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• Describing impairment and disability for children with cerebral palsy
  Christopher Morris
  Published on: 22 March 2016

• Published on: 22 March 2016

  Describing impairment and disability for children with cerebral palsy

  • Christopher Morris, Honorary Research Associate
  • Other Contributors:
    • Peter L. Rosenbaum, CanChild Centre for Childhood Disability Research, McMaster University

  Dear Editor

  We concur with Drs Colver and Sethumadhavan that the term diplegia has limited clinical value as a way to communicate about children with cerebral palsy and that use of the term should generally be discouraged.[1]

  The definition of diplegia is imprecise and requires judgment; the dividing lines between diplegia and quadriplegia, or between diplegia and hemiplegia with ‘some’ involvement of t...

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  Dear Editor

  We concur with Drs Colver and Sethumadhavan that the term diplegia has limited clinical value as a way to communicate about children with cerebral palsy and that use of the term should generally be discouraged.[1]

  The definition of diplegia is imprecise and requires judgment; the dividing lines between diplegia and quadriplegia, or between diplegia and hemiplegia with ‘some’ involvement of the non-hemiplegic side, are very unclear; and there is no evidence of inter-observer reliability to demonstrate that people can make these clinical distinctions accurately. Further, we agree with their recommendation about using the classification system developed by the Surveillance of Cerebral Palsy in Europe (SCPE) to arrive at a description of the ‘impairment’,[2] although we remain unaware of any evaluation of the inter-rater reliability of that system.

  However, we are concerned that the SCPE system does not currently encompass a reliable measure of functional ability. We propose that in order to describe children with cerebral palsy appropriately for the purposes of epidemiological or clinical studies the SCPE classification needs to be supplemented with a more dependable measure of the child’s functional ability (in effect, of the ‘severity’ of disability). This would describe, for example, whether the child can sit, stand or walk unsupported or with assistive devices. The Gross Motor Function Classification System (GMFCS) was developed explicitly for this purpose and its validity and reliability have been demonstrated.[3] The GMFCS provides a means to describe the functional ability of children with cerebral palsy at different ages in one of five explicitly defined levels. Children in Level I can perform most or all the activities of their age- matched peers, albeit with some difficulty with speed, balance, and coordination; children in Level V have difficulty controlling their head and trunk posture in most positions and achieve little or no voluntary control of movement. The recently published Motor Development Curves report significantly different patterns of gross motor development in children with cerebral palsy from a longitudinal study, classified according to each of the five levels of the GMFCS.[4] Since the initial publication in 1997 the GMFCS has had a major impact (over 50 citations) and has been utilised across the spectrum of epidemiology and clinical research.[5]

  In summary, we agree that ‘the term diplegia should be abandoned’ but argue that most epidemiological or clinical studies require information on the functional ability of children. The Gross Motor Function Classification System is the condition-specific scale of ‘gross motor functional ability’ for children with cerebral palsy and should be used to supplement the SCPE classification of ‘impairment’. Furthermore we are optimistic that reaching an international consensus on clear and reliable operational definitions of clinical pictures might provide a basis for assessing differences in aetiology and neuropathology on the theme of developmental motor impairment.

  References

  (1) Colver AF, Sethumadhavan T. The term diplegia should be abandoned. Arch Dis Child 2003;88:286-90.

  (2) Anon. Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol 2000;42:816-24.

  (3) Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 1997;39:214-23.

  (4) Rosenbaum PL, Walter SD, Hanna SE, Palisano RJ, Russell DJ, Raina P et al. Prognosis for Gross Motor Function in Cerebral Palsy Creation of Motor Development Curves. JAMA 2002;288:1357-63.

  (5) Morris C, Bartlett D. Gross Motor Function Classification System: impact and utility. (submitted for publication).

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  Conflict of Interest:
  None declared.

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