Cerebral palsy classification
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Cerebral palsy can be classified based on number of limbs involved, physiologically and functionally. Based on number of limbs involved cerebral palsy can be classified into monoplegia, hemiplegia, diplegia, paraplegia and quadriplegia. Physiologically, cerebral palsy can be divided into a spastic type (pyramidal), and an extrapyramidal type. The extrapyramidal types of cerebral palsy include athetoid, choreiform, ataxic, rigid, and hypotonic. The Manual Ability Classification System (MACS) and the Gross Motor Function Classification System (GMFCS) are two most commonly employed systems for functional classification of cerebral palsy. The Manual Ability Classification System (MACS) classifies children with cerebral palsy into five levels. The levels are based on the children’s self-initiated ability to handle objects and their need for assistance or adaptation to perform manual activities in everyday life. The Gross Motor Function Classification System (GMFCS) also classifies children with cerebral palsy into five levels. The levels are based on self-initiated movement abilities, in particular sitting and walking.
Based on number of limbs involved cerebral palsy can be classified into 4 subtypes
|Monoplegia||One extremity involved, usually lower|
|Hemiplegia||Both extremities on the same side involved
Usually, upper extremity involved more than lower extremity
|Paraplegia||Both lower extremities equally involved|
|Diplegia||Lower extremities more involved than upper extremities
Fine-motor/sensory abnormalities in upper extremity
|Quadriplegia||All extremities involved equally
Normal head/neck control
|Double hemiplegia||All extremities involved, upper more than lower|
Physiologically, cerebral palsy can be divided into a spastic type, which affects the corticospinal tracts (pyramidal) , and an extrapyramidal type, which affects the other regions of the developing brain. The extrapyramidal types of cerebral palsy include athetoid, choreiform, ataxic, rigid, and hypotonic.
|Spastic diplegia||Spastic hemiplegia||Spastic quadriplegia|
- Spastic cerebral palsy is the most common form of cerebral palsy.
- Spastic cerebral palsy is usually associated with injury to the pyramidal tracts in the immature brain.
- Spasticity is caused due to exaggeration of the normal musclepassive stretch reflex.
- Histologically altered muscle function leads to the deposition of type I collagen in the endomysium of the affected muscle, leading to thickening and fibrosis, the degree of which correlated to the severity of the spasticity.
- Simultaneous co-contraction of normally antagonistic muscle groups leads to fatigue, loss of dexterity and coordination, and balance difficulties.
- Athetoid cerebral palsy is caused by an injury to the extrapyramidal tracts.
- Athetoid cerebral palsy is characterized by dyskinetic, purposeless movements that may be exacerbated by environmental stimulation.
- With the improvements in prevention of Rh incompatibility leading to kernicterus, the incidence of athetoid cerebral palsy is decreasing.
- Dystonia, characterized by an increased overall tone and distorted positioning in response to voluntary movements, or hypotonia also can occur with athetoid cerebral palsy.
- Choreiform cerebral palsy is characterized by continual purposeless movements of the patient's wrists, fingers, toes, and ankles.
- This continuous movement can make bracing and sitting difficult.
- Patients with rigid cerebral palsy are the most hypertonic of all cerebral palsy patients.
- Hypertonicity occurs in the absence of hyperreflexia, spasticity, and clonus, which are common in spastic cerebral palsy.
- Patients with rigid cerebral palsy have a “cogwheel” or “lead pipe” muscle stiffness that often requires surgical release.
- Ataxic cerebral palsy is a very rare type.
- Ataxic cerebral palsy is characterized by the disturbance of coordinated movement as a result of an injury to the developing cerebellum.
- It is important to distinguish true ataxia from spasticity because with treatment many children with ataxia are able to improve their gait function without surgery.
- Hypotonic cerebral palsy is characterized by weakness in conjunction with low muscle tone and normal deep tendon reflexes.
- Many children who ultimately develop spastic or ataxic cerebral palsy pass through a hypotonic stage lasting 1 or 2 years before the true nature of their brain injury becomes apparent.
- Persistent hypotonia can lead to difficulties with sitting balance, head positioning, and communication.
Functional Classification of Cerebral Palsy
The Manual Ability Classification System (MACS) and the Gross Motor Function Classification System (GMFCS) are two most commonly employed systems for functional classification of cerebral palsy.
Manual Ability Classification System
The Manual Ability Classification System (MACS) classifies children with cerebral palsy into five levels. The levels are based on the children’s self-initiated ability to handle objects and their need for assistance or adaptation to perform manual activities in everyday life.
|Does the child handle most kind of|
daily activities independently
( during play and leisure, eating and dressing)
|Does the child handle even more difficult tasks|
with fair speed and accuracy and
does not need alternative ways to perform
|Does the child perform number of mannual tasks|
which commonly need to prepared or adapted
and help is needed occasionally
Handles objects easily and successfully
Handles most objects with
reduced quality and speed of acheivement
Handles objects with
difficulty but needs preparation
|Can the child perform|
easy activites with frequent support
Handles easy activites
with limitations and support
Cannot handle daily activites
has severely limited abilities to perform even simple actions
Gross Motor Function Classification System
The Gross Motor Function Classification System (GMFCS) also classifies children with cerebral palsy into five levels. The levels are based on self-initiated movement abilities, in particular sitting and walking.
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- Shamsoddini A, Amirsalari S, Hollisaz MT, Rahimnia A, Khatibi-Aghda A (2014). "Management of spasticity in children with cerebral palsy". Iran J Pediatr. 24 (4): 345–51. PMC 4339555. PMID 25755853.
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- Paulson A, Vargus-Adams J (2017). "Overview of Four Functional Classification Systems Commonly Used in Cerebral Palsy". Children (Basel). 4 (4). doi:10.3390/children4040030. PMC 5406689. PMID 28441773.
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