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

REHABILITATION INSTITUTE OF CHICAGO

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

LETS START
What do parents ask about?
Diagnosis - what does my child have?
Function - what can my child do?

CEREBRAL PALSYDEFINITION-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

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CLINICAL DESCRIPTION-START WITH

Predominant tone abnormality
Most children will have spasticity
Many have mixed tone disorders

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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

TOPOGRAPHY

Hemiplegia
Diplegia
Quadraplegia
Triplegia

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)
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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

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NEW/WHO/ICF
Health Condition
(disorder or
disease)
Body Functions
& Structures

Environmental
Factors

Activities

Participation

Personal Factors

Interactions between components of the

ICF
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GMFC-GROSS MOTOR FUNCTION CLASSIFICATION

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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.

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

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

GMFCS E&R

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GMFCS LEVELS

Level I: Walks without assistive

device indoors. Climbs stairs
without limitation. Able to run
and jump. Impaired speed,
balance, coordination.

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.

GMFCS LEVELS

Level IV: Walks for short

distances on a walker.
Wheeled mobility for
outdoors, school and
community.

GMFCS LEVELS

Level V: All areas of motor

function are limited. No
independent mobility even
with assistive technology.

FUNCTIONAL MOBILITY SCALE

Exercise
Household
Community

MACS-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

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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

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GMFCS DOES NOT PREDICT MACS

COMMUNUCATION CLASSIFICATION FUNCTION SYSTEM

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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 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)

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

E a tin g a n d D r in k in g A b ility C la s s if ic a t io n S y s te m - A lg o r it h m
Is th e in d iv id u a l
a b le t o s w a llo w
f o o d a n d d r in k
w ith o u t r is k o f
a s p ir a tio n ?

Is th e in d iv id u a l a b le
Yes
to b ite a n d c h e w o n
h a rd lu m p s o f fo o d
w ith o u t a ris k o f
c h o k in g ?

Is th e in d iv id u a l
a b le to e a t a m e a l
in th e s a m e tim e
as p eers?
Yes

L evel I
E a ts a n d d rin k s
s a f e ly a n d
e f f ic ie n t ly

Yes

No

Yes

No

No

L e v e l III
E a ts a n d d r in k s
w it h s o m e
lim it a t io n s t o
sa fe ty ; th e re m a y b e
lim it a t io n s t o
e f f ic ie n c y.

L e v e l IV
E a ts a n d d rin k s w ith
s ig n ific a n t
lim ita t io n s to s a f e t y.

C a n r is k s o f
a s p ir a t io n b e
m a n a g e d to
e lim in a te h a r m t o
th e in d iv id u a l?
No

L evel V
U n a b le to e a t o r
d r in k s a fe ly t u b e
f e e d in g m a y b e
c o n s id e r e d to
p r o v id e n u tr it io n .

L e v e l II
E a t s a n d d r in k s
s a fe ly b u t w ith
s o m e lim it a t io n s
t o e f fic ie n c y.
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ICF

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
(Limitatio
n)
GMFCS,FM
S
MACS
,
CFCS,EADS
C,.

Environmental Factors

Participatio
n
(Restriction
)
Daily Living
activities,
Social roles in
community
(children, student,
friends,etc.)

WeeFIM
Personal Factors
PEDI etc.

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

GROSS MOTOR CURVES AND GMFCS

90%offinalGMFachieved

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

IN A VARIABLE DISORDER-ALLOWS-CLINICIANSPARENTS
Common language
Common groupings
Common Goals