01 Definition Se qxd

(except perhaps for some degree of hypotonicity) is not

included within the concept of CP.

18. ‘communication’ – Expressive and/or receptive commu-

nication and/or social interaction skills may be affected, both

as a function of the ‘primary’ disturbance(s) to which CP is attrib-

uted, and as a secondary consequence of activity limitations that

restrict learning and perceptual development experiences.

19. ‘behaviour’ – This includes psychiatric or behavioural

problems such as autistic spectrum disorders, ADHD, sleep

disturbances, mood disorders and anxiety disorders.

20. ‘epilepsy’– Virtually every seizure type and many epilep-

tic syndromes may be seen in persons with CP. 

21. ‘secondary musculoskeletal problems’ – People with

CP may develop a variety of musculoskeletal problems, such

as muscle/tendon contractures, bony torsion, hip displace-

ment, spinal deformity. Many of these problems develop

throughout life and are related to physical growth, muscle

spasticity, ageing and other factors. 

References

1. World Health Organization. (2001) International Classification

of Functioning, Disability and Health (ICF). Geneva: World

Health Organization.

2. Cans C. (2000) Surveillance of Cerebral Palsy in Europe: 

a collaboration of cerebral palsy surveys and registers. Dev Med

Child Neurol 42: 816–824.

3. NINDS Workshop on Classification and Definition of Disorders

Causing Hypertonia in Childhood. (2001) http://www.ninds.nih.gov/

news_and_events/Hypertonia_ Meeting_2001.htm

4. World Health Organization. (1980) International Classification

of Impairment, Activity and Participation – ICIDH-2. Geneva:

World Health Organization.

5. Palisano R, Rosenbaum P, Walter S, et al. (1997) Development and

reliability of a system to classify gross motor function in children

with cerebral palsy. Dev Med Child Neurol 39: 214–223.

6. Beckung E, Hagberg G. (2002) Neuroimpairments, activity

limitations, and participation restrictions in children with

cerebral palsy. Dev Med Child Neurol 44: 309–316.

7. Eliasson AC, Rösblad B, Krumlinde-Sundholm L, Beckung E,

Arner M, Ohrwall A-M, Rosenbaum P. (2006) Manual Ability

Classification System (MACS) for children with cerebral palsy: scale

development and evidence of validity and reliability. Dev Med

Child Neurol 48: 549–554.

8. Bartlett DJ, Purdie B. (2005) Testing of the Spinal Alignment and

Range of Motion Measure: a discriminative measure of posture

and flexibility for children with cerebral palsy. Dev Med Child

Neurol 47: 739–743.

9. Gorter JW, Rosenbaum PL, Hanna SE, Palisano RJ, Bartlett DJ,

Russell DJ, Walter SD, Raina P, Galuppi BE, Wood E. (2004) Limb

distribution, type of motor disorder and functional classification

of cerebral palsy: how do they relate? Dev Med Child Neurol 

46: 461–467.

10. Ashwal S, Russman BS, Blasco PA, et al. (2004) Practice

parameter: diagnostic assessment of the child with cerebral

palsy: report of the Quality Standards Subcommittee of the

American Academy of Neurology and the Practice Committee of

the Child Neurology Society. Neurology 62: 851–863.

II. Classification of cerebral palsy

Cerebral palsy (CP) describes a group of permanent disorders

of the development of movement and posture, causing activ-

ity limitation, that are attributed to non-progressive distur-

bances that occurred in the developing fetal or infant brain.

The motor disorders of cerebral palsy are often accompanied

by disturbances of sensation, perception, cognition, commu-

nication and behaviour, by epilepsy, and by secondary muscu-

loskeletal problems. 

The above definition of cerebral palsy covers a wide

range of clinical presentations and degrees of activity

limitation. It is therefore useful to further categorize

individuals with CP into classes or groups. The purposes

of classification include:

1. Description: providing a level of detail about an individ-

ual with CP that will clearly delineate the nature of the prob-

lem and its severity.

2. Prediction: providing information that can inform health-

care professionals of the current and future service needs of

individuals with CP. 

3. Comparison: providing sufficient information to permit

reasonable comparison of series of cases of CP assembled in

different places.

4. Evaluation of change: providing information that will

allow comparison of the same individual with CP at different

points in time.

Traditional classification schemes have focused principally

on the distributional pattern of affected limbs (e.g., hemiple-

gia, diplegia) with an added modifier describing the predom-

inant type of tone or movement abnormality (e.g., spastic,

dyskinetic). However, it has become apparent that additional

characteristics must be taken account of for a classification

scheme to contribute substantively to the understanding and

management of this disorder. 

INFORMATION REQUIRED FOR CLASSIFICATION

The information available to provide an adequate classifica-

tion of the features of CP in any individual will vary over the

age span and across geographic regions and settings. The

role of aging in changing the clinical phenomenology of CP

has been little studied, and the possibility of classification

changes over time cannot be completely dismissed. Defining

the presence or degree of accompanying impairments, such

as cognitive deficits, is age-dependent, and in young children

the type of motor disorder may be hard to characterize. Some

young children diagnosed as having CP may in fact have as

yet undiagnosed neurological disorders that are very slowly

progressive. While progressive disorders are not included in

the CP rubric by definition, a period of observation that includes

serial examinations of the child may at times be needed

before their exclusion can be assured.

Factors other than age will affect classification. Historical

data, especially about the course of pregnancy, will vary in

reliability and validity. Where neuroimaging facilities, diag-

nostic specialists and biochemical laboratories are not avail-

able, it may not be possible to completely exclude progressive

disorders and underlying pathology, as described by neu-

roimaging and other laboratory findings, However, all clas-

sification documentation should include the age of the

child, the nature of the information available from clini-

cal history (e.g. whether from clinical notes, maternal

recall or period of observation of the child), and the

extent to which metabolic and neuroimaging investiga-

tion has been performed.

USES AND LIMITATIONS OF A CLASSIFICATION SYSTEM

Classification often requires making difficult decisions about

where to draw the boundaries within ordinal or quantitative

measures. Some degree of arbitrariness is inevitable. Assignment

of individuals with the diagnosis of CP to distinct clinical

groups is not straightforward, and will differ depending on

the characteristic(s) chosen as the basis for classification. No one

Definition and Classification of CP April 2006  Peter Rosenbaum et al.

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