee flexed Knee extended

Ankle dorsiflexion

Ankle dorsiflexion – knee flexed

Fast – plantarflexors (R1)

Ankle dorsiflexion – knee extended

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Leg Length

Position: patient should be parallel to the edge of the plinth with the pelvis as straight as possible (at right angles to the edge of the plinth) the trunk should be straight, the head in mid lineand arms by sides.

Measure from ASIS (tape pressed under the notch of the ASIS) to the inferior border of the medial malleolus.

Leg length

ASIS to medial malleolus

Measuring leg length

Duncan Ely Test

Duncan Ely

ProneStarting position: prone with hips extended and pelvis fixed. Flex knee until the pelvis lifts on the same side. Firm pressure is not requiredThe fulcrum of the goniometer is placed over the lateral aspect of the knee joint, the fixed arm aligned with the femur towards the greater trochanter and the moving arm is placed along the fibula aligned with the lateral malleolus. Flex knee and record the angle between the plinth and the shank when the pelvis starts to lift.

R1 should be measured.

Rectus femoris length

Duncan Ely Duncan Ely – Fast (R1)

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Hip Extension

Starting position: prone on plinth with both legs relaxed, pelvis held stable with one hand then extend the hip by lifting the thigh / femur off the plinth with the other hand.

The fulcrum of the goniometer is placed over the greater trochanter with the fixed arm bisecting a line between the ASIS and PSIS and the moving arm is aligned with and moves with the femur.

Beware an increased lumbar lordosis giving the impression of more extension than is actually present.

Hip extension

Pelvis neutral

Hip extension

Internal / External Rotation (GMFCS I-III)

Starting position: prone with hip to be measured extended and knee flexed. Pelvis should be stabilised to minimise pelvic rotation and the hip rotated by moving the shank and foot towards the other leg (external rotation) and away from the other leg (internal rotation).

The fulcrum of the goniometer is placed on the plinth directly anterior to the knee, the fixed arm rests on the plinth and the moving arm is aligned with the anterior border of the tibia (at an angle of 90°) it then follows the shank as its moved, the angle between the vertical and the shank is measured.

Beware movement at the pelvis allowing greater movement of the shank giving a false measurement. Make sure the thigh resting on the plinth is straight and in line with the trunk.

In prone position

Hip – internal range of motion

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Hip internal rotation Hip external rotation

Midfoot Break

Correctable

Abnormalities

Sitting

Spine

Sitting over the side of the plinth assess if scoliosis is present and if it is correctable.

Above: Spine check – sittingRight: Spine check – Standing

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Standing

Foot – Weight Bearing

Varus Normal Valgus

Note: Tardieu – Velocity of Stretch

• V1 as slow as possible (slower than the natural drop of the limb segment under gravity).

• V2 speed of limb segment falling under gravity.

• V3 as fast as possible (faster than the rate of natural drop of the limb segment under gravity).

• R1: the fast velocity movement of the joint through the full range of motion to determine thepoint of catch in the range of motion (Tardieu velocity V3). The angle at which the musclereaction (“catch” or R1 ) occurs is measured.

• R2: the slow passive range of motion or muscle length (conducted at Tardieu velocity V1).

Heels Varus / Valgus

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The Traffic Light System – adapted from CPUP

Green indicates what we regard as a normal or almost normal value.

Amber value should prompt a review of the child’s management strategy.

Red value may require referral to orthopaedic department for assessment.

GMFCS I – III RED AMBER GREEN

Hip abduction/knee ext <30º 30º - 40º >40º

Popliteal angle >50º 40º - 50º <40º

Knee extension <0º 180º /0º

Dorsiflexion with flexed knee <10ºDF 10ºDF - 20ºDF >20ºDF

Dorsiflexion with extended knee 0<ºDF 0ºDF - 10ºDF >10º

Hip internal rotation <30º 30º - 40º >40º

Hip external rotation 3<0º 30º - 40º >40º

Duncan Ely test <100º 100º -120º >120º

Hip extension < 10º >10º

GMFCS IV – V RED AMBER GREEN

Hip abduction <20º 20º - 30º >30º

Popliteal angle >60º 40º - 60º <40º

Knee extension>10º fixed

flexion0º/10 fixed

flexion180º /0º

Dorsiflexion with flexed knee 1ºPF 0º-10ºDF >10ºDF

Dorsiflexion with extended knee <-10º -10º - 0º >0º

Hip internal rotation <30º 30º - 40º >40º

Hip external rotation <30º 30º - 40º >40º

Ely test <90º 90º - 110º >110º

Hip extension <-10ºFFD -10ºFFD - 0º >0º

Glossary- CPIPS

Acetabular Index (AI) Angle between the Hilgenreiner line and a line drawn from the triradiate epiphysis to the lateral edge of the acetabulum. The angle decreases with age and should measure less then 20° by the age of two.

Active Stretch A physical therapy intervention in which the child or young person actively stretches their muscles with the aim of increasing range of movement.

Ataxic A lack of balance, poor coordination and depth perception. Generalised hypotonia, may have intention tremor especially in the upper limbs.

Boccia Is a precision ball sport similar to bowls and petanque. The name boccia is derived from the Latin word for boss bottia.

Cerebral Palsy (CP) Describes a group of permanent disorders of the development of movement and posture, causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing foetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication and behaviour, by epilepsy, and secondary musuloskeletal.

Diplegia Primarily affecting the legs most children will have some upper limb involvement but to a lesser extent.

Duncan Ely Physical examination test to detect rectus femoris contracture and spasticity

Dyskinetic Predominate feature is rapid involuntary abnormal movements caused by the individual’s inability to control muscle tone resulting in both hypotonia and hypertonia primarily associated with damage to the basal ganglia.

Dystonic Involuntary movements accompanied by abnormal sustained postures, resulting in fixed twisted postures characterized by muscle rigidity. Muscle tone fluctuates varying from normal to hypotonic to extreme hypertonia , dystonia usually occurs during voluntary movements.

Environmental Factors

Lack of space, physical assistance, accessible transport or equipment

Femoral Neck Anteversion (FNA)

Angle between an imaginary transverse line that runs medially to laterally through the knee joint and an imaginary transverse line passing through the centre of the femoral head and neck. In the newborn the average FNA angle is 31° this decreases until about 15 years of age to between 15° and 18°.

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Functional Mobility Scale (FMS)

Quantifies mobility according to the need for assistive devices in different environmental settings. It is a robust tool for documenting mobility status at one point in time and for assessing change over time.

Gross Motor Function Classification System (GMFCS)

Is a five level classification system that describes the gross motor function of children and youths with cerebral palsy on the basis of their self-initiated movement with particular emphasis on sitting, walking and wheeled mobility. Distinctions between levels are based on functional abilities, the need for assistive technology, including hand-held mobility devices or wheeled mobility, and to a lesser extent, quality of movement. https://canchild.ca/en/resources/42-gross-motor-function-classification-system-expanded-revised-gmfcs-e-r#

Hemiplegia Condition affecting one side of the body

Hip Dislocation The femoral head is completely displaced from under the acetabulum (MP =100%)

Hip Displacment / subluxation

Gradual, lateral displacement of the femoral head from under the acetabulum is defined by a migration percentage (MP) of between 10% and 99%.

Hip Surveillance Process of monitoring and recognising the early signs of progressive hip displacement, it involves both physical and radiological examination.

Intrathecal Baclofen (ITB)

Baclofen delivered directly into the cerebrospinal fluid via an implanted infusion system.

Midfoot Break When the hindfoot including the talus is forced into equinovalgus by excessive triceps surae force, an excessive ground reaction force then pushes the forefoot into relative dorsiflexion, abduction and supination. These forces result in tibialis posterior and ligaments being unable to sustain the longitudinal arch with the result the navicular

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Midfootbreak (picture)

subluxes dorsally and laterally on the talus. This is a lever arm dysfunction of the foot resulting in external rotation of the foot in weight bearing the midfoot break occurs in the attempt to keep the foot plantigrade.

Migration percentage (MP)

MP is calculated by dividing the width of the femoral head outside the lateral margin of the acetabulum by the total width of the head of the femur.

Neck to Shaft Angle (NSA)

Is the angle of inclination of the femoral neck, it is formed between the long axes of the neck and shaft of the femur. In the newborn the angle is very large and decreases with age. Normal adult range is 125° to 135°.

Neurodevelopmental Therapy (NDT)

Neurodevelopmental treatment based approach. Intervention involves direct handling and guidance to optimise function, incorporating information from neuroplasticity motor learning and motor control.

Oral antispasmodics Medication taken by mouth to reduce spasticity , baclofen, dantrolene, diazapam

Passive Stretch A physical therapy intervention involving sustained stretching using positioning with equipment, orthoses or serial casting.

Quadriplegia All four limbs and trunk affected

Racerunning Is an innovative sport for disable athletics with impaired balance, predominantly suitable for those with Cerebral Palsy.

Spastic Spasticity –velocity dependant resistance to stretch where a lack of inhibition results in excessive contraction of the muscle

Selective Dorsal Rhizotomy (SDR)

A neurosurgical procedure to reduce spasticity, by identifying the dorsal rootlets that are causing the spasticity and surgically dividing a proportion of them

Social Factors Factors which affect the ability of the parents or carers to support surveillance and interventions

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Task-focused Active-use

Thomas Test

A physiotherapy technique where a specific goal is identified and the child or young person carries out exercises or activities using the affected limb or limbs to improve their performance.

Physical examination test used to detect hip flexion contracture named after Dr Hugh Owen Thomas (1834-1891)

Total Body Involvement

All four limbs, trunk and head involved.

Triplegia Effects three limbs i.e. both legs and one arm or both arms and one leg

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CPIPS- Assessment for Hip Surveillance GMFCS 1-3

Name: DOB: CHI:

Date:

Therapist :

GMFCS:

Right Left Right Left

HIP - supine

Thomas Test/Hip flexion deformity GMFCS I- III any FFD

Abduction – bilateral knees flexed over corner of plinth Slow passive movement (R2) GMFCS I-III <30° 30°- 40° >40°

Abduction hip neutral knee extended Fast (R1)

Abduction –opp hip and knee flexed on plinth (unilateral) Slow passive movement (R2) GMFCS I-III <30° 30°- 40° >40°

Popliteal angle Slow passive movement (R2) GMFCS I-III >50° 40°- 50° <40°

Popliteal angle Fast (R1)

Pain on Hip ROM yes/no

KNEE- supine

Extension (Fixed Flexion) GMFCS I-III any FFD 180°/0°

Knee hyperextension

ANKLE/FOOT-supine

Dorsiflexion-knee flexed GMFCS I-III <10° 10°- 20° > 20°

Dorsiflexion-knee extended Slow passive movement (R2) GMFCS I-III < 0° 0°- 1 0° >10°

Dorsiflexion knee extended Fast (R1)

Leg Length mm

Name: DOB: CHI:

Date :

Therapist :

Right Left Right Left

HIP - prone

Duncan Ely Slow Passive movement (R2) GMFCS I-III <100° 100°- 120° >120°

Duncan Ely Fast (R1)

Hip Extension GMFCS I-III < 10° >10°

Internal rotation hip extended <30° 30°- 40° >40°

External rotation hip extended <30° 30°- 40° >40°

HINDFOOT - weight bearing Valgus/norm/varus

MIDFOOT BREAK - weight bearing Yes/No

SPINE- Scoliosis sitting Scoliosis standing Lumbar lordosis excessive Thoracic kyphosis excessive

Yes or No

Functional Mobility Scale FMS

5m 5m

50m 50m

500m 500m

Red: value requires referral to orthopaedic department for further assessment Amber: value should prompt a review of the child’s management strategy Green: indicates what we should regard as normal or almost normal value (Traffic light values apply to slow PM only)

Signed:

Designation:

*Optional not in database

CPIPS- Assessment for Hip Surveillance GMFCS 4&5 GMFCS Name: DOB: CHI:

Date: Therapist :

Right Left Right Left HIP - supine Thomas Test/Flexion deformity GMFCS IV-V < -10° -10°- 0° > 0° Abduction – bilateral knees flexed over corner of plinth Slow passive movement (R2) GMFCS IV-V <20° 20°- 30° >30° Hip abduction Fast (R1) knee ext

Abduction –opp hip and knee flexed on plinth (unilateral ) Slow passive movement (R2) GMFCS IV-V <20° 20°- 30° >30° Hip abduction Fast (R1) knee ext Hip Adduction Contracture (degrees) Abduction with both hip and knee flexed to 90° (optional)* Internal rotation hip in 90° flexion <30° 30°- 40° >40° External rotation hip in 90° flexion <30° 30°- 40° >40° Popliteal angle Slow passive movement (R2) GMFCS IV-V >60° 40°- 60° <40° Popliteal angle fast (R1)

Pain on Hip ROM yes/no KNEE- supine Extension (Knee fixed flexion) GMFCS IV –V >10°FFD 1-10°FFD 180°/ 0° Knee Hyperextension (degrees) ANKLE/FOOT-supine Dorsiflexion-knee flexed GMFCS IV –V <0° 0°-10 ° >10° Dorsiflexion-knee extended Slow passive movement (R2) GMFCS IV –V < -10° -10°- 0° >0°

Dorsiflexion Knee extended Fast (R1) Leg length

Name: DOB: CHI: Date :

Therapist : Right Left Right Left

HIP - prone Duncan Ely Slow Passive movement (R2) GMFCs IV-V < 90° 90°-110° >110°

Duncan Ely Fast (R1) Hip Extension GMFCS IV-V < -10° -10°- 0° > 0° SPINE- scoliosis In sitting

Lumbar lordosis excessive Thoracic kyphosis excessive

Yes/no

Functional Mobility Scale FMS

5m 5m 50m 50m 500m 500m

Red: value requires referral to orthopaedic department for further assessment Amber: value should prompt a review of the child’s management strategy Green: indicates what we should regard as normal or almost normal value (Traffic light values apply to slow PM only)

Signed:

Designation:

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Discuss Hip Surveillance

With family

GMFCS I GMFCS II GMFCSIII

GMFCS IV GMFCS V

Diagnosis of Cerebral Palsy

Confirm GMFCS level and review at defined age bandings

Standardisedclinical examination

X-ray protocol Data Entry secure server – Reportsgenerated

Locally agreed pathway for ongoing management of hipdisplacement and musculoskeletal system

Families, Orthopaedic Surgeons, Physiotherapist,Paediatricians Neurologists



GMFCS I

Discuss Hip Surveillance with family

Standardised clinical examination

X-ray protocolData Entry secure server –

Reports generated

Locally agreed pathway for ongoing management of hip displacement and musculoskeletal system

Families, Orthopaedic Surgeons, Physiotherapist, Paediatricians Neurologists

GMFCS II GMFCS III

GMFCS IV GMFCS V


With family


GMFCS IV GMFCS V








With family


GMFCS IV GMFCS V








With family


GMFCS IV GMFCS V








With family


GMFCS IV GMFCS V







CPIPS Flowchart

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Age 16Final Hip

X-ray

CPIPS Clinic

Every year

Diagnosis of CP from 2 years old

Older child presenting

with CP

2 years old

CPIPS Clinic

Every 6 months

Hip X-ray

Further X-rays

depending on severity

6 years old

CPIPS Clinical Measure

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4 5 6 7 8 9 10 11 12 13 14 15 16III

IVV

All children get a pelic x-ray at two years, six years and at 16 years old before transition.

Green annual x-ray Grey x-ray as necessary Yellow no x-ray

X-ray Protocol

Standardised radiographic positioning

1. Legs parallel, patellae facing upwards.

2. Pelvis flat, lordosis reduced.

Hilgenreiner’s line ’H’ = a horizontal line joining the triradiate cartilages.

Perkins line ‘P’ = a perpendicular to Hilgenreiner’s line drawn at the lateral margin of the bony acetabulum.

Migration Percentage (MP)

The MP is the proportion of ossified femoral head lateral to Perkin’s line = A/B x 100.

P

HA1

MP

BA

Incorrect – lordotic lumbar spine

Correct – flat

Pelvis horizontal

Patellae facing upwards

Neutral adduction/ abduction

1. 2.

Additional measure 2016Head Shaft Angle (HSA)

Head-shaft angle is a risk factor for hip displacement in children with cerebral palsyHermanson M,Hagglund G,Riad J, Wagner P,. Acta Orthopaedica 2015; 229-232

The prognostic value of the head-shaft angle on hip displacement in children with cerebral palsyJ.P.J. van der List, M.M Witbrevick, A.I. Buizer, J.A. van der Sluijs

JChildOrthop,2015Apr 9(2) 129-135

"The HSA is measured by drawing a line midway through the femoral shaft and then drawing another line perpendicular to the proximal femoral physis through the center of the proximal femoral epiphysis. It has been shown to be predictive of hip displacement in children with cerebral palsy."

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Rating 6

Independent on all surfaces:

Does not use any walking aids or need any help from another person when walking over all surfaces including uneven ground, curbs et, and in a crowded environment.

Rating 5

Independent on level surfaces:

Does not use walking aids or need help from another person. *Requires a rail for stairs.

* If uses furniture, walls,fences, shop fronts for support,please use 4 as appropriatedescription.

Rating 4

Uses sticks (one or two):


Rating 3

Uses crutches:


Rating 1

Uses wheelchair:

May stand for transfers, may do some stepping supported by another person or using a walker / frame.

Rating 2

Uses a walker or frame:


Rating C

Crawling:

Child crawls for mobility at home (5m).

Rating N

N = does not apply:

For example, child does not complete the distance (500m).

Walking distance

Rating: select the number (from 1-6) which best describes current function

5 metres (yards)

50 metres (yards)

500 metres (yards)


1. How does your child move around for short distances in the house?(5m)2. How does your child move around in and between classes at school?(50m)3. How does your child move around or long distances such as at the shoppingcentre? (500m)The distances are a guide. It is the environment that is most relevant.

QualifiersThe difference between 1–4 is self-explanatory, however the difference between 5 and 6 is less clear.

5 metres: children who require a rail for stairs would be rated as 5 and children who do not require a rail or help would be rated as 6.

50 metres: children who can walk on all surfaces including uneven surfaces and steps, particularly at school are rated as 6 and children that require help on these surfaces but can walk on level surfaces without help are rated as 5.

500 metres: children who can walk on all surfaces including rough ground, curbs, steps and in crowded environments in the community without help are rated as 6 and children who walk long distances only on level surfaces and have difficulty walking in crowds are rated 5

www.schn.health.nsw.gav.au/files/attachments/the_functional_mobility_scle_version_2pdf

QuestionsTo obtain answers that reflect performance,the manner in which the questions are asked of the child/parent is important.The questions used to obtain the appropriate responses are:


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30

Consent to participate in the Cerebral Palsy Integrated Pathway for Scotland

Name of child: ...................................................................................................................

Date of birth: (DD/MM/YY) ...............................................................

For office use

I confirm that I consent to my child being included in CPIPS programme.

I understand that all data will be stored securely in an NHS database.

I understand anonymised data will be used for audit and research purposes.

Signature: ................................................... Date: .........................................................

Name: ........................................................ Relationship to patient: ..............................

Consent

The healthcare professionals involved in your child’s care will be pleased to discuss any aspect of the CPIPS programme with you.

Please complete the consent section below to confirm you are willing to participate:

Copy to be retained by parents/guardians.

CPIPS PATIENT MANAGEMENT SYSTEM


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GMFCS 1-3 GMFCS 4-5 CLINICAL EXAM -Example

GMFCS 1-3


Physiotherapy, Orthosis, Activity

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Documents

Cerebral Palsy Integrated Pathway Scotland (CPIPS) · This collaboration resulted in the Cerebral Palsy Integrated Pathway Scotland (CPIPS) programme, supported financially by the