CPNUES Upper Extremity Evaluation Summary and Special Tests

The pre-surgical evaluation of the upper extremity affected by cerebral palsy is a challenging and complex undertaking. The individual's diagnosis, tone type, concurrent issues and goals are only some of the diagnostic factors needing to be considered. Both neurological and orthopedic factors must then be  evaluated. The following is a summary of our intake evaluation with expanded descriptions of special tests. Our team has found all the following information to be important to the assessment process.

Before beginning the evaluation, make certain that there is wheelchair accessible space, a wheelchair or child's height table and seating for a parent or guardian to attend. Both hand and pediatric therapy clinics may need to find a less busy time or a free private room to avoid distraction for the patient. We advocate videotape and often see the patients on more than one occasion as neuromotor tone can fluctuate with fatigue, mood and apprehension. We hope that this evaluation will assist in guiding clinical decision making in your setting.

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I. General Information

History: Medical and birth history, surgeries, current therapy regimen, medications. Include other treatment such as Botox and splinting.

Concurrent Findings: Cognitive status, type of classroom, other diagnoses or conditions such as seizures or vision impairment.

Involvement Type: Our team considers primary diagnosis and underlying factors in a tiered approach. Remember to consider all of the following.

Hemiplegia	Spasticity	Flaccidity
Diplegia	Athetosis	Rigidity
Quadraplegia	Mixed Tone

          Sensory Status: 

Stereognosis: The items described by Van Heest et al1 . Poor stereognosis does not preclude surgery. If the patient makes attempts to use the extremity, then surgery may still be advised. Goals may be modified depending on how able the patient is to use vision and other strategies to compensate for lack of discriminative sensation.

Neglect: Discern true neglect from preferred one handed techniques by presenting tasks that require two hands, not just those that are typically bimanual. Try handing the patient a large light object (ie a cafeteria tray with a non breakable item it) or ask the patient to open a grip size jar with the cue "pretend the jar is dirty and you don't want to hold it against your shirt". Asking the patient "Do you use your arm/hand?" is not adequate. Many hemiplegic patients will say "no" and are really describing their preferred use of efficient one-handed techniques.

II. Musculoskeletal Evaluation:.

Active and Passive Range of Motion: The musculoskeletal evaluation requires an expanded range of motion assessment which includes traditional passive and active range of motion of the upper extremity and the additional concepts of position at rest and the position of the extremity during associated reactions.

Position at Rest: This is the position the patient assumes while sitting at rest.

Postion with Associated Reactions. It is important know how the involved side postures during activity because associated reactions are a common complaint and can be a functional limitation. Test this area by either having the patient walk fast, perform rapid in-hand manipulation with the non involved hand or take the non involved arm and perform a rapid alternating movement for 30 seconds such as "touch you head and then your knee". Watch to see the postural angle of the involved elbow, wrist and hand to get the Associated ROM value.

Muscle Testing: Along with these varied range of motion assessments, modified muscle tests are required at specific muscles commonly impacted by reconstruction. Most patients require testing and grading elbow extension, pronation, supination, FCU, FCR, wrist extension and EPL. The tests are considered modified because in testing strength, neuromotor tone and spasticity may be recruited. The goal of the modified isolated tests is to discern if the patient can actively fire the suggested muscles. The grade is a measure of the patients' ability to activate motion and may be helpful to the surgeon in choosing to perform certain procedures. Other patients that are being considered for less common procedures may require other functional or manual muscle tests

Special Tests2: The special tests incorporate findings of range of motion combined with active motor control. Assessing patients with cerebral palsy may prompt questions such as: Is wrist flexion due to tight wrist and digital flexors or weak wrist extensors? If the wrist is neutral what happens to active finger use? How does tone impact active control? The special tests, combined with the range of motion findings, are designed to assist in answering these types of questions. The tests begin proximally with the wrist and progress distally.

Wrist: -

Volkman's Angle is measured by passively opening and holding the fingers fully extended with the wrist resting in flexion. Gradually bring the wrist up passively towards extension. When the fingers begin to curl down due to tightness in the long flexors look at the angle of the wrist. The wrist angle is "Volkman's Angle".

Fingers flexed due to tightness Too much wrist extension.	0° Volkman's angle with digits extended to full.  Proper way.

DEN Test: Active digit extension with wrist neutral passively. Can the patient actively open the fingers while the wrist is held in neutral? Yes, no or partial.

Actice digit extension with wrist held in neutral.  "Yes" DEN test.

ACE Test: Active Composite Extension. The maximum angle of active wrist extension with active digit extension. Verbally cue the patient to open the fingers and bring the wrist up best as they can.

30° Ace Test

Digits: - 

Swan-Neck: Does the pt have arching at the IP (interphalangeal) joint greater than 10°?

Small finger swan neck

Thumb: 

Radial web is the web to the side. Measure the active and passive web. For the box labeled "radial plane" measure in degrees (to the nearest 10) how far below the plane of the hand the thumb is during the active radial web. Cue the patient by demonstrating the web to the side.

50° radial web	0° or pure radial plane	-30° radial plane

Palmar web is the down web or web perpendicular to the palm. Measure it actively and passively. Cue the patient to bring thumb down from the palm and demonstrate it.

70° palmer web

Thumb at Rest: At rest is the thumb out to the side slightly (WNL), even with the index (even), adducted in the pal (add) or bent tightly at the MP (FPB)? 

Thumb in Fist: When pt is cued to make a fist, does the thumb go into the palm?

MP Instability: Does the thumb MP (big joint of the thumb) arch into the palm? "Minimal" is if it arches in with passive slight pressure. "Moderate" is if it arches with active use. Significant is arching is over 25°.

Significant MP instability

Functional Evaluation: 

Range of motion and special tests provide important neuromotor information, but actual tasks integrate biomechanical findings, tone, synergies and strategies into an actual patient presentation. For example, a patient may be able to actively extend their wrist on command in isolation, but during a task when using other muscles, may revert to wrist flexion. Functional tasks, which we videotape, are included in our evaluation for this reason. We include The Jebson Taylor Test of Hand Function3 as our sample tasks. Our intake also includes a self/parent report adl survey.

This patient is able to extend his wrist, but does not use extension in tasks.

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III. Decision Making

Goals: Goal categories include hygiene, asthetic or functional concerns. Goal development can assist planning and may uncover unattainable patient and family expectations. In our clinic, the three goal categories are described and all patients are asked to pick a specific goal. If a severely involved patient wants to self button or a patient with hemiplegia desires to have the involved hand as the dominant writing hand, the clinician can guide the patient to goals that are more appropriate. It is important that a patient and their family have appropriate goals and expectations.

Team Approach: Lastly, we strongly advocate using a team approach of the surgeon, therapist and patient/family. The amount of information gathered is large, complex and interrelated. A therapist may have more time with a patient, and therefore get a more accurate presentation. A surgeon may have the skills to best interpret the complex findings of the tests. The family may be able to say, "Today is a more tight day" or "Yes, that is typical". With a team approach, the evaluation becomes easier to interpret and will be more accurate.

Summary: Background: Accessible environment, increased time allowed, videotaping, team approach Concurrent Descriptives: Cognition, sensory status, typical history, neglect Diagnostic Information: Location and type of involvement Musculoskeletal: Position @ rest, PROM, AROM, associated reactions, selected muscle tests. Special Tests: Volkman's, DEN, ACE, Web, Swan, Thumb MP 

Functional: Standardized tasks and scales 

Goals: Hygiene, Asthetic, Functional

1. Jebson R, Taylor N, Treischmann R, Trotter M, Howard L: An Objective Standardized Test for Hand Function. Arch Phys Med and Rehab. 1969. v 50 p311-315.

2. Brooks C, Carlson M. An Expanded Assessment of the Upper Extremity Involved by Cerebral Palsy. Submitted for publication May 2001.

3. Waters P, Van Heest A.( 1998) Spastic hemiplegia of the upper extremity in children. Hand Clinics 14(1):119-134.