**5. Current classifications of CP**

Currently, functional classification of each case of CP is internationally advocated due to its important role in management. Thus, current classifications of CP are functional scales for various functions impaired in CP such as communication, gross motor, fine motor, and oromotor/oropharyngeal functions. They are basically ordinal scales to categorize functional abilities or severity of limitation of activity and are not used as outcome measures, tests or 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 and subjective functional classifications of CP into mild, moderate and severe.

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 change introduced by the ICF is topical.

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 include


There are other functional scales like the Functional Mobility Scale (FMS), Bimanual Fine Motor Function (BFMF), Functional Assessment Questionnaire (FAQ), the Pediatric Orthopaedic Society of North America Outcomes Data Collection Instruments (PODCI), etc.

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

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

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

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

Currently, functional classification of each case of CP is internationally advocated due to its important role in management. Thus, current classifications of CP are functional scales for various functions impaired in CP such as communication, gross motor, fine motor, and oromotor/oropharyngeal functions. They are basically ordinal scales to categorize functional abilities or severity of limitation of activity and are not used as outcome measures, tests or

of patients with CP.

advocacy as the functional classifications.

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

30 Cerebral Palsy - Clinical and Therapeutic Aspects

**5. Current classifications of CP**

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:

**a.** Level I—Walks without limitations.

**e.** Level V—Transported in a wheelchair.

**c.** Level III—Walks using hand-held mobility device.

**d.** Level IV—Self mobility with limitations; may use powered mobility.

These general headings or titles for each level represent the method of mobility or highest

Clinical Classification of Cerebral Palsy http://dx.doi.org/10.5772/intechopen.79246 33

Current management of CP involves a liberal use of adaptive/augmentative equipment in addition to impairment-based treatment approaches to achieve independence [5]. A major goal in the management of CP is to ambulate the children and enable independent living; this gave birth to the changing concepts and the GMFCS. So, how GMFCS is a useful guide to

A child on GMFCS level I will walk independently and so requires no adaptive mobility equipment but appropriate stimulation. The child on level II may need hand-held mobility device when first learning to walk (younger than 4 years) and eventually walks with limitations (after 6 years). Thus, a hand-held mobility device may be provided initially for the child on level II. Therefore, the management of patients on GMFCS levels I and II would focus on appropriate stimulation, preventing complications from occurring and treatment of accompanying impairments. The child on GMFCS level III will require adaptive equipment for low back support for floor and chair sitting and at about 6 years, a hand-held mobility device for walking indoors and a self-propelled manual wheelchair for mobility outdoors and in the community. The management is multidisciplinary depending on the nature and number of accompanying impairments. It is important to note that the child on GMFCS level III may be added to children on levels I and II (walking at least indoors) or to children on levels IV and V (wheeled mobility at least in the community). Nevertheless, GMFCS level III is usually classified as ambulatory because the child is independently mobile in some settings irrespective of the need for assistive mobility device. This need or use of adaptive mobility equipment is acceptable (current thinking) [5]. In addition to multidisciplinary care, the child on GMFCS level IV requires initially a body support walker that supports the pelvis and trunk for floor and chair sitting and later powered mobility and a manual wheelchair for transportation outdoors, at school, and in the community. The management of a child on GMFCS level V involves pervasive supports and a manual wheelchair for transportation in all settings (physi-

level of mobility that a child with CP is expected to achieve after 6 years of age [11].

providing care appropriate for the functional level and age of a child with CP?

**5.2. Manual Abilities Classification System (MACS) and mini-MACS**

The MACS [14] and the mini-MACS [31] are five-level scales for classifying arm and hand function (manual abilities/manual dexterity) in children with CP aged 4–18 years and 1–4 years, respectively. They classify children's usual performance in handling objects with two hands (not best use or individual hand function) in important daily activities (**Figures 3** and 4).

**b.** Level II—Walks with limitations.

cal assistance at all times) [11].

**Figure 2.** Gross Motor Function Classification System—Expanded & Revised (GMFCS—E & R). Reproduced with permission.


These general headings or titles for each level represent the method of mobility or highest level of mobility that a child with CP is expected to achieve after 6 years of age [11].

Current management of CP involves a liberal use of adaptive/augmentative equipment in addition to impairment-based treatment approaches to achieve independence [5]. A major goal in the management of CP is to ambulate the children and enable independent living; this gave birth to the changing concepts and the GMFCS. So, how GMFCS is a useful guide to providing care appropriate for the functional level and age of a child with CP?

A child on GMFCS level I will walk independently and so requires no adaptive mobility equipment but appropriate stimulation. The child on level II may need hand-held mobility device when first learning to walk (younger than 4 years) and eventually walks with limitations (after 6 years). Thus, a hand-held mobility device may be provided initially for the child on level II. Therefore, the management of patients on GMFCS levels I and II would focus on appropriate stimulation, preventing complications from occurring and treatment of accompanying impairments. The child on GMFCS level III will require adaptive equipment for low back support for floor and chair sitting and at about 6 years, a hand-held mobility device for walking indoors and a self-propelled manual wheelchair for mobility outdoors and in the community. The management is multidisciplinary depending on the nature and number of accompanying impairments. It is important to note that the child on GMFCS level III may be added to children on levels I and II (walking at least indoors) or to children on levels IV and V (wheeled mobility at least in the community). Nevertheless, GMFCS level III is usually classified as ambulatory because the child is independently mobile in some settings irrespective of the need for assistive mobility device. This need or use of adaptive mobility equipment is acceptable (current thinking) [5]. In addition to multidisciplinary care, the child on GMFCS level IV requires initially a body support walker that supports the pelvis and trunk for floor and chair sitting and later powered mobility and a manual wheelchair for transportation outdoors, at school, and in the community. The management of a child on GMFCS level V involves pervasive supports and a manual wheelchair for transportation in all settings (physical assistance at all times) [11].

#### **5.2. Manual Abilities Classification System (MACS) and mini-MACS**

**Figure 2.** Gross Motor Function Classification System—Expanded & Revised (GMFCS—E & R). Reproduced with

permission.

32 Cerebral Palsy - Clinical and Therapeutic Aspects

The MACS [14] and the mini-MACS [31] are five-level scales for classifying arm and hand function (manual abilities/manual dexterity) in children with CP aged 4–18 years and 1–4 years, respectively. They classify children's usual performance in handling objects with two hands (not best use or individual hand function) in important daily activities (**Figures 3** and 4).


The MACS, developed in 2006 by Eliasson et al. [14] and modeled on the GMFCS, has been shown by various studies to be valid and reliable. However, a study in 2009 by Plasschaert et al. [33] reported lower inter-rater reliability of the MACS when used in children aged 1–5 years (linear weighted Kappa (k) of 0.67 and 0.55 for 2–5 years and 2 years, respectively). Thus, the MACS was adjusted in 2016 by Eliasson et al. [31] to obtain the mini-MACS which was shown to have excellent inter-observer reliability. The adjustments were simply to obtain descriptions that are applicable to children less than 4 years of age. The mini-MACS differs from the MACS due to the need for assistance in handling objects in children 1–4 years and the nature of the objects they are expected to

Clinical Classification of Cerebral Palsy http://dx.doi.org/10.5772/intechopen.79246 35

The MACS is used to ascertain the child's needs and inform management decisions such as choosing an appropriate upper limb intervention. That is, they are used like the GMFCS to guide functional intervention. For instance, children on MACS levels I and II handle objects independently and do not require any adaptive device to handle objects. The children on level III require some assistance and sometimes adaptive equipment for independent handling of objects. Children on level IV require continuous assistance and adaptive equipment while those on level V need total assistance. Eliasson et al. [31] posited that the mini-MACS is probably not sensitive to changes and should therefore not be used to evaluate development or intervention, but rather to categorize how suspected CP affects the manual abilities

**Figure 5.** The Communication Function Classification System (CFCS). Reproduced with permission [16].

handle.

of children 4 years and younger.

**Figure 4.** The mini-Manual Ability Classification System (mini-MACS). Reproduced with permission.

The MACS, developed in 2006 by Eliasson et al. [14] and modeled on the GMFCS, has been shown by various studies to be valid and reliable. However, a study in 2009 by Plasschaert et al. [33] reported lower inter-rater reliability of the MACS when used in children aged 1–5 years (linear weighted Kappa (k) of 0.67 and 0.55 for 2–5 years and 2 years, respectively). Thus, the MACS was adjusted in 2016 by Eliasson et al. [31] to obtain the mini-MACS which was shown to have excellent inter-observer reliability. The adjustments were simply to obtain descriptions that are applicable to children less than 4 years of age. The mini-MACS differs from the MACS due to the need for assistance in handling objects in children 1–4 years and the nature of the objects they are expected to handle.

The MACS is used to ascertain the child's needs and inform management decisions such as choosing an appropriate upper limb intervention. That is, they are used like the GMFCS to guide functional intervention. For instance, children on MACS levels I and II handle objects independently and do not require any adaptive device to handle objects. The children on level III require some assistance and sometimes adaptive equipment for independent handling of objects. Children on level IV require continuous assistance and adaptive equipment while those on level V need total assistance. Eliasson et al. [31] posited that the mini-MACS is probably not sensitive to changes and should therefore not be used to evaluate development or intervention, but rather to categorize how suspected CP affects the manual abilities of children 4 years and younger.

**Figure 5.** The Communication Function Classification System (CFCS). Reproduced with permission [16].

**Figure 4.** The mini-Manual Ability Classification System (mini-MACS). Reproduced with permission.

**Figure 3.** The Manual Ability Classification System (MACS). Reproduced with permission [14].

34 Cerebral Palsy - Clinical and Therapeutic Aspects

#### **5.3. Communication Function Classification System (CFCS)**

The CFCS was developed and validated by Hidecker et al. [16] in 2011. It classifies everyday communication performance of an individual with CP into five levels ranging from effective communication in all settings (level I) to ineffective communication even with familiar partners (level II). The categorization of the effectiveness of current communication is based on the performance of sender and receiver roles, the pace of communication, and the type of conversational partner. In ascertaining the current level of communication, the CFCS aptly considers and includes use of all methods of communication. This implies that it describes both use of normal verbal and non-verbal communication (speech, gestures, behaviors, eye gaze, and facial expressions) and use of augmentative and alternative communication systems (AACs) (manual sign, pictures, communication books, communication boards and talking devices such as speech generating devices and voice output communication aids) [16]. The CFCS level identification chart is shown in **Figure 5**.

scale is based on the range of food textures eaten, the presence of cough and gag when eating or drinking, and the control of movement of food and fluid in the mouth. The three-level scale is categorized into independent, requires assistance, and dependent for eating and drinking. Thus, the EDACS ranges from independent ability to safely and efficiently eat and drink like peers on a wide range of textures (level I) to total dependence for eating and drinking and reliance on tube feeding (level V) [17]. The EDACS algorithm is shown in **Figure 6**.

The final goal of a managing doctor and the final hope of a patient and his family is an ambulatory self-dependent individual. Using the functional classifications to guide management helps the pediatrician, the occupational therapist, the physiotherapist, the speech and language therapist and all involved in the care of children with CP to achieve this goal. For instance, the GMFCS is used to ascertain the requirements for ambulation appropriate for the age of the child and gross motor functional abilities while the MACS helps ascertain appropriate upper limb interventions for independent performance of activities of daily living. The CFCS by classifying communication effectiveness in CP is useful in service delivery. It helps identify those that will require augmentative and alternative communication systems to improve their communication. The EDACS assists in identifying the appropriate food texture to give a particular child, need for assistance, the risks involved in eating and drinking and the appropriate method of feeding (oral/tube feeding). Therefore, in simplistic terms, these current classifications tell us what to do

to the child with CP. A summary of all groups of classifications is shown in **Tables 1**–**3**.

**Suitability for research (description, comparison/ stratification) (on a scale of 1–5)**

Poor ++ No No

Poor ++ No No

Not reported Not reported No Yes

Not reported Not reported No No

Not available Not available Not

Not available Not available Not

Good +++ (good) Yes. Its

**Indication of functional abilities**

available

available

major advantage **Aiding/ guiding current management**

Clinical Classification of Cerebral Palsy http://dx.doi.org/10.5772/intechopen.79246 37

No

No

Yes. Its strength

**Inter rater/ inter observer reliability**

**6. The importance of the current classifications**

**Criterion/characteristic** 

abnormality (quality and changes in tone)

of motor impairment

**used**

Physiological Type of motor/movement

Typographic Distribution/localization

Aetiologic Actual cause and timing of insult

impairments

alterations on neuroimaging

activity limitation

**Table 1.** Comparison of traditional (Minear's) classifications based on single variables.

Supplemental Accompanying

Neuroanatomic Brain structural

Therapeutic Individual treatment needs

Functional Degree of severity/

**Classification axis**

#### **5.4. Eating and Drinking Ability Classification System (EDACS)**

The EDACS was developed by Sellers et al. [17] in 2014 and comprises two ordinal scales that describe eating and drinking ability in people with CP from 3 years of age. The five-level scale classifies the safety and efficiency of eating and drinking while the three-level scale classifies level of assistance required to bring food and drink to the mouth. The five-level

**Figure 6.** Eating and Drinking Ability Classification System (EDACS) algorithm. Reproduced with permission [17].

scale is based on the range of food textures eaten, the presence of cough and gag when eating or drinking, and the control of movement of food and fluid in the mouth. The three-level scale is categorized into independent, requires assistance, and dependent for eating and drinking. Thus, the EDACS ranges from independent ability to safely and efficiently eat and drink like peers on a wide range of textures (level I) to total dependence for eating and drinking and reliance on tube feeding (level V) [17]. The EDACS algorithm is shown in **Figure 6**.

#### **6. The importance of the current classifications**

**5.3. Communication Function Classification System (CFCS)**

36 Cerebral Palsy - Clinical and Therapeutic Aspects

[16]. The CFCS level identification chart is shown in **Figure 5**.

**5.4. Eating and Drinking Ability Classification System (EDACS)**

The CFCS was developed and validated by Hidecker et al. [16] in 2011. It classifies everyday communication performance of an individual with CP into five levels ranging from effective communication in all settings (level I) to ineffective communication even with familiar partners (level II). The categorization of the effectiveness of current communication is based on the performance of sender and receiver roles, the pace of communication, and the type of conversational partner. In ascertaining the current level of communication, the CFCS aptly considers and includes use of all methods of communication. This implies that it describes both use of normal verbal and non-verbal communication (speech, gestures, behaviors, eye gaze, and facial expressions) and use of augmentative and alternative communication systems (AACs) (manual sign, pictures, communication books, communication boards and talking devices such as speech generating devices and voice output communication aids)

The EDACS was developed by Sellers et al. [17] in 2014 and comprises two ordinal scales that describe eating and drinking ability in people with CP from 3 years of age. The five-level scale classifies the safety and efficiency of eating and drinking while the three-level scale classifies level of assistance required to bring food and drink to the mouth. The five-level

**Figure 6.** Eating and Drinking Ability Classification System (EDACS) algorithm. Reproduced with permission [17].

The final goal of a managing doctor and the final hope of a patient and his family is an ambulatory self-dependent individual. Using the functional classifications to guide management helps the pediatrician, the occupational therapist, the physiotherapist, the speech and language therapist and all involved in the care of children with CP to achieve this goal. For instance, the GMFCS is used to ascertain the requirements for ambulation appropriate for the age of the child and gross motor functional abilities while the MACS helps ascertain appropriate upper limb interventions for independent performance of activities of daily living. The CFCS by classifying communication effectiveness in CP is useful in service delivery. It helps identify those that will require augmentative and alternative communication systems to improve their communication. The EDACS assists in identifying the appropriate food texture to give a particular child, need for assistance, the risks involved in eating and drinking and the appropriate method of feeding (oral/tube feeding). Therefore, in simplistic terms, these current classifications tell us what to do to the child with CP. A summary of all groups of classifications is shown in **Tables 1**–**3**.


**Table 1.** Comparison of traditional (Minear's) classifications based on single variables.


**7. A holistic (standardized) classification of CP: the future**

CP for both developed and developing countries should include:

**1.** Classification of motor abnormalities according to SCPE.

and the reconceptualization of the management of CP.

the functional scales so as to guide management.

holistic or standardized classification of CP.

major components namely:

**2.** Associated impairments

**4.** Causation and timing.

**2.** Accompanying impairments

**8. Conclusions**

**3.** Anatomic and radiologic findings

abilities)

The development of a standardized or holistic classification of CP is topical and in tandem with advances in understanding of CP, imaging techniques and quantitative motor assessments [1]. Bax et al. [1] in 2005 proposed a standardized CP classification scheme with four

Clinical Classification of Cerebral Palsy http://dx.doi.org/10.5772/intechopen.79246 39

**1.** Motor abnormalities (a. nature and typology of motor disorder and b. functional motor

Currently, there are obvious limitations with categorization of neuroimaging findings and identifying specific causes of CP. Therefore, as we await comprehensive and acceptable neuroanatomic and etiologic classifications, the minimum acceptable multiaxial classification of

**3.** Functional classification levels for: gross motor/ambulatory function (GMFCS), manual abilities (MACS), communication, (CFCS) and eating and drinking ability (EDACS).

This implies that only the first two components of the standardized classification proposed by Bax et al. [1] are applicable currently. The classification by SCPE provides enough clinical descriptive information about children with CP while the supplemental and functional classifications are useful for management and service delivery. The use of the functional scales in clinical context (to aid management) and in research is in accordance with current thinking

Each classification system used in CP has its merits and shortcomings. Therefore, the clinical classification of CP needs to use many axes to be comprehensive. Currently, it must include

The neuropathologic classification is being awaited, and due to its contribution to the assessment of etiological factors and timing of insults in CP, it is critical to the development of a

**Table 2.** Comparison of traditional classifications based on multiple variables.


**Table 3.** Comparison of current (functional) classifications.
