New Classification System for Severity
of Cerebral Palsy

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The newly published Gross Motor Classification System allows parents and professionals who work with children (age 0-12 years) with Cerebral Palsy to communicate clearly and consistently. The current system of classifying children as having “severe”, “moderate” or “minimal” Cerebral Palsy, has been found to have little inter and intra-rater reliability (superscript the reference below). The new system emphasizes the child’s functional abilities rather than their limitations. The level system allows us to credit the child for actual performance even when an assistive device is needed without undue emphasis on quality of performance.

Level I
An infant in this category can move in and out of sitting, floor sit independently, and manipulate objects with their hands before at 18 months. This same child is able to independently ambulate before age two years without an assistive device. By four years of age, the child can get up from the floor into standing without assistance. By age six years, the child can climb stairs. By age 12 years, a child performing at this level, is able to ambulate without assistance on all surfaces and can successfully complete more advanced gross motor skills. The Level One child can run and jump with reduced speed, balance and coordination.

Level II
An infant who is classified as functioning at Level Two is able to maintain floor sitting, but needs to use their hands to maintain their balance. This child is commando or belly crawling, pulling to stand on furniture, and beginning to cruise before age 2 years old. By age four, the child is still needing one or two hands to balance in floor sitting, so the hands are not free to manipulate objects bilaterally in space. Transitions in and out of sitting are accomplished independently, the child can pull to stand on a stable surface. Crawling is accomplished with a reciprocal pattern, and ambulation accomplished with an assistive device. When children who are functioning at Level Two are six years old, they can floor sit independently with both hands free, can get up from the floor using a stable surface, and ambulate short distances without an assistive device. These children usually require an assistive device walking outdoor and in the community until age twelve. These children can climb stairs using the railing, but cannot run or jump. By age twelve, uneven surfaces, inclines, and crowds are still difficult for these children to negotiate. For most conditions, the are able to ambulate without and assistive device.

Level III
Infants are able to maintain floor sitting when their low back is supported. These children are able to roll and creep forward on their stomachs. Between the ages of 2-4, these children often “W” sit (sitting between flexed and internally rotated hips and knees) and may require adult assistance to assume sitting. These children creep on their stomach or crawl on hand and knees (often without reciprocal leg movements). These children may pull to stand on a stable surface and cruise short distances. They may walk short distances indoors using an assistive mobility device and adult assistance for steering and turning. By age 6, these children sit indep in a chair, transfer using a stable object, walk with an assistive device and climb stairs with assistance from an adult. By age 12, they are indep community ambulators with an assistive device, climb steps using a railing and use a wheelchair for longer distances.

Level IV
Infants and toddlers in this category have head control, but truncal support is needed for sitting. These children can usually roll independently by age two. By age four, these children can sit when placed, but are need both hands on the floor to maintain their balance. These children need adaptive devices to accomplish sitting and standing. They are able to roll and creep, but do not use reciprocal leg movements. By their sixth birthday, these children can sit independently in a chair, but require truncal stabilization to maximize hand function. Transfers require minimal adult assistance. Ambulation is accomplished using assistive devices for short distances, but adult supervision is required and difficulty persists in negotiating turns and uneven surfaces. These children use wheeled mobility systems in the community and may achieve independence using a powered mobility system. By age twelve these children may accomplish higher levels of function but may still rely on wheeled mobility systems.

Level V
Before their second birthdays, children functioning at this level have limited voluntary control of movement. They are unable to hold up their head or trunk against gravity and require adult assistance to roll. By age twelve, these children cannot sit, stand or walk. Adaptive equipment and assistive technology are used extensively to attempt to compensate for the child’s deficits. Some children are able to use power mobility systems.

Summary
Thanks to the Neurodevelopmental Clinical Research Unit at McMaster University in Ontario, Canada, we now have a better way to communicate our assessment and expectations for gross motor development in children with cerebral palsy. This system works very well with clinical tools, such as the Gross Motor Function Measure, to allow families and professionals to track gains and make predictions about the future.

References:

Palisano, R, Rosenbaum, P, Walter, S, Wood, E, and B Galuppi. Gross Motor Function Classification System for Cerebral palsy. Dev Med Child Neurol 1997; 39:214-223

For free copies of this Classification System contact the Neurodevelopmental Clinical Research Unit at Mc Master University in Ontario, Canada at (905) 525-9140 or e-mail: ncru@fhs.mcmaster.ca

Ginny Paleg, is the FOCUS program coordinator at the Hospital for Sick Children in Washington, DC. She is NDT certified and a MOVE International Trainer. She can be reached at (800) 226-4444, ext. 279.