**4. Traditional classifications of CP based on multiple variables**

These are the Swedish classification [8], Edinburgh classification [9] and Surveillance for Cerebral Palsy in Europe (SCPE) classification [10].

#### **4.1. The Swedish classification**

migrational disorders can occur in the last 2–3 months of pregnancy [27]. Nevertheless, malformations are more likely to occur earlier in gestation, and thus, neuroimaging confirmation of their presence can help establish that the cause of CP is unrelated to perinatal events [27]. Categorizing patients with CP based on neuroradiologic findings implies that neuroimaging studies be carried out on all patients. Therefore, it will be difficult to apply such classification in resource-poor countries where neuroimaging facilities are not readily available or affordable and the professional expertise needed may be lacking. Despite this, the American Academy of Neurology (AAN) recommends neuroimaging studies on all children with CP whenever possible [27]. The bottom line is that neuroimaging can be used to identify the neuropathologic substrates of the various etiologic and risk factors of CP, possibly provide information about timing of insults and detect cerebral dysgenesis or malformations but, at

This scheme categorizes CP cases based on treatment needs into four groups namely: nontreatment, modest treatment, need for a CP treatment team, and pervasive support groups [6, 20]. Parents/caregivers want their children to receive treatments that will improve their condition, so any classification that is implicative of treatment is important to the patients and their caregivers and relevant to clinical practice. There is a consensus in the literature that the therapeutic and functional classifications are the most important to the patient [1, 6, 20]. However, the therapeutic classification simply identifies how much treatment or the extent of interventions a given child requires without specifying what is actually needed to improve

Functionally, CP is classified into levels of severity based on functional (motor) abilities and/ or limitation of activity [1, 6, 20]. Currently, the emphasis on the functional classification is due to its important role in the management of CP. So there is a rekindled interest in this

The functional classification remains the best classification of CP because it is a useful guide to providing care for patients appropriate for their functional level and helps clinicians set and discuss with parents/caregivers realistic rehabilitation goals [1, 4, 5, 11, 12]. The functional classification satisfies the needs of patients and parents/caregivers by informing the current and future service needs of children with CP [5]. It provides information that will permit comparison of CP cases in different locations. It provides information that will allow evaluation of change at different points in time in the same patient such as after an

However, it falls short of giving full descriptive information about a child with CP that clearly delineates the nature of the problem. It does not indicate the nature of the motor abnormality, the topography, the etiology, or neuropathologic substrates which in their own respects are

present, a comprehensive neuropathologic classification is still in the pipeline.

function. This explains the little emphasis on the therapeutic classification.

**3.6. Therapeutic classification**

28 Cerebral Palsy - Clinical and Therapeutic Aspects

**3.7. Functional classification**

scheme.

intervention [1].

CP subtypes based on the Swedish classification (1989) [8] are spastic (hemiplegic, tetraplegic, and diplegic), dyskinetic (dystonic and athetotic), ataxic and unclassified/mixed. It is immediately obvious that this classification combines the Minear's Physiologic and Topographic schema. Thus, it shares the same merits and demerits as the physiological and topographic classifications as earlier discussed.

#### **4.2. The Edinburgh classification**

According to the Edinburgh classification [9], there are six subtypes of CP namely hemiplegia, bilateral hemiplegia, diplegia, ataxic, dyskinetic and other forms of CP including mixed forms. This classification is a combination of classifications based on topography and physiology and so has the same advantages and shortcomings as the topographic and physiologic classifications.

#### **4.3. The Surveillance for Cerebral Palsy in Europe (SCPE) classification**

The SCPE [10] classifies CP into the following four subtype groups: spastic (bilateral and unilateral), dyskinetic (dystonic and choreoathetotic), ataxic, and non-classifiable. This grouping also combines the physiological and topographic classifications. The classification tree of the SCPE for subtypes of CP is shown in **Figure 1**.

Due to the lack of reliability of the terms used in Minear's topographic classification, SCPE [10] introduced two new terms to replace quadriplegia, diplegia, and hemiplegia. These terms are bilateral and unilateral used to describe involvement of both sides and one side of the body, respectively. By this classification, spastic quadriplegia and spastic diplegia are classified as bilateral spastic CP (BS-CP) while spastic hemiplegia is termed unilateral spastic CP. This

assessments [14, 30]. They are simple and easy to apply both by healthcare professionals and care givers and are good for clinical use and patient stratification for research purposes [5, 11, 30]. They have been validated by studies [12, 13, 15] and shown to be objective and reliable clinical classification systems for CP. They have replaced previously used imprecise

Clinical Classification of Cerebral Palsy http://dx.doi.org/10.5772/intechopen.79246 31

Their development resulted from the paradigm shift from a focus on body structure and function (impairment-based assessments and treatments) to current emphasis on activity or participation (function and social engagement) [3–5]. These concepts are contained in the ICF [3]. The ICF is a new classification system for health and disease that is universal (for everybody not only people with disabilities) [3]. It is a new way to consider health conditions and posits an interactive relationship between health conditions and contextual factors (environmental and personal factors) in which all components are linked together [3, 4]. It represents a coherent view of health from biological, individual and social perspectives (a biopsychosocial approach to health, functioning and disability) [4]. The ICF model has been used to guide clinical thinking and service delivery to patients with CP [4]. This conceptual

The functional classifications are analogous and when used together complete the description of daily functional activities in CP at the activity or participation level of the ICF [3, 30]. They

There are other functional scales like the Functional Mobility Scale (FMS), Bimanual Fine Motor Function (BFMF), Functional Assessment Questionnaire (FAQ), the Pediatric Orthopaedic

This is the most widely used clinical functional classification of CP [1]. It is an ordinal scale that categorizes a child's mobility/ambulatory or lower limb function in five levels ranging from walking without restrictions (level I) to inability to maintain antigravity head and trunk postures (level V) [11]. The first version of GMFCS was published in 1997 by Palisano et al. [11] and described gross motor functional abilities and limitations in children aged less than 12 years. The upper limit of 12 years (before end of adolescence) was a limitation of the first version, and the GMFCS was revised and expanded in 2007 by Palisano et al. [32] to include an age group for youths 12–18 years. This current version of GMFCS [32] emphasizes the concepts inherent in the WHO's International Classification of Functioning, Disability and Health (ICF). The GMFCS— ER [32] is shown in **Figure 2**. A summary of the criteria for the GMFCS [11, 32] is as follows:

and subjective functional classifications of CP into mild, moderate and severe.

change introduced by the ICF is topical.

**a.** Gross Motor Function Classification System (GMFCS) [11]

**c.** Communication Function Classification System (CFCS) [16]

**5.1. Gross Motor Function Classification System (GMFCS)**

**d.** Eating & Drinking Ability Classification System (EDACS) [17]

**b.** Manual Abilities Classification System (MACS) [14] & Mini—MACS [31]

Society of North America Outcomes Data Collection Instruments (PODCI), etc.

However, the first four are more commonly used and will be discussed here.

include

**Figure 1.** Classification tree for sub types of CP by SCPE.

classification is easy to apply and is more reliable than the earlier traditional classifications. Therefore, by improving the reliability of the terms used in the topographic component of this classification, the SCPE currently seems to be the best traditional classification for description of patients with CP.

However, the SCPE classification [10] does not include functional abilities and so does not aid therapy for patients with CP. Hence, this classification currently has not had a similar level of advocacy as the functional classifications.
