This document provides an overview of various classification systems used for cerebral palsy, including the Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS), Communication Function Classification System (CFCS), and Eating and Drinking Ability Classification System (EDACS). It describes what each system evaluates, such as gross motor skills, manual abilities, communication abilities, and eating/drinking abilities. The classifications aim to categorize individuals based on their functional abilities rather than impairments. They can help guide intervention planning, resource allocation, research, and understanding of medical needs variations across levels of ability.

1. 11/1/15
1
Clinical Classifications
for
Cerebral Palsy
Objectives
• CP-descriptors
• the context of the icf
• Classifications and relationships
• How this moves us forward together
Let’s start
• What do parent’s ask about?
• Diagnosis-what does my child have
• Function-what can my child do
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
Cerebral palsy clinical
discriptors
• Tone type-Spastic athetoid, dystonia
• Topography-diplegia, quadraplegia,
hemiplegia
• Severity-mild, moderate severeity
• Unreliable and many times parents
physcians team not in agreement
Clinical Description-Start
with
• Predominant tone abnormaity
• Most children will have spasticity
• Many have mixed tone disorders

2. 11/1/15
2
Topography
• Hemiplegia
• Diplegia
• Quadraplegia
• triplegia
Cerebral
Palsy
Spastic Dyskinetic Ataxic
Bilateral Unilateral Hypokinetic Hyperkinetic
Diplegic
Quadriplegic
Triplegic
Hemiplegic Dystonic Choreoathetosis
Dyskinetic: involuntary movement disorder
with varying tone
Mixed CP: combination of subtypes
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
nonprogressive 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)
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
New/WHO/ICF
Health Condition
(disorder or disease)
Body Functions &
Structures
Activities Participation
Environmental
Factors Personal Factors
Interactions between components of the ICF

3. 11/1/15
3
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.
GMFCS
• Reliable mthod of classifying based
on funciton
• Inherent meaning to families-
therapists-phsyicans
• Usual preformance
Gross Motor Curves and
GMFCS
90% of final GMF achieved
FUNCTIONAL
CLASSIFICATION OF CP
• GMFCS
• Stratification according to functional level
• Observed at ages 2-12
GMFCS E&R
GMFCS LEVELS
Level I: Walks without assistive
device indoors. Climbs stairs
without limitation. Able to run and
jump. Impaired speed, balance,
coordination.

4. 11/1/15
4
DIAGNOSIS? 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
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.
DIAGNOSIS? GMFCS LEVELS
Level IV: Walks for short distances
on a walker. Wheeled mobility for
outdoors, school and community.

5. 11/1/15
5
DIAGNOSIS? GMFCS LEVELS
Level V: All areas of motor function
are limited. No independent
mobility even with assistive
technology.
DIAGNOSIS? Functional Mobility Scale
• Exercise
• Household
• Community
Manual Ability
Classification
• Fine motor • Arm placement
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

6. 11/1/15
6
Eliasson et al. 2006
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
MACS
MAC 2 MAC 3
GMFCS does not predict
MACS
Distribution does not
predict hand function
Communication Functional
Classification
Oral motor task Cognitive task

7. 11/1/15
7
Cooley Hidecker et al., 2009
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.
Why
are
they
important
§
Meant
to
discriminate
and
categorize
rather
than
'assess’
(Damiano
et
al.,2006).
§ Easily
applied,
simple
and
quick
classifica=ons
which
may
be
performed
by
a
physical
therapist,
the
family
or
a
related
person,
and
provide
informa=on
about
the
func=onal
level
of
the
child
with
CP
(Morris
et
al.,
2004b;
Eliasson
et
al.,
2006,
Mutlu
et
al.,
2010).
§ Not
only
peer
outcome
measures,
but
they
also
may
fulfill
each
other
for
a
total
and
whole
classifica=on
of
children
with
CP
(Morris
et
al.,2006;
Kerem-­‐Gunel
et
al.,
2009).
§ Universal,
translated
and
studied
on
many
different
languages
(www.canchild.ca)
Gait Classifications
Koman et al. 1994
Physicians Rating Scale Oral motor-Eating

8. 11/1/15
8
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 easts safely-G tube
EADCS
• 1-E /D safely
• 2-E/D safely but with some
limitation to efficiency
• 3-E/D limitations to safety and
efficiency
• 4-E/D signimifacnt safety
• 5-unable to eat or drink-
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.
ICF
Environmental
Factors
Personal
Factors
Body
func=on&structure
(Impairment)
Muscle
strength
(muscle
test,
dynamometer)
Spas9city(M.Ashworth,
Tardieu)
ROM(Goniometry
)
Selec9ve
motor
control
(SCALE-­‐TASC
Tests
)Percep9on,
cogni9on
Postural
problems
Ac=vity
(Limita9on)
GMFCS,FMS
MACS
,
CFCS,EADSC,
RS.
Par=cipa=on
(Restric9on)
Daily
Living
ac;vi;es,
Social
roles
in
community
(children,
student,
friends,etc.)
WeeFIM
PEDI
etc.
Classifica=on
Systems
§ GMFCS-­‐
E&R
(includes
12-­‐18
years)
§ MACS
(both
hands
manual
ability)
§ CFCS
(Communica=on
Func=on
Classifica=on
System)
§ Ea9ng
and
Drinking
newly
added
§ Gait
classifica9on-­‐PRS

9. 11/1/15
9
Optimizes Management
• Sharpens aligns focus on function
versus impairments
• more useful than severity, type and
distribution
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
Facilitates Caseloads
• Should there be GMFCS specialists?
• Resource allocations for social
leisure and educational support
Therapy interventions
• secondary impairments vary with
GMFCS level
• Endurance, fatigue, weakness –can
target better interventions for
groups
• Supports evidence based research
Variations in medical and
surgical needs
Hip pathology increases with GMFCS
level
Use of G tube and co morbidities
increase with GMFCS levels