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Cerebral Palsy Description Form Part I: Motor Impairments

This document contains a cerebral palsy description form with sections on motor impairments and function/associated impairments. Section I addresses spasticity, muscle tone, ataxia, dystonia, athetoid/choreoform movements, and general hypotonia. Section II covers gross motor function classification, manual ability classification, and other impairments such as intellectual disability, epilepsy, visual, hearing, speech, and swallowing difficulties. The form is used to describe a child's cerebral palsy type and severity for medical records.

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191 views2 pages

Cerebral Palsy Description Form Part I: Motor Impairments

This document contains a cerebral palsy description form with sections on motor impairments and function/associated impairments. Section I addresses spasticity, muscle tone, ataxia, dystonia, athetoid/choreoform movements, and general hypotonia. Section II covers gross motor function classification, manual ability classification, and other impairments such as intellectual disability, epilepsy, visual, hearing, speech, and swallowing difficulties. The form is used to describe a child's cerebral palsy type and severity for medical records.

Uploaded by

navuru5k
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CEREBRAL PALSY DESCRIPTION FORM Part I: MOTOR IMPAIRMENTS

Child’s name: Please attach sticky label if available DOB: Examining clinician: Date:

1. Is there spasticity in one or more limbs? 2. Describe face/ 3. Is muscle tone varying? 4. Is ataxia present?
neck/trunk tone

Please tick Yes No Yes


Yes / No Yes No No
boxes as
appropriate
Is there
Athetosis generalised
Dystonia and/or Chorea hypotonia
with
increased
reflexes?

Yes No

R L R L R L Please number tone/


movement abnormalities
Stick Figure 2
present in this child in order
of predominance
(1 = most predominant or
only abnormality)
Stick Figure 1 Go to 2 Go to 3 Stick Figure 3a Stick Figure 3b Spasticity

Dystonia
Instructions for completing Stick figures 1 and 2 above: Go to 4
Athetosis
Limb muscle tone: Face/neck/trunk muscle tone:
Instructions for completing Chorea
Enter: Highest Australian Enter: = Hypotonic
Stick figures 3a and 3b above:
Spasticity Assessment = Hypertonic Ataxia
Scale score in that limb = Fluctuating Please tick triangles Generalised
(PTO for scoring criteria) N = Normal where signs are present. Hypotonia

Please describe CP type and severity in words as you would write in the medical record:
PTO
Form designed for the Australian Cerebral Palsy Register: April 2013

Please explain this form to parents if there is interest and opportunity. It will be useful to retain a copy for your records. Please forward to the address overleaf.
Australian Spasticity Assessment Scale (ASAS)
Love SC, Gibson N, Blair E

0 No catch on rapid passive movement (RPM) (no spasticity).


1 Catch on RPM followed by release. There is no resistance to RPM throughout rest of range.
2 Catch occurs in second half of available range (after halfway point) during RPM and is
followed by resistance throughout remaining range.
3 Catch occurs in first half of available range (up to and including the halfway point) during
RPM and is followed by resistance throughout remaining range.
4 When attempting RPM, the body part appears fixed but moves on slow passive movement.

NB Contractures do not need to be recorded on this form.

Part II: FUNCTION AND ASSOCIATED IMPAIRMENTS

Please indicate Gross Motor Function Classification System E&R level (Palisano et al, 2007):

GMFCS: Level I Level II Level III Level IV Level V

Please indicate Manual Ability Classification System level (Eliasson et al, 2006):

MACS: Level I Level II Level III Level IV Level V

Please indicate associated impairments present in this child:

Intellectual: IQ / DQ or severity range


Normal Method of assessment / Date assessed
Comments

Epilepsy: Previously, but now resolved


None Seizure type(s) if current
Age at onset

Visual: Some impairment


Normal Bilateral blindness
Strabismus
Uncertain

Hearing: Some impairment


Normal Bilateral deafness
Uncertain

Speech: Some impairment


Normal Non-verbal
Uncertain

Swallowing: Modifications required (eg, special spoon, food thickening)


Normal Non-oral feeding
Uncertain

Please forward to: Western Australian Register of Developmental Anomalies - CP


PTO
King Edward Memorial Hospital, PO Box 134, Subiaco WA 6904

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