Classification

Cerebral palsy is a global term that requires a classification system to further define the clinical picture. However, classification is often challenging given that a diagnosis of CP represents a collection of many symptoms in the absence of a standard clinical picture.

The most widely used classification system for this disorder was developed by the American Academy of Pediatrics (AAP). The AAP classifies CP using two scales based on symptoms rather than etiology. The motor classification scale characterizes the quality of movement, whereas the topography scale describes affected body parts.

Characteristics of movement quality are described as spastic, athetoid, rigid, ataxic, hypotonic, or mixed (Table IV). Lesions in specific regions of the brain have been associated with specific abnormalities of movement. The motor area of the cerebral cortex, including the prefrontal cortex, premotor cortex, and primary motor cortex, is commonly affected. Specifically, involvement of the motor cortex, which projects to and from the cortical sensorimotor areas, is associated with a diagnosis of spastic cerebral palsy. Damage to the basal ganglia results in a diagnosis of dyskinesia or athetosis. The basal ganglia functions to regulate voluntary motor function, thus modulating purposeful movement and suppressing unnecessary motion. Lastly, the cerebellum, functioning to control coordination, timing, and sequencing of movement, is associated with an ataxic movement disorder.

Topographically, the individual is described as having one limb involved (monoplegia), one half of the body involved (hemiplegia), both legs involved (diplegia), or both legs and one arm involved (quadriplegia). Therefore, an individual with

Characteristic

Table IV

Definitions of Motor Characteristics" Definition

Characterized by sudden muscle contractions that are convulsive in nature with persistent rigidity; increased resistance to passive movement that is velocity dependent; diminished threshold for stretch response and clonus; Involvement usually is greater in antigravity muscles

Writhing, uncontrolled movements with poor coordination and midrange control

Resistance to slow-speed passive movement from both the agonist and the antagonist; lead pipe resistance throughout the range of motion; cog wheel discontinuous resistance throughout the range of motion Poor coordination and timing with voluntary movement; deficits in balance, equilibrium, and depth perception decreased ability of the muscle to generate force; diminshed muscle tension at rest; excessive joint mobility

Spasticity

Athetosis Rigidity

Ataxia Hypotonia aAdapted from Minear (1956). Pediatrics 18, 841-852.

velocity-dependent resistance to passive movement involving the right half of the body would be classified as having right spastic hemiplegic cerebral palsy.

Until recently, a classification system was not in place to provide a functional picture of the individual with cerebral palsy. In 1997, Palisano et al. developed the Gross Motor Function Classification System for Cerebral Palsy to provide a method to standardize clinical observations of child function. In addition to providing a numerical classification of function, the scale standardizes communication between professionals. Palisano et al.'s purpose was to describe discrete levels that represent present motor performance and limitations based on self-initiated movement. The classification system emphasizes sitting and walking and ranges from level 1 to level 5, with distinctions between levels based on functional limitations and the need for an assistive device, assistive technology, and/or mobility aides. The classification system uses the concept of disability as defined by the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) of the World Health Organization and the concept of functional limitation as outlined in the disablement model as described by Nagi. The ICIDH defines disability as "the restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being'' (1980). Nagi defines functional limitation as a "limitation in performance at the level of the whole person'' (1965).

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