Cerebral palsy  

(CP) is a non-progressive neuromotor disorder. The primary

impairments associated with CP include movement dysfunction, alterations
in muscle tone and posture. A range of secondary conditions also develop
over time which can affect functional ability. The underlying cause of CP is
injury to the developing brain in the prenatal through neonatal periods. [1]

Specific Tests

The General Movements Assessment

Barry Albright Dystonia Scale

The Barry Albright Dystonia Scale (BADS) is used to assess secondary

dystonia in patients with traumatic brain injury or CP. The BADS is a
criterion-based, ordinal scale covering eight body regions using a 5-point
scale.[4]

Gross Motor Function Measure

The Gross Motor Function Measure  is an assessment tool used with

children with CP. This test uses a 4-point ordinal scale to evaluate a child's
ability to complete motor functions such as sitting, standing, rolling,
crawling, stair use, jumping, etc. [5]

The Gross Motor Function Classification System

The Gross Motor Function Classification System  (GMFCS) is used on

children aged 2-18 years old to describe gross motor function, especially
the ability to walk. This scale can be used to describe movements that
require assistive devices  (walkers, crutches, wheelchairs etc), as well as
self-initiated movements. [1]

The Hammersmith Infant Neurological Examination

The Hammersmith Infant Neurological Examination (HINE) is used for

infants aged from 2 months to 2 years to provide a framework for
monitoring and identifying deviations from normal development. The
HINE has been shown to have high specificity and sensitivity for predicting
cerebral palsy. [3]

Manual Ability Classification System (MACS)

The Manual Ability Classification System (MACS) details the typical use of
upper extremities and hands for children aged 4-18 years. [1]

The Communication Function Classification System

(CFCS)

The Communication Function Classification System (CFCS) is used to

assess daily routine communication in individuals with CP (i.e. receiving or
sending a message). All types of communication can be assessed in the
CFCS, including eye gaze, pictures, speech generating devices, vocalisations
and communication boards. [1]

Eating and Drinking Ability Classification System

(EDACS)

The Eating and Drinking Ability Classification System (EDACS) is used for
children aged 3 years and older, and it reports on their eating and drinking
function. More specifically, this test assesses eating and drinking efficiency
and safety (risk for aspiration or choking). [1]

The following table from Paulson et al. (2017) [6] shows classification levels
of CP using the GMFCS, MACS, CFCS and EDACS:

Leve GMFCS MACS CFCS EDACS

l

I Walks without Handles objects Effective sender Eats and drinks safely
limitation easily and and receiver and efficiently
successfully

II Walks with Handles most objects Effective but slow- Eats and drinks safely
limitations (no with reduced paced sender and but with some
mobility aid by 4 speed/quality receiver limitations to efficiency
years)

III Walks with hand- Handles objects with Effective sender Eats and drinks with
held mobility difficulty, help to and receiver with some limitations to
 device prepare or modify familiar partners safely; there may also
activity be limitations to
efficiency

IV Self-mobility with Handles limited Inconsistent sender Eats and drinks with
limitations, may number of objects in and receiver with significant limitations to
use power adapted setting familiar partners safety

V Transported in Does not handle Seldom effective Unable to eat or drink

manual objects sender and receiver safely; consider
wheelchair with familiar feeding tube
partners
[6]

Spasticity Tests

Modified Ashworth Scale

The most universally accepted tool to measure increases in muscle tone is

the Modified Ashworth  scale. As detailed in Harb and Kishner, [7] grading
of spasticity  using this scale is as follows:

 0: No increase in muscle tone

 1: Slight increase in muscle tone, with a catch and release or
minimal resistance at the end of the range of motion when an
affected part(s) is moved in flexion or extension
 1+: Slight increase in muscle tone, manifested as a catch, followed
by minimal resistance through the remainder (less than half) of
the range of motion
 2: A marked increase in muscle tone throughout most of the range
of motion, but affected part(s) are still easily moved
 3: Considerable increase in muscle tone, passive movement
difficult
 4: Affected part(s) rigid in flexion or extension [7]

Tardieu Scale

The Tardieu Scale  is another tool used to measure spasticity . This scale

assesses resistance to passive movement at different velocities - i.e. fast
and slow. It allows the assessor to differentiate between non-neural factors
(e.g. contracture) and neural factors (e.g. spasticity) that may explain an
increased resistance to passive stretch. [8] A passive stretch is applied to a
muscle group at two velocities [8]:

1. First stretch is as slow as possible (V1); equivalent to passive

range of motion
2. Second stretch:
1. 'speed of the limb segment falling under gravity'
(V2)
2. 'as fast as possible' (V3)
** A six point scale is used for grading with 0 indicating ‘no resistance
through the course of the passive movement’ and 5 indicating that ‘the joint
is immobile’[8]

Hip Tests

Barlow and Ortolani Manoeuvres

Barlow Test: identifies a dislocated hip by adducting a flexed hip using a

gentle posterior force. [9]

Ortolani Test: attempts to relocate a dislocated hip by abduction of a flexed

hip with a gentle anterior force. [9]

Galeazzi Sign

The Galeazzi sign is used when you are looking for instability, dislocation
or anterior translation of the hip. The child lies supine with their legs in
hooklying and the clinician looks for asymmetry in knee height.

This sign is positive if one knee is higher than the other. This indicates that
there is instability, dislocation, or anterior translation of the hip socket on
the lower side. [10]

Please see the videos below for a description and demonstration of these
tests.

[11]
[12]
Activity Scale for Kids (ASK)

The Activities Scales for Kids (ASK) is a self-administered 30-item

questionaire of what the child can do or would do at home, school and in
the playground.[13]

Pediatric Evaluation of Disability Inventory (PEDI)

The Pediatric Evaluation of Disability Inventory (PEDI) is a thorough

clinical assessment that checks key functional performances and
capabilities in children between the ages of 6 months to 7½ years. [14]

Functional Independence Measure for Children (WeeFIM)

WeeFIM is an assessment tool that measures a child’s consistent

performance in essential daily functional skills. The instrument consists of
an 18-item, 7-level ordinal scale over three main domains (self-care,
mobility, and cognition). [15]

Functional Balance Tests

1. Timed Up and Go : assesses mobility

2. Timed Floor to Stand: assesses transition to and from floor
3. Five Times Sit to Stand :assesses 5 consecutive cycles of sit to
stand
4. Paediatric Reach: assesses the distance one hand can reach
forward laterally while maintaining sitting or standing
balance[16]

Resources
 Functional Independence Measure for Children

 Cerebral Palsy Aetiology and Pathology

 10 Metre Walk Test
 6 Minute Walk Test
 Timed Up and Go Test
 Pediatric Balance Scale
 CanChild
Practical Assessment and Treatment of
Cervicogenic Headaches
An online course by Ari Kaplan

Learn more on this topic

Related articles
Cerebral Palsy Aetiology and Pathology - Physiopedia Introduction Cerebral
palsy (CP) is a permanent movement and posture disorder caused by issues in the
developing foetal and infant brain.[1] CP is the most common childhood disability.
[2] The core symptom of cerebral palsy is motor function disorder, but other
associated dysfunctions frequently occur, including cognitive, communication,
sensation, perceptual, and behavioural conditions, as well as epilepsy.[3] Despite
cerebral palsy being non-progressive in nature, secondary conditions often develop
over time that affect functional abilities.[4] Aetiology[edit | edit source] The
incidence of CP is 2-3 per 1,000 live births.[4] Most cases of CP are due to
complications in the foetal or neonatal brain, but post-neonatal onset CP can occur.
The main pathologic findings for preterm infants are intracerebral hemorrhage and
periventricular leukomalacia (i.e. "diffuse injury of deep cerebral white matter,
accompanied in its most severe form by focal necrosis"[5]). Injuries that occur after
the neonatal period and before 5 years of age are considered post-neonatal CP; these
injuries are generally caused by traumatic brain injury, meningitis and near-
drowning.[4] Risk Factors[edit | edit source] Two important risk factors associated
with CP are prematurity (delivery before 37 weeks) and low birth weight (less than
2.5 kg). Other factors can also increase risk such as multiple gestation, maternal and
foetal infections, malformation of the brain and genetic causes.[2][4] Management
strategies to help decrease prematurity prevalence include prescribing magnesium
sulphate, progesterone and corticosteroids to pregnant women.[2] Pre-conception
Risk Factors[edit | edit source] Substance abuse Maternal undernutrition
Swallowing harmful substances Systemic illness in the mother Fertility issues
Previous spontaneous termination of pregnancy[2] Gestation Risk Factors[edit | edit
source] Gestational diabetes Maternal abnormalities of the central nervous system
Preeclampsia Excessive bleeding per vagina Multiple gestations Genetics
Encephalopathy of prematurity[2] Delivery Risk Factors[edit | edit source] Vacuum-
assisted delivery Forceps delivery C-section Labour induction Prolonged labour
Asphyxia Delivery after due date[2] Diagnosis[edit | edit source] The diagnosis of CP
is generally more reliable after 2 years of age. Before the age of 2, signs and
symptoms suggestive of CP could also be a developmental lag, which resolves in
many infants. Diagnosing CP is largely based on clinical findings. Early diagnosis
needs a combination of clinical findings including history, neuromotor assessments
and MRI (to determine the extent of the brain lesion or congenital brain
malformation). Clinical findings can continue to evolve up to the age of 4-5 years.[4]
Novak et al.[6] report that the most predictive tools for diagnosing CP are as follows:
Infants before 5 months corrected age: "term-age magnetic resonance imaging
(86%-89% sensitivity), the Prechtl Qualitative Assessment of General Movements
(98% sensitivity), and the Hammersmith Infant Neurological Examination (90%
sensitivity)"[6] Infants after 5 months corrected age: "magnetic resonance imaging
(86%-89% sensitivity) (where safe and feasible), the Hammersmith Infant
Neurological Examination (90% sensitivity), and the Developmental Assessment of
Young Children (83% C index)"[6] Signs of Cerebral Palsy[edit | edit source] Failure
to acquire certain key milestones at the expected age first raises suspicion of a CP
diagnosis. Key clinical characteristics of CP are the persistence of primitive reflexes
or primary motor patterns beyond the expected age. When primitive reflexes do not
dissipate, motor development progression and sequential attainment of higher level
neuromotor skills can be prevented and delayed.[4] ** Early diagnosis optimises
long-term functional outcomes.[4] The following are common signs of CP by age
group: 3-6 months[edit | edit source] Feels stiff Feels floppy Head falls back when
being picked up from supine Overextended back and neck when cradled in a
caregiver's arm Legs stiff or scissor when being picked up[4] Older than 6
months[edit | edit source] Unable to roll in either direction Unable to bring hands
together Reaches out with one hand with the other fisted Difficulty with hands to
mouth[4] Older than 10 months[edit | edit source] Scoots around on buttocks or
hops on knees, but does not crawl on all fours Lopsided crawl[4] Symptoms[edit |
edit source] The most common symptom seen in individuals with CP is hypertonicity
of the muscles secondary to brain injury.[2] Each case of CP presents differently
depending on the lesion in the brain. Some children may only have musculoskeletal
issues, while others might have a broad range of symptoms that limit daily activities
and/or have life-threatening comorbidities. As the nervous systems matures,
symptoms may improve.[2] Paul et al.[2] listed the comorbidities associated with CP
and their frequency: Pain: 75% Intellectual disability: 50% Gait disorders: 33% Hip
displacements: 33% Speech problems 25% Epilepsy: 25% Incontinence: 85%
Behavioural disorders: 25% Sleep disorders: 40% Hearing impairments: 9% Vision
impairments: 10% Cognitive impairments: 77% Thyroid dysfunction: 3%
Gastrointestinal disturbances: 2%[2] Classification of Cerebral Palsy[edit | edit
source] Cerebral palsy is classified into three categories: spastic, dyskinetic and
ataxic.[2] Spastic Cerebral Palsy[edit | edit source] The most common type of CP is
spastic CP. This type is also the most amenable to treatment.[1] Individuals with
spastic CP present with hyperreflexia and hypertonicity. Spastic CP be bilateral or
unilateral.[2] Individuals may present with diplegia, quadriplegia or hemiplegia.
Diplegia[edit | edit source] In diplegia, the lower extremities are more affected than
the upper extremities. This is the most common clinical phenotype of CP. Children
with spastic diplegia usually have a good prognosis for independent ambulation and
have normal cognitive function.[4] Quadriplegia[edit | edit source] In quadriplegia,
all four limbs involved, but the hands are more affected than the legs.[2] Children
present with:[2] Limited voluntary movements of all extremities Pseudobulbar signs
Accidental food entry in the airways Swallowing difficulty Optic atrophy Seizures
Severe intellectual abnormality ** Children with spastic quadriplegia have a poor
prognosis for independent ambulation.[4] Hemiplegia[edit | edit source] In
hemiplegia, one side of the body is affected, but hand function is most affected.[2]
Children present with:[2] Severely impaired dorsiflexion and eversion of the foot
Increased spasticity in the flexor muscles Sensory abnormalities Seizures Visual
problems[2] ** Most children with spastic hemiplegia have a high level of functional
ability, normal cognitive ability and are able to maintain independent ambulation.
[4] Dyskinetic Cerebral Palsy[edit | edit source] Dyskinetic CP (also referred to as
dystonic or athetoid CP) involves an injury to the basal ganglia.[7] Individuals with
dyskinetic CP display abnormal movements and postures. These deviations are due
to impaired movement control, muscle tone and coordination.[8] Children with
dyskinetic CP waver from hypotonia to hypertonia.[9] Cerebral Palsy Guide[9]
provides the following definitions: Dystonia - Slow, rotational movements of the
torso, arm or leg. Chorea - Sudden involuntary movements, especially in the fingers
and toes. Athetosis - Sluggish, writhing movements, mainly in the fingers and face.
Choreoathetoid - A combination of chorea and athetosis. Dyskinesia - A general term
used to describe involuntary movements.[9] Ataxic Cerebral Palsy[edit | edit source]
Ataxic CP is the rarest form of CP.[10] Individuals with ataxic CP demonstrate
incoordination of goal-directed movements, which results in trunk and gait
deviations, intention tremor and slurred speech.[11] The video below by Cerebral
Palsy Alliance shows the various types of CP classifications: Assessment Scales[edit |
edit source] There are four assessment scales used to classify and assess support and
therapy needs for individuals with CP:[4] Gross Motor Function Classification
System (GMFCS): used for children aged 2 to 18 years to describe gross motor
function, especially the ability to walk. Manual Ability Classification System
(MACS): used for children aged 4 to 18 years to describe how they use their hands
and upper extremities. Communication Function Classification System (CFCS): used
to describe a child's ability for routine daily communication, including vocalisations,
manual signs, eye gaze, pictures, communication boards or speech generating
devices. Eating and Drinking Ability Classification System (EDACS): used for
children aged 3 years or older to describe eating and drinking function, including
safety (risk of aspiration / choking) and efficiency (time taken, any food lost).[4] The
following chart by Paulson et al., (2017) [12][4] displays all four tests and what you
would observe at each level: Level GMFCS MACS CFCS EDACS I Walks without
limitation Handles objects easily and successfully Effective sender and receiver Eats
and drinks safely and efficiently II Walks with limitations (no mobility aid by 4
years) Handles most objects with reduced speed/quality Effective but slow-paced
sender and receiver Eats and drinks safely but with some limitations to efficiency III
Walks with hand-held mobility device Handles objects with difficulty, help to
prepare or modify activity Effective sender and receiver with familiar partners Eats
and drinks with some limitations to safely; there may also be limitations to efficiency
IV Self-mobility with limitations, may use power Handles limited number of objects
in adapted setting Inconsistent sender and receiver with familiar partners Eats and
drinks with significant limitations to safety V Transported in manual wheelchair
Does not handle objects Seldom effective sender and receiver with familiar partners
Unable to eat or drink safely; consider feeding tube Table 1. Assessment Scales for
Cerebral Palsy from Paulson et al., (2017) [12][4] The following video by Cerebral
Palsy Foundation discusses early detection tools for diagnosing CP: Resources[edit |
edit source] Motor Development Principles Early Intervention in Cerebral Palsy
Early Intervention and the Importance of Early Identification of Cerebral
PalsyClassification of Cerebral Palsy - Physiopedia Introduction The
information on this page has developed for you from the expert work of Roelie
Wolting alongside the Enablement Cerebral Palsy Project and Handicap
International Group. Cerebral Palsy is caused by an injury to the brain or by
abnormal brain development. Although the injury is neurological in nature, it
produces affects to the body that impair movement, coordination, balance and
posture. There are various types of Cerebral Palsy.  There are 3 major types of
Cerebral Palsy: Spastic (70-80%), Dyskinetic (10-20%) and Ataxic (5-10%); or a
combination of the three can occur. Some children develop further disorders such as
seizure, mental impairments and suffer from other problems such as difficulty
learning to chew, swallow and talk, difficulty communicating, Poor eyesight and
hearing difficulties, perception, growth problems, dental problems, constipation,
sleep problems, slow learning, challenging behaviour. The specific needs of this
heterogeneous group vary widely. Every child is unique with varying degrees of
impairment. Classification is important in understanding the individual child’s
impairment, and for coordinating the management of care but treatment must be
adapted to each individual child's needs. Professionals who specialize in treatment of
cerebral palsy approach the condition from a number of different vantage points. For
these reasons, many cerebral palsy classification systems are used today. Over the
last 150 years, the definition of Cerebral Palsy has evolved and changed as new
medical discoveries contributed to growing knowledge of the condition. Although a
myriad of classifications, used differently and for many purposes, exists today, those
involved in Cerebral Palsy research are working towards a universally accepted
classification system. Classification of Cerebral Palsy is important, as this enables
realistic expectations and can play an important role in influencing treatment. There
are many ways of classifying Cerebral Palsy and tools available to be able to do this.
Methods of Classification[edit | edit source] Severity[edit | edit source] Cerebral
Palsy is often classified by severity level as Mild, Moderate, Severe. These are broad
generalizations that lack a specific set of criteria. Even when doctors agree on the
level of severity, the classification provides little specific information, especially
when compared to other means of Classification. Still, this method is common and
offers a simple method of communicating the scope of impairment, which can be
useful when accuracy is not necessary. Mild[edit | edit source] Mild Cerebral Palsy
means a child can move without assistance; his or her daily activities are not limited.
Moderate[edit | edit source] Moderate Cerebral Palsy means a child will need braces,
medications, and adaptive technology to accomplish daily activities. Severe[edit |
edit source] Severe Cerebral Palsy means a child will require a wheelchair and will
have significant challenges in accomplishing daily activities and will need important
support. Topographical Distribution[edit | edit source] Topographical classification
describes body parts affected. The words are a combination of phrases combined for
one single meaning. When used with Motor Function Classification, it provides a
description of how and where a child is affected by Cerebral Palsy. This is useful in
ascertaining treatment protocols. Term at the heart of this classification method;
Plegia/Plegic - Means Paralyzed The prefix and root word are combined to yield the
topographical classifications commonly used in practice today; Monoplegia[edit |
edit source] Means only one limb is affected. It is believed this may be a form of
hemiplegia/hemiparesis where one limb is significantly impaired. Diplegia[edit |
edit source] Usually indicates the legs are affected more than the arms; primarily
affects the lower body. Hemiplegia[edit | edit source] Indicates the arm and leg on
one side of the body is affected. Triplegia[edit | edit source] Indicates three limbs are
affected. This could be both arms and a leg, or both legs and an arm. Or, it could
refer to one upper and one lower extremity and the face. Double Hemiplegia[edit |
edit source] Indicates all four limbs are involved, but one side of the body is more
affected than the other. Quadriplegia[edit | edit source] Means that all four limbs are
involved. Muscle Tone[edit | edit source] Many motor function terms describe
Cerebral Palsy’s effect on muscle tone and how muscles work together. Proper
muscle tone when bending an arm requires the biceps to contract and the triceps to
relax. When muscle tone is impaired, muscles do not work properly together and can
even work in opposition to one another. Two terms used to describe Muscle Tone are
hypertonia and hypotonia. Hypertonia[edit | edit source] Increased muscle tone,
often resulting in very stiff limbs. Hypertonia is associated with spastic cerebral
palsy. Hypotonia[edit | edit source] Decreased muscle tone, often resulting in loose,
floppy limbs. Hypotonia is associated with non-spastic cerebral palsy. Functional
Classification of Cerebral Palsy[edit | edit source] The functional abilities of children
with Cerebral Palsy vary immensely in the domains of cognition, self-care, mobility
and social aspects. However, the classification of gross motor function in children
with Cerebral Palsy has proven to be successful. The Gross Motor Function
Classification System (GMFCS) was the first Classification system developed for
children with cerebral palsy, first published in 1997 and revised and expanded in
2007. The GMFCS was developed by CanChild Centre for Childhood Disability
Research (Canada). After the GMFCS the Manual Ability Classification System
(MAC) was developed and published in 2010. The members of this group have
different competencies and professions, they are located in different universities in
Sweden. The team collaborates with CanChild, Centre for Childhood Disability
Research. In 2011 the Communication Function Classification System (CFCS) was
published, also developed by a team of professionals at University of Central
Arkansas (US). They have all 5 levels in functioning. Only the GMFCS has different
descriptions for 5 different ages: the first before the age of 2 and the last one for age
12-18. During their life it is expected that children will stay at the same level and the
GMFCS describes what gross motor functions the child will be able to learn during
life at different ages. The Gross Motor Functional Classification Scale (GMFCS), first
devised in 1997, has been universally implemented as the common language between
health professionals to communicate the gross motor ability of children with
Cerebral Palsy.[1] All Functional Classifications can be done together with parents or
by parents. So, it is not a classification system to be used only be professionals.
Using the three different classification systems will help you and the parents to look
at different developmental areas of the child and to develop goals and interventions
(and when these are needed) for three different areas. It will provide a basis for
discussion what the child can do and where to work on. Below each classification
system is explained in a little more detailed. Gross Motor Function Classification
System[edit | edit source] The aims of developing the GMFCS was to enhance
communication amongst families and medical professionals, encourage the efficient
use of healthcare services, allow comparisons and generalizations between
homogenous groups of children, assist with the making of clinical decisions and help
establish treatment goals.[2] The original GMFCS was based on the concept of
identifying the abilities and limitations in a child’s gross motor function and are
analogous to the staging and grading systems used in medicine to describe cancer.
[3] The revised and expanded version of the GMFCS describes the movement ability
of children with CP in one of five ordinal levels across five age bands, with the
emphasis on the child’s typical performance in different settings.[4] The
specification of age brackets accounts for any age-related differences in gross motor
function. Descriptors of a child’s abilities for each GMFCS level is provided across all
of the five age bands. These bands are less than 2 years of age, 2 to 4 years, 4 to 6
years, 6 to 12 years and 12 to 18 years. The distinctions between the levels of
function are based on the ability of the child to mobilise in the home, school and
community settings and the requirement for any assistive devices to aid mobility. An
example of the GMFCS functional description for the 6 to 12 year-old age bracket is
shown in FIGURE 1. The GMFCS assesses the child for self-initiated movements in
sitting, walking and wheeled mobility, with the levels of distinction focusing on the
functional abilities and the use and type of aids to achieve mobility. It has been
widely used in both clinical and research settings and proven to be valid, reliable,
relatively stable with time and has become the primary tool to describe and
communicate a child’s gross motor function. [5] [6] It is a classification system and
not an outcome measure, however it is pertinent in all discussions of Cerebral Palsy
management because treatment goals and selection of relevant interventions must
be based on a sound knowledge of a child’s long-term gross motor prognosis. [5] The
original version, the GMFCS, The Gross Motor Function Classification System was
developed in 1997. As of 2007, the expanded and revised version (GMFCS – E&R)
further includes an age band for youth 12 to 18 years. The 2007 version will be used
in this module. The GMFCS has 5 classification levels for 5 different age groups:
Before 2 years Between 2 and 4 years Between 4 and 6 years Between 6 and 12 years
Between 12 and 18 years The Gross Motor Function Classification System is a 5 level
classification system that describes the gross motor function of children and youth
with cerebral palsy on the basis of their self-initiated movement with particular
emphasis on sitting, walking, and wheeled mobility. The primary criterion has been
that the distinctions between levels must be meaningful in daily life. Distinctions
between levels are based on functional abilities, the need for assistive technology
(including wheeled mobility versus hand-held mobility devices such as walkers,
crutches, or canes) and, to a much lesser extent, quality of movement. The GMFCS
emphasises the concepts inherent in the World Health Organisation's International
Classification of Functioning, Disability and Health (ICF). We encourage users to be
aware of the impact that environmental and personal factors may have on what
children and youth are observed or reported to do. The descriptions for the 6 to 12
year and 12 to 18 year age bands reflect the potential impact of environment factors
(e.g. distances in school and community) and personal factors (e.g. energy demands
and social preferences) on methods of mobility. Here is a video with some examples
of the different levels of the GMFCS. [7] Use of the GMFCS Therapists and
physicians can reliably use the GMFCS with no training, simply by reading the
criteria. When you are familiar with the GMFCS you can classify a child you know
quite well in less than 5 minutes. If you are unfamiliar with a child (and therefore
require an observation session) you may need 15-20 minutes. Most distinctions are
fairly clear and decisions about which level most closely resembles the child’s
current gross motor function can be made quite quickly. Sometimes (i.e. at certain
ages), the distinctions between two adjacent levels are more subtle and require more
careful deliberation. A classification can be made based on general familiarity with a
child’s current gross motor abilities without necessitating an observation.
Information about the child’s usual performance and limitations in gross motor
function in home, school and community settings can be obtained by
parent/caregiver interview or by review of recent (clinic) notes that describe gross
motor function. GMFCS Level Description Level I Walks without limitations indoors
or outdoors and climbs stairs without limitations. Speed, balance and co-ordination
are reduced Level II Walks with limitations indoors or outdoors, climbs stairs
holding on to a rail. Experiences limitations walking on uneven surfaces and
inclines, in crowds or confined spaces Level III Walks indoors or outdoors using a
hand held mobility device and climbs stairs holding onto a railing. May require a
self-propelled wheelchair when travelling longer distances, outdoors or on uneven
terrain Level IV Self-mobility with great limitations and may use powered mobility
Level V Physical impairments restrict voluntary control of movement and have no
means of independent mobility. Transported in a manual wheel chair Here are some
of the age specific assessment sheets that can be used by the family and the child to
help assessment: Written instruction on use of GMFCS Ages 2-4 years Ages 4-6 years
Ages 6-12 years Ages 12-18 parents' assessment Ages 12-18 self assessment The
GMFCS has application for clinical practice, research, teaching, and administration.
For your work, knowledge of a child’s GMFCS level is very useful for communicating
with parents and setting the stage for collaborative goal setting. For example, the
probability of ambulation for a child classified at level V is extremely low and very
different from children in levels I, II, or III. As a result, the system is extremely
useful in terms of intervention planning at the levels of impairment and activity. An
emphasis in intervention for children in levels IV and V might be health promotion,
prevention of secondary impairments, and use of technology and adapted
equipment, whereas intervention for children in levels I, II, and III might be focused
more on achievement of gross motor abilities. A child should first be classified when
referred for rehabilitation services to assist with realistic goal setting and
appropriate intervention planning. Although this area is being studied in more
depth, the most recent information indicates that GMFCS levels are quite stable after
2 years of age and children are not likely to change levels even following
intervention. As an example, once classified in level 2, a child probably will remain
in level 2 thereafter, thus the GMFCS can be used to give a prognosis of the gross
motor function later in life. Manual Ability Classification System[edit | edit source]
The Manual Ability Classification System (MACS) can be used for children of
different ages (4-18 years) but the interpretation of the levels needs to be related to
the age of the child. Obviously, children handle different objects at age four years
compared to adolescent age. The same point concerns independence because a
young child needs more help and supervision than an older child but their handling
of objects is the primary focus of MACS. To date the stability of the classification
over time has not been investigated but our belief is that most children will stay at
the same level. The MACS tool has been designed to evaluate the child's typical
performance when using their hands This document gives an overview of MACS.
MACS has 5 levels. Read about how to recognize the different levels by reading the
whole brochure The MACS level identification chart will help guide you as well in
deciding on classification. MACS brochure Communication Function and
Classification System[edit | edit source] The Communication Function Classification
System (CFCS) provides a valid and reliable classification of communication
performance and activity limitations that can be used for research and clinical
purposes. The CFCS does not rate the person’s potential for improvement. The CFCS
provides a valid and reliable classification of communication performance and
activity limitations that can be used for research and clinical purposes. It is
analogous, and complementary to the Gross Motor Function Classification System
(GMFCS-ER) and the Manual Ability Classification System (MACS). The CFCS
consists of 5 descriptive levels for everyday communication performance and gives a
uniform way to describe functional communication. It helps to understand the
possible communication forms and assistive devices. It recognizes the influence of
different components which are related to communication and It is the starting point
for making intervention goals to improve effective communication. The number of
speech therapists is limited in many countries and since the CFCS (like the GMFCS
and the MACS) does not require a specialist to decide on the level of classification,
this tool is very attractive to health care professionals. Parents can also use these
tools. Here is the CFCS Brochure and Assessment Tool. Even if you are not a speech
therapist, classifying the Communication of a child with Cerebral Palsy will help to:
Adapt your own way of communication to the child Make intervention goals to
improve effective communication with the child. [8] Communication and
Children with Cerebral Palsy - Physiopedia Communication Introduction
Communication occurs when a sender transmits a message and a receiver
understands the message. An effective communicator independently alternates as a
sender and a receiver regardless of the demands of a conversation including settings
(e.g. community, school, work, home), conversational partners and topics. All
methods of communication performance are considered in determining the CFCS
level. To find out more about the GFCS have a look at this page. Methods and
Challenges of Communication[edit | edit source] Here is a list of methods of
communication and what challenges a child with Cerebral Palsy may come across:
Method Challenge Speaking Coordination of mouth and tongue muscles People do
not listen to them Listening Concentration Writing Fine Motor Skills Showing /
Pointing at Pictures Fine Motor Skills Hand - Eye Co-ordination Making Gestures /
Sign Language Fine Motor Skills Motor Planning Body Language / Facial Expression
Muscle Control of Body / Face Here are some examples of specific problems that
some children with Cerebral Palsy can have when communicating: Floppy Children
(Hyoptonia): These children can have problems speaking with a clear voice because
the muscles of the trunk are weak and this also influences the loudness of the
speech. Children with Complex Disabilities (CP and Intellectual disability): They will
have problems with understanding as well If children who have problems with
speaking are not given an alternative to speech, they may have difficulty sending a
response and the communication cycle will break down. Developing Communication
Skills[edit | edit source] There are many different ways to influence and develop
communication skills in children with Cerebral Palsy. Here are some ideas of games
to help improve mouth control: Imitate a chicken by keeping a "worm" between the
lips (not between the teeth!). How long can you hold it (make a game - who is the
champion?!) Making Funny Noises e.g. the noise of a starting car or motor bike Blow
a Kiss Imitate the wailing siren of a police care: i-u-i-u-i Clicking the tongue, fast
and slow, like the sound of a horse on the road Make the tip of the tongue like a
tower and stick it out of the mouth as far as possible Try to touch the nose, cheek,
and chin with the tongue. Who is doing best? Inflate a balloon (or imitate it) Make
funny faces, using all parts of the face (you can also use a mirror) Try to blow a ping-
pong ball or a piece of cotton wool away: who is the best? Can you blow further than
last week? Speech and Language Therapists or Occupational Therapists will ideally
be involved in the treatment and development of speech with the child with Cerebral
Palsy. In this video an Occupational Therapist talks about the problems and
treatments for communication difficulties in children with Cerebral Palsy.  [1]
Additional Resources[edit | edit source] Hambisela_Module_4 In: Getting to Know
Cerebral Palsy: A learning resource for facilitators, parents, caregivers, and persons
with cerebral palsy Family Centred Intervention and Early Diagnosis -
Physiopedia Early Intervention Early intervention services are a set of interventions
that support and provide resources for families of special needs infants and toddlers,
aged between 0 and 3 years old.[1] Can Child[2] definition of family centred service:
"Family-centred service is made up of a set of values, attitudes, and approaches to
services for children with special needs and their families. Family centred service
recognizes that each family is unique; that the family is the constant in the child’s
life; and that they are the experts on the child’s abilities and needs. The family works
with service providers to make informed decisions about the services and supports
the child and family receive. In family-centred service, the strengths and needs of all
family members are considered. Children with developmental disabilities are
entitled to various services including:  An interdisciplinary early intervention teams
may include the following disciplines depending on the family and child’s needs and
availability of services"[2] An interdisciplinary early intervention team may include
the following disciplines depending on the family and child’s needs and availability
of services: early intervention Physical therapy / physiotherapy Occupational
therapy Speech therapy Vision therapy Nursing Assistive technology Special
education Evaluations and follow-up care are provided in the child's least restrictive
or natural environment, typically at their home or daycare centre.[3] Traditionally,
early intervention has worked off an expert model where the therapist created goals
and provided follow-up care based on the impairment. Any interventions provided
by the family were adjuncts to those provided by the healthcare professional. The
overall care and decision making for the child was in the hands of the therapist. This
model is referred to as a rehabilitation model.[4] Family-Centred Care[edit | edit
source] Over the past decade, there has been a shift from the therapist-driven model
to a family education/empowerment model. The family-centred care (FCC) model
[5] provides collaboration between the therapist and family where the goals and
aspirations of the family are central to the intervention.[1] The therapist works as a
“coach” helping families identify needs, goals and solutions. FCC, thus, transfers
decision-making from just the therapist to the family, who are empowered to create
goals and plan intervention strategies.[1] When families are involved in the care and
decisions of their child, the family and the child reap better outcomes.[4]
Additionally, research has shown the FCC model to result in greater parent
satisfaction, reduced cost of healthcare, behavioural/emotional support to a child
and a faster recovery.[6] Solution Focused Coaching[edit | edit source] Traditionally,
early intervention was problem-oriented with a focus on identifying impairments in
the body. Interventions were targeted at fixing the dysfunction and decisions about
care were made solely by the therapist. However, with a solution focused coaching
(SFC) model, the therapist and family work together to envision possibilities and
seek solutions to the family's needs and targeted goals.[7] [1] Family empowerment
is a priority in FSC. In addition, a solution focused coaching model looks towards the
child's strengths and abilities rather than their problems to initiate goal setting and
intervention planning.[1] Early Diagnosis and Referral[edit | edit source] Cerebral
Palsy[edit | edit source] The most common physical disability in childhood is
cerebral palsy (CP), occurring in every 1 in 500 births. CP is caused by brain injury
early in development and presents with disorders in posture and movement leading
to activity limitations.[8] Traditionally, a diagnosis would be concluded between 12
and 24 months of age when symptoms were evident. New research, however, reveals
that signs and symptoms of CP appear and develop before 2 years of age. Using a
combination of medical history, neuroimaging and standardised motor and
neurological assessments for infants under 2, the risk of cerebral palsy can be now
be predicted.[9] Using diagnostic-specific early assessments can lead to referral of
services which will strengthen caregiver well-being, prevent secondary complications
and optimise infant cognitive and motor plasticity.[10] The tools below are
commonly used for infants aged under 2 to estimate the risk of a cerebral palsy
diagnosis. Hammersmith Infant Neurological Examination[edit | edit source] HINE
TEST[11] The Hammersmith Infant Neurological Examination (HINE) is a free tool
with good interobserver reliability that is typically used on infants aged between 3
and 24 months. It has shown high sensitivity in detecting CP in infants, (98% in
infants under 5 months old, 90% in infants over 5 months old).[9] Neurological
function is tested with 26 different criteria based on movements, behaviour, cranial
nerve function, protective reactions, reflexes and gross and fine motor function.
Symmetry between left and right sides are also scored.[1] Test results not only
identify children at risk, but detail the severity and type of motor impairment.
Having this specific information allows early intervention to be targeted to the
specific neurological sequelae.[8] Scores range from 0-73. Romeo et.al[8] found that
infants tested between 3 and 6 months showed the following pattern: Scores below
40: quadriplegia (IV and V levels of GMFCS), severe diplegia (III level) Scored 40-
60: mild or moderate diplegia (I-II level); hemiplegia (I-II level)[8] Gross Motor
Function Classification System[edit | edit source] The Gross Motor Function
Classification System (GMFCS) tool classifies children aged under 2 into five distinct
levels depending on their self-initiated movement. It specifically focuses on mobility,
transfers and sitting. These criteria relate to functional limitations for the child
versus quality of movement.[12]The GMFC is a way of classifying function severity
and not a diagnostic tool. Gross Motor Function Classification System – Expanded
and Revised (GMFCS – E & R) for children aged 2 and under is as follows:[12]
"LEVEL I: Infants move in and out of sitting and floor sit with both hands free to
manipulate objects. Infants crawl on hands and knees, pull to stand and take steps
holding on to furniture. Infants walk between 18 months and 2 years of age without
the need for any assistive mobility device." LEVEL II: Infants maintain floor sitting
but may need to use their hands for support to maintain balance. Infants creep on
their stomach or crawl on hands and knees. Infants may pull to stand and take steps
holding on to furniture. LEVEL III: Infants maintain floor sitting when the low back
is supported. Infants roll and creep forward on their stomachs. LEVEL IV: Infants
have head control but trunk support is required for floor sitting. Infants can roll to
supine and may roll to prone. LEVEL V: Physical impairments limit voluntary
control of movement. Infants are unable to maintain antigravity head and trunk
postures in prone and sitting. Infants require adult assistance to roll." *** Less
favourable outcomes are noted in low and middle income countries with over 73% of
children classified as GMFCS level of III-IV.[13] The Prechtl General Movement
Assessment[edit | edit source] The Prechtl General Movement Assessment is a
general movement tool where clinicians watch a short video of a supine infant. 
Quality and type of movements are scored as “normal” or “abnormal” for 26 items. 
Abnormal movements are further classified into one of three categories below: Poor
repertoire (sequence of movements is monotonous; different body part movements
are not complex) Cramped-synchronised (lack of smooth and fluent movement;
rigid; trunk and limb muscles relax and contract simultaneously[14] Chaotic (no
smoothness, chaotic and abrupt movements of large amplitude)[15] [14][1] Based on
scores from this test, the presence, type and severity of CP can be predicted. This
tool is reliable and quick, but does require training.[1] Prechtl Exam[15]
Resources[edit | edit source] CanChild Family Centred Service Gross Motor
Function Classification System - Expanded and Revised (GMFCS-ER) Early
Intervention and the Importance of Early Identification of Cerebral Palsy Early
Intervention in Cerebral Palsy Cerebral Palsy Introduction Gross Motor Function
Classification System - Expanded and Revised (GMFCS-ER) -
Physiopedia Objective The revised and expanded version of the GMFCS (2007)
builds upon the original version of the Gross Motor Function Classification System
developed in 1997[1] to classify and describe the abilities of children and youth with
cerebral palsy. It has 4 age bands namely, less than 2 years, 2-4 years, 4-6 years and
6-12 years. This newer version describes the movement ability of a child with
cerebral palsy in one of five levels