Virtual Clinical Examination on IPP cerebral Palsy patient. IPP Videos of patient & multiple clinical test to evaluate CP.

1. Virtual Clinical
Examnination:
IPP-Cerebral Palsy
(long case)
Prof. Anisuddin Bhatti
Dr. Ziauddin University
Hospital,
Clifton, Karachi.
Secretary,
Orthopaedic Faculty,
CPSP.

2. Virtual Clinical Examination: (VCE)
• A Virtual Patients (VPs) in clinical examinations
instead of real patients.
• A Computer-based programs with a VPs that simulate
real-life clinical scenarios.
• Requires a linear dialogue between examiner and
examinee, for which VPs need to be adapted
accordingly.
Harless et al 1971 & Cook et al, 2010.

3. Virtual Clinical Examination
• Provides an Interactive role to the examinee, as opposed
to passively watching videos/ visuals and answering
written or oral questions.
• Examinee is required to interact with the examiner by
posing and answering questions regarding evolving
condition of the V. patient presented.
(Huang G, Reynolds R, Candler C).

4. Interactive Paper Patients (IPPs)
• The simulator, computer-based photo, video or scenario used in VCE is
referred as an IPP.
• IPP is presented phase wise to allow an interactive dialogue
between Examinee with examiner
• IPPs has been extensively used for the Cognitive Assessment in:
o Modified Essay Questions (MEQs)
o Task Oriented Assessment of Clinical Skill (TOACS)
o Objective Structured Assessment of Technical Skills (OSATS)
o Patient Management Problems (PMPs)
o Workplace Based Assessment (WPBA):
Mini-CEX & Direct observation of procedural skills (DOPS).
o Virtual Clinical examination (VCE)
(Huang G, Reynolds R, Candler C).

5. VCE Process
• IPPs reveal patient condition and workup phase-wise.
• Examiner poses questions to the examinee after
description of each phase.
• Student ask additional questions about patient condition,
investigation or response to therapy.
• Examiner responds verbally or furnishes Laboratory
reports / Imaging films.
• Answers are scored phase-wise on a key.

6. Long case: KEY - CONNTEMPORARY
Answers are scored phase-wise on a key.
Excellent, Good, Adequate, Inadequate, Poor
Examiner 1: [both examiners R Silent Observer]
A. History Taking & Examination: Examinee’s attitude, behavior,
communication skill, clinical examination skill.
B. Presentation skill: Correct history, relevant exam findings, Positive /
negative findings.
C. Order relevant Investigation & justify. He shall be shown that report ,
Xray, MRI, CT etc
D. Differential Diagnosis & confirmation of diagnosis most suitable.
Examiner 2:
A. Management plan. Discussion: What, How, When & When not.
B. Complications. Why & how to manage
C. Recent advances.

7. Long case: KEY – Virtual Examination
Answers are scored phase-wise on a key.
Excellent, Good, Adequate, Inadequate, Poor
Examiner 1: [one examiner may act as simulator – IPP]
A. Examiner presents: Short history with Picture, video, Scenario.
Student advised to ask additional question from examiner.
A. Examiner poses questions to the student after description of each phase.
B. Student be advised to ask further questions and asked for relevant
investigation & justify. What U want to evaluate with that investigation.
He shall be shown that Lab. report , Xray, MRI, CT etc
A. Differential Diagnosis & confirmation of diagnosis most suitable.
Examiner 2:
A. Management plan. Interactive Discussion: What, How, When & When not.
B. Complications. Why & how to manage
C. Recent advances.

8. VCE:
Case Example
Long case:
Cerebral Palsy

9. Plz look at these Pictures:
A 9-year old boy presented with tip toe walking since age 2
years and having difficulty in walking for the last 3 years. He
is able to sit at ease. Very enthusiastic & cooperative.
Q.1. U may ask few
question for patient
condition?

10. Q.1. Key
1. Birth history: Liquor aspiration - Birth Asphyxia. Delayed
milestones for one year. mentally alert, Intelligent, he study in
class 3.
2. Development history: Walked independently for 6 years,
deteriorated with difficulty in walking, for the last 3 years. He
manage his daily accustomed habits independently.
3. He is an independent walker, sometimes need support, when
outside [functional walker].

11. Q.2. How
would you
proceed to
reach
diagnosis in
your mind ?

12. Q.2. Key
Exmine to
1.Asses his Gait, Posture, walking ability
2.Perform multiple clinical test to look for spasticity,
hyperreflaxia, Contractures: static & dynamic.

13. Okay. Plz. Look at his Gait &
Posture again.
Q.3. What type of gait is this?
Q.4. What type of walker he is?
Let him speak freely to justify

14. Q.3a. Key.
• Spastic Diplegic
• Jump gait [Unstable]
• Decompensated with Pes
Plano-Valgus.. A Danger sign.

15. Q.3b. Key. Interactive discussion continued
GAIT PATTERNS
• Different Gait patterns observed in CP depends on the
involvement of spasticity or contracture of different muscles:
• Variations relates to topographical type of CP { Hemiplegia,
Diplegia, monoplegia. With or without Ataxia etc}.
• Best seen in contrast between unilateral spastic CP and bilateral
spastic CP.

16. Q.3c. Key. Spastic Diplegia Gaits:
Four common patterns of gait in spastic Diplegia.
[Rodda et al.]
• Type 1 – True equinus
• Type 2 – Jump gait
• Type 3 – Apparent equinus
• Type 4 – Crouch gait

17. Q.3c.
Rodda et al. JBJS. 2004

18. Q.4. Key: Waking Pattern
Assessment to Qualify as walker can be made best after the age 7 years. Till than
brain maturation reach to a plateau.
TYPES OF WALKING:
• Walker: when child could walk a minimum of 15 meters without
falling. [Independent walker]
• Functional Walker: when a child could walk only with crutches
[Community walker].
• Non-Walker: when child could walk with aid of mobility device
or only in parallel bars

19. Q.5.How would you proceed
further to reach definite
diagnosis and plan treatment?

20. Q.5. Key: Clinical examination
Detailed clinical Examination. Examiner interact here.
1. In systemic examination he has no significant abnormality.
Plz Proceed
2. Focused Neuro - MSK examination: to terform certain clinical
test to evaluate for spasticity & contractures: Dynamic & satatic.
3. Examiner asks to name such test (?/9 tests).
4. Plz perform ?? Test on examiner 1 OR he just ask how to do and
what are pre-Requisites of that test. OR He may show U test in
video and ask you few question to know ur knowledge & skill.

21. Clinical Evaluation: Tests
Q.6. Which test is
this?
Q.7. What are the
Findings?
Q.8. Is there any flaw
while performing this
test.

22. Q.6,7,8 Key
Q.6. Thomas test… for Hip Flexion contracture. FFC
Q.7. Knee cntracture & Hamstring spasticity
Q.8. Flaws: Pillow & Soft bed. Modified Thomas at
edge of bed to exclude Knee contracture. Not
done
Speaking on Flaws test your knowledge & Skill.

23. Thomas Test- Modified:
to exclude Knee Contracture, avoid flaw

24. Staheli’s Hip Flexors Stretch test: Hip FFD
• More accurate for FFD hip
• Prone position
• Pelvis over table edge
Thomas test
Staheli’s

25. Q.9. Which tests R this.
What R the
Findings.
Any Flaw in
performing
tests?

26. Q.9. Key
9.A. Combined Abduction test. 700 . Adductors contracture
bilateral.
Flaw: Not significant. Individual side may b done.
9.B. Pop Angle test. +900 . Significant Hamstring contracture /
Spasticity.
Flaw: not significant
9.C. Silverskiold test. Negative. Combined Gastro-Solus
contracture.

27. Adductor Longus Stretch Test
• Hip abduction angle in Knee extension & flexion
When measurements are same: Adductors tight. Why?
• Hip abduction improves on Knee flexion: Gracilis tight
Same angle
Adductors tight
Abduction
improved
Gracilis is tight

28. Gracilis spasticity – Phelp’s Test
• Passive abduction with knee in extension.
• Improved hip abduction with knee flexion indicates
Gracilis / medial hamstring tightness. Why?

29. Popliteal Angle: Normal ranges in Children. Discussion
• 1-3 yrs mean angle 60 [00-150]
• @ 4 yrs mean angle 170 in girls, 270 in boys [50-450].
• >5 yrs mean angle 260 little change [0-50]
• PoP angle of >500 in above age groups indicate abnormal
hamstring tightness.
Katz, Kalman. University Telaviv Israel. J Ped ortho 1992. 12:229-231

30. POP Angle: Hamstring Stretch Test: Discussion
• Hip flexed to 900 & knee
extend
• Measure Popliteal angle
900 flexion to 00 extension
• Hamstring Shift:
Difference b/t Rt & Lt
measurements
00
900
500
RtLt

31. Achilles Stretch Test: Discussion
Silverskiold test- Gastroc. vs Soleus
“Spastic Gastrocnemius contracture”
Correction of ankle
equinus with
Knee flexion indicates
Predominantly
gastrocnemius
Contracture. Why?

32. Q.10. Which tests are being performed
What R Findings?
What is wrong in
performing these
tests ?

33. Q.10.a. Key
10.A. Rectus Strech test: Aly Duncan test.
Pelvis rise on knee flexion.
10.B. Hip Rotation test: Anteversion

34. 10.b. Key
Craig Test: FAV: Trochanteric Prominence Test
• Prone position and knee at 90°
flexion.
• Angle between the vertical line
and long axis of the leg at the
greatest prominence of the
greater trochanter palpated
laterally measures the amount
of FAV.
In recent studies, it has been found that trochanteric prominence test in combination
with hip internal rotation, X-rays is a better predictor of FAV and neck-shaft angle as
compared with computed tomography.

35. Q.11. Any additional
Clinical tests U Know.
Just name that?

36. 11.a. Key. Rotational Malalignment/s
• Foot propagation
angle
• Tibial rotation
Foot – Thigh Angle

37. Q.11.b. Tibial torsion mal-alignment
Thigh foot Angle
• Prone position, knee in 90°
flexion, and neutral ankle
and hind foot position.
• Angle between the thigh
axis and foot axis (axis
between the 2nd and
3rd metatarsals) gives Tibial
torsional measurement

38. Differential diagnosis.
• Q.12. In what pathological status this clinical
condition occurs?
• Q.13 How would you confirm your best possible
diagnosis?

39. 12, 13. Key
12. Cerebarl Palsy,
Spinal Dysraphysm,
Fredrix Ataxia &
Cerebral demyelination syndrome.
13. Detailed Birth history, Clinical examination, Observational gait
analysis, Video assisted observational gait analysis & Advanced
Imaging.
Use Algorythm: Diagnostic Matrix

41. Q.14. How can you classify his
functional disability ?
Q.15. In which functional
disability class (level) he fits &
Justify?
Let him speak freely to justify

42. 14.a. Key: Gross Motor Function Assesment
GMFCS

43. GROSS
MOTOR
FUNCTION
CLINICAL
SCORE:
LEVELS
14.b Key:

44. Q.15. Is there any
Advance Clinical or
laboratory tests
available to check CP
Patients Motor
functions & disabilty?

45. 15.a. key Advanced tests
• Foot propagation angle
• Observational Gait Analysis & Video Assisted OGA
• Videographic Gait analysis:
Gait Laboratory test: Computer base gait and indiviual muscle
functions programme, that include:
oEMG Muscle charting.
o3D camera gait analysis.
oFoot pressure Pedography.

46. 15.b. Advanced tests:
Repeated examination &
careful analysis of the gait [VAOGA/
Gait laboratory] & posture
and recognition of potential skeletal
changes lead to better judgment
to correct or prevent structural
changes reasonably early i.e before
15 (13) years. (Molnar-Gordon)
Gait Laboratory
Plays important
role in accurate
Judgment
Video Assisted
Observational
Gait Analysis

47. NED University Gait Laboratory:
Videographic gait analysis
Gait Lab test being performed on patients during CP workshop on
19 March 2011

48. Gait Laboratory:
PEDOGRAM: Cavovarus & Planovalgus
EMG: Indicating spastic, normal & Weak Muscles

49. Management Plan: 9 yr aged, boy, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Recall findings:
Examiner helps to recall
findings.
1. Functional walker
2. GMFC-2
3. Thomas’s FFC 15-200
4. Combined Abduction 700
5. Phelp’s positive
6. Pop angle +900
7. Silverskiold’s Negative [-150]
8. Pes-planovalgus
9. Ely’s Positive
10. Stable pelvis & Spine
11. Upper limb Normal
12. No neuro deficit

50. Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Q.16. What shall be
the objective to
treat him?
Q.17. How shall U
manage him?

51. 16. & 17 Key: management Plan
16. a. Help him to be an independent walker without
support.
b. prevent deterioration of pes planovalgus and
develop crouch gait
17. A. 3-4 weeks pre-operative rehabilitation training exercises /
physiotherapy & Occupational therapy.
B. Exclude structural abnormalities on X-ray.
C. Reconstructive surgery @ Knee & Ankle
C. Postoperative Rehabilitation programmes

52. Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Q.18. What shall be
contraindications other
than general well
being?
Q.19. Let us know Ur
plan of Reconstructive
surgery as u decided?
No need to go in
detailes of surgical
steps

53. 18 & 19. Key. Contra Indications & Recon Surgery
18. Reconstructive surgery is better in Spastic Cerebral palsy, best in
Hemiplegia than diplegia. Before embarking to surgery.
MUST MUST: Exclude Ataxia, chorioform movements & other
abnormal features of basal ganglia involvement.
19. A. Reconstructive surgery @ Knee & Ankle +/- Hip
Hamstring Fractional Lengthening, Keats transfer to adductor
tubercle, TAL, 1/2 Tibialis Anterior Transfer to neck of talus.
[+/- Adductor Myotomy without Neurectomy]
19.B. Postoperative Rehabilitation programmes
Quad strengthening and Gluteal Muscle development excercises.

54. Management Plan: 9 yr aged, CP child, Diplegic,
Mentally alert, cooperative & enthusiastic for Rx
Q.20. Describe
postoperative
care?
Let him speak freely

55. 20. Key. Rehabilitation Programme.
Rehab programme
• Hospital & home bases exercises
• Muscle streghening execrcise
• Occupational therapy
Bracings – Temporary addjuncts
• AFO
• KFO

58. References
• VCE Guidelines Designed by:
DR. Sirajul Haque Shaikh, Director DME. CPSP, Karachi.
• References:
1. Harless et al 1971
2. Cook et al, 2010.
3. Huang G, Reynolds R, Candler C.
• Clinical Material:
Prof. Anisuddin Bhatti’s collection
• Videos Prepared @ DZUH Clifton, Karachi
Assisted by: Dr. Sadam Mazar Baloch & Dr. Nida Hameed