This document discusses updated clinical classifications for cerebral palsy. It begins by defining cerebral palsy and describing the typical classifications based on tone, topography, and motor involvement. It then introduces newer classification systems like the Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) which focus on functional ability rather than impairments. These systems aim to provide a common language for clinicians, researchers, and families to describe what individuals with CP can do, not just what body structures are involved. The classifications systems can help guide treatment planning and set realistic functional goals.

1. UPDATE-CLINICAL
CLASSIFICATIONS FOR
CEREBRAL PALSY Deborah Gaebler-Spira
XIII International ORITEL Conference
Foundational and First General Assembly
of the Latin American Academy on Child
Development and Disability

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REHABILITATION INSTITUTE OF CHICAGO
2

3. OBJECTIVES
 CP - descriptors
 The context of the ICF
 Classifications and relationships
 How this moves us forward together

4. LET’S START
 What do parents ask about?
• Diagnosis - what does my child have?
• Function - what can my child do?

5. CEREBRAL PALSY-
DEFINITION-BAX-2001
 Disorder of movement and posture resulting from a
condition of non-progressive brain damage that occurred
in infancy
 Abnormality of tone
 Inclusive-many etiologies
 Brain lesion is static-musculoskeletal system changes

6. CLINICAL DESCRIPTION-START WITH
 Predominant tone abnormality
 Most children will have spasticity
 Many have mixed tone disorders

8. Dyskinetic: involuntary movement disorder
with varying tone
Mixed CP: combination of subtypes
Cerebral
Palsy
Spastic Dyskinetic Ataxic
Bilateral Unilateral Hypokinetic Hyperkinetic
Diplegic
Quadriplegic
Triplegic
Hemiplegic Dystonic Choreoathetosis

9. TOPOGRAPHY
 Hemiplegia
 Diplegia
 Quadraplegia
 Triplegia

10. DEFINITION OF CEREBRAL PALSY
 Cerebral palsy (CP) describes a group of permanent
disorders of the development of movement and posture,
causing activity limitation, that are attributed to non-
progressive disturbances that occurred in the developing
fetal or infant brain.
 The motor disorders of cerebral palsy are often
accompanied by disturbances of sensation, perception,
cognition, communication, and behavior, by epilepsy,
and by secondary musculoskeletal problems.
Rosenbaum, et al. (2007)

11. HOW THAT CHANGES THE PERSPECTIVE
 Creates an emphasis on activities, not just
impairments
 Creates the inclusion of sensory abnormalities
 Attributes co-morbidities as important factors in
prognosis

12. NEW/WHO/ICF
Health Condition
(disorder or disease)
Body Functions &
Structures
Activities Participation
Environmental
Factors
Personal Factors
Interactions between components of the ICF

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GMFC-GROSS MOTOR FUNCTION CLASSIFICATION

14. GMFCS
 The Gross Motor Classification System
 Developed to classify severity of functional
limitation/disability in children with cerebral palsy.
 Ages birth to 12 years
 Not to be used as a diagnostic tool- describes gross motor
function with an emphasis on movement initiation, sitting
control and walking.

15. GMFCS
 Reliable method of classifying based on function
 Inherent meaning to families-therapists-physicans
 Usual performance

16. FUNCTIONAL CLASSIFICATION OF CP
GMFCS
 Stratification according to functional level
 Observed at ages 2-12

17. GMFCS E&R

18. GMFCS LEVELS
Level I: Walks without assistive
device indoors. Climbs stairs
without limitation. Able to run
and jump. Impaired speed,
balance, coordination.

19. GMFCS LEVELS
Level II: Children walk indoors
and climb stairs holding onto
railing. Difficulty with walking
on uneven surfaces and
inclines or within crowds or
confined spaces.

20. GMFCS LEVELS
Level III: Walks with assistive
mobility devices on level
surface. Limitations on uneven
surfaces or inclines. May
propel wheelchair manually.
May use wheelchair for long
distance transport.

21. GMFCS LEVELS
Level IV: Walks for short
distances on a walker.
Wheeled mobility for
outdoors, school and
community.

22. GMFCS LEVELS
Level V: All areas of motor
function are limited. No
independent mobility even
with assistive technology.

23. FUNCTIONAL MOBILITY SCALE
 Exercise
 Household
 Community

24. MACS-MANUAL ABILITY CLASSIFICATION
FINE MOTOR ARM PLACEMENT

25. MANUAL ABILITY CLASSIFICATION-MACS
 Children with cerebral palsy use their hands when
handling objects in daily activities
 Assesses typical, not optimal performance
 Ages 4-18 years

26. Eliasson et al. 2006

27. MACS
I. Handles objects easily and successfully
II. Handles most objects but with somewhat reduced quality and/or speed of
achievement
III. Handles objects with difficulty; needs help to prepare and/or modify activities. The
performance is slow and achieved with limited success regarding quality and quantity.
Activities are performed independently if they have been set up or adapted.
IV. Handles a limited selection of easily managed objects in adapted situations. Performs
parts of activities with effort and with limited success. Requires continuous support
and assistance and/or adapted equipment, for even partial achievement of the activity.
V. Does not handle objects and has severely limited ability to perform even simple
actions. Requires total assistance

28. GMFCS DOES NOT PREDICT MACS

29. Cooley Hidecker et al., 2009

30. VIKING SPEECH SCALE
 Speech is not affected by motor disorder.
 Speech is imprecise but usually understandable to unfamiliar listeners. Loudness of speech is
adequate for one to one
 Conversation. Voice may be breathy or harsh sounding but does not impair intelligibility.
Articulation is imprecise; most consonants are produced, but deterioration is noticeable in longer
utterances. Although difficulties are noticeable, speech is usually understandable to unfamiliar
listeners out of context.
 Speech is unclear and not usually understandable to unfamiliar listeners out of context. Difficulties
controlling breathing for speech – can produce one word per utterance and/or speech is
sometimes too loud or too quiet to be understood. Voice may be harsh sounding; pitch may
change suddenly. Speech may be markedly hyper nasal. A very small range of consonants are
produced. The severity of the difficulties makes the speech difficult to understand out of context.
 No understandable speech.

31. WHY ARE THEY IMPORTANT
 Meant to discriminate and categorize rather than 'assess’ (Damiano et
al.,2006)
 Easily applied, simple and quick classifications which may be performed by
a physical therapist, the family or a related person, and provide information
about the functional level of the child with CP (Morris et al., 2004b; Eliasson
et al., 2006, Mutlu et al., 2010)
 fulfill each other for a total and whole classification of children with CP
(Morris et al.,2006; Kerem-Gunel et al., 2009)
 Universal, translated and studied on many different languages
(www.canchild.ca)

32. EDACS
 I - Eats safely and efficiently
 II - Eats and drinks safely but have limitations to efficiency
 III - Eats and drinks safely but have limitations to efficiency
and safety
 IV - Eats and drinks with significant safety issues
 V - Unable to eat safely-G tube

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Is the individual
able to swallow
food and drink
without risk of
aspiration?Is the individual able
to bite and chew on
hard lumps of food
without a risk of
choking?
Is the individual
able to eat a meal
in the same time
as peers?
Level I
Eats and drinks
safely and
efficiently
Level IV
Eats and drinks with
significant
limitations to safety.
Level V
Unable to eat or
drink safely – tube
feeding may be
considered to
provide nutrition.
Can risks of
aspiration be
managed to
eliminate harm to
the individual?
No
Yes No
Yes No
Yes
Eating and Drinking Ability Classification System - Algorithm
Yes No
Level II
Eats and drinks
safely but with
some limitations
to efficiency.
Level III
Eats and drinks
with some
limitations to
safety; there maybe
limitations to
efficiency.

34. ICF
Environmental Factors Personal Factors
Body Function & Structure
(Impairment)
Muscle strength (muscle test,
dynamometer)
Spasticity(M.Ashworth, Tardieu)
ROM(Goniometry )
Selective motor control (SCALE-TASC
Tests )Perception, cognition
Postural problems
Activity
(Limitation)
GMFCS,FMS
MACS
,CFCS,EADSC,.
Participation
(Restriction)
Daily Living activities,
Social roles in
community (children,
student, friends,etc.)
WeeFIM
PEDI etc.

35. OPTIMIZES MANAGEMENT
 Sharpens aligns focus on function versus impairments
 More useful than severity, type and distribution

36. INTERVENTION PLANNING
 Assists with realistic goal therapy setting
 Children with GMFCS 3 –community wheelchair
 GMFCS 3,4-use walker part time
 GMFCS 5 limited self mobility

37. GROSS MOTOR CURVES AND GMFCS
90% of final GMF achieved

38. THERAPY INTERVENTIONS
 Secondary impairments vary with GMFCS level
 Endurance, fatigue, weakness –can target better
interventions for groups
 Supports evidence based research

39. VARIATIONS IN MEDICAL AND SURGICAL NEEDS
Hip pathology increases with GMFCS level
Use of G-tube and co-morbidities increase with GMFCS
levels

40. IN A VARIABLE DISORDER-ALLOWS-CLINICIANS-
PARENTS
 Common language
 Common groupings
 Common Goals