SPECIAL ARTICLE A CLASSIFICATION OF CEREBRAL PALSY By W. L. Minear, M.D., Ph.D. A REvuw of the literature reveals con- which the olden term, cerebral spastic paral- fusion in nomenclature and classifica- ysis, is only one of the group. It is fre- tion in the field of cerebral palsy. Using as quently a combination of both motor and a basis the majority opinion from question- sensory involvement. It was formerly con- names sent to the members of the American sidered as involving only a motor handicap, Academy for Cerebral Palsy during 1953 and on this basis confusion arose among (all members were polled; 64 per cent re- those treating such cases, since the other plied) by the Nomenclature and Classifica- associated handicaps were not recognized tion Committee, the following classification and difficulties arising from treating these for cerebral palsy is presented. children were attributed to their being A complete diagnosis should include one mentally defective. However, it is very diffi- on more titles from each of the main head- cult to explain how mental deficiency can ings of this nomenclature. The motor classi- be associated with pure athetosis on ataxia. fication is given precedence. Next, there The brain is a very complicated organ and should be a statement as to topography of any injury or lack of development in it gives the disease (body pants involved). There rise to unusual disturbances of function, also should be a statement as to the etiology both along the line of motor control and of the disease. A statement of the capabili- sensation. This places cerebral palsy in a ties of the patient should include the pen- group by itself, being made up of more than tinent motor, sensory, intellectual, emo- one entity depending on the area injured, tional, visual, speech, and hearing status, diseased, or defective.” (From lecture notes and should be made under each heading of Winthrop Phelps.) in the supplemental classification. If the In Cerebral Palsy: Its Individual and pathology in the brain has been determined Community Problems by Denhoff, as a accurately at necropsy or by means of standard definition, reference is made to electroencephalograms, pneumoencephalo- Perlstcin who is quoted as stating that cere- grams, or surgical exploration, a statement bral palsy is generally defined as a “condi- of structural disease should be made (neu- lion, characterized by paralysis, weakness, roanatomical diagnosis). Finally, a state- incoordination, or any other aberration of ment of the functional and therapeutic motor function due to pathology of the classification of the patient completes the motor control centers of the brain.” A limited list. Thus, a comprehensive diagnosis will definition cited by Denhoff is one wherein it demand a careful consideration of every is conceived as “a condition in which inter- aspect of the patient and will afford a fenences with the control of the motor sys- sound basis for prognosis, neuroanatomical tem arises as a result of lesions occurring correlation, and treatment. from birth trauma.” The practical definition, according to Dcnhoff, warrants serious con- CEREBRAL PALSY DEFINED sideration : “One component of a broader “The term, cerebral palsy, constitutes five brain damage syndrome comprised of neu- main classes of handicapped children, of romotor dysfunction, psychological dys- Dr. Minear is Chairman, Nomenclature and Classification Committee, American Academy for Cere- bra! Palsy. The proposed classification has the approval of the American Academy for Cerebral Palsy. This classification has been reviewed by the Committee on the Handicapped Child of the American Academy of Pediatrics and receives the endorsement of this committee. 841 Downloaded from www.aappublications.org/news by guest on September 27, 2021 842 MINEAR - CLASSIFICATION OF CEREBRAL PALSY function, convulsions, and behavior dis- disturbances should be excluded as well as orders of organic origin. those primarily the result of spinal cord “The characteristics of the cerebral pal- lesions.” sied child are paralysis, weakness, inco- Cruickshank and Raus,6 state : “As a dis- ordination, on any other aberration of motor ease, cerebral palsy is not progressive nor function due to malfunction of the motor is it contagious or epidemic in form. As a centers of the brain. neuro-physical and neuro-psychological “He may also have other symptoms which deviation, however, it is basically a disease. reflect a damaged brain. There may be con- Glidden Brooks has correctly spoken of vulsions, mental retardation on deficiency, cerebral palsy as a ‘long-term, non-fatal, vision, hearing or perceptual problems, as non-curable disease.’ He considers it a dis- well as speech, behavioral and emotional ease in the sense of the present discussion. disturbances. It is non-curable, but oftentimes amenable “The underlying cause of these symp- to therapy and training. It is non-fatal per toms-brain damage-is not a specific type. Se. Rather similar pathological findings are Cerebral palsy comprises those motor and found in such clinical entities as mental other symptom complexes caused by a non- deficiency, epilepsy, amid behaviour dis- progressive brain lesion (or lesions). The orders or organic origin. Thus originates characteristic thing about cerebral palsy is the term ‘brain damage’ syndrome which in- that it is a well defined entity with a eludes cerebral palsy along with other con- variety of etiologies and pathologies. When ditions mentioned. clinical syndromes become better deline- “Cerebral palsy is the neunomotor com- ated with respect to known etiologies and ponent of the ‘brain damage’ syndrome. It pathological changes, they too can be re- must always be kept in mind that the cere- moved from the general category of cere- bral palsied child may suffer from any other bral palsy, and placed in their own cate- component or components of the syndrome gonies. For example, it is not unlikely that along with the neuromotor handicap. bilirubin encephalopathy will someday be “The concept of the ‘brain damage’ syn- removed from the category of cerebral palsy drome has many practical applications, par- and given its own name. In the aging, ticularly from an educational and ‘parent arteriosclerosis or parkinsonian disease can understanding’ viewpoint. It negates the cause a change in the patient who has had propaganda that the cerebral palsied child cerebral palsy since infancy or childhood, presents a problem unique from that of but these are morbid entities superimposed other similarly handicapped children.” on the original lesion causing the cerebral John F. Pohl defines cerebral palsy as palsy. follows : “Cerebral palsy is the term used to The decision of the American Academy designate a group of neuromuscular dis- for Cerebral Palsy to delete neoplastic brain orders in which there is impairment or loss diseases and the progressive neurological of muscular control due to a lesion of the degenerative diseases of the brain has sev- brain.” cral important advantages. This decision C. L. Balf and T. T. S. Ingram, in a reduced the field of cerebral palsy to a more recent article,2 state as follows : “Cerebral logical and manageable unit. The treat- palsy is a descriptive term, applied to a ment of brain neoplasms is frequently sur- group of motor disorders of young children, gical or radiological and the treatment pro- in whom full function of one on more limbs gram depends on the type of neoplasm. It is prevented by panesis, involuntary move- is a great mistake to treat a brain neoplasm ment, on incoondination. Tacit agreement as cerebral palsy. Obviously, the correct has been reached that progressive diseases diagnosis should be made and the proper and those characterized by transient motor treatment program carried out. Downloaded from www.aappublications.org/news by guest on September 27, 2021 AMERICAN ACADEMY OF PEDIATRICS - SPECIAL ARTICLE 843 After the tumor is removed and there is often sensory involvement in the areas of no danger of recurrence, the patient may proprioception to point discrimination and form perception. Aphasias appear more fre- then be accepted to the ranks of those with quently in right than in left hemiplegias and cerebral palsy to be treated symptomati- are much more common in the acquired than cally for residuals of the lesion. The same in the congenital cerebral palsy. is true for a child with hydrocephalus, D. Triplegia traumatic on infectious damage to the brain. Involves 3 extremities, usually both legs and Under the new definition, the patient is one arm, usually spastic. This may represent hemiplegia plus paraplegia, or incomplete not accepted as cerebral palsy until a pro- quadriplegia. In the latter case, both arms gnessive nature of the etiology has been will be equal or nearly equal in length. In eliminated. This does not mean that treat- the former, the involved arm will be shorter. ment technique suitable for cerebral palsy E. Quadnplegia cannot be used on patients with progressive (Tetraplegia) Involvement of all 4 extremities. Patients with the greatest involvement of brain lesions, but rather that attention the legs are usually spastic, and patients with should be concentrated on the treatment greatest involvement of the arms are usually and elimination of progressive damage to the dyskinetics, including athetoids. the brain as long as this is a possibility. F. Diplegia This term is seldom used. “Paralysis affecting CLAssIFICATIoN OF CEREBRAL PALSY#{176} like parts on either side of the body; bilateral paralysis.” (The American Illustrated Mcdi- I. Physiological (motor) cal Dictionary, Dorland, 21st Edition.) A. Spastic C. Double Hemiplegia B. Athetotic This term is seldom used. “. implies those Types of athetosis accept- cases in which the arms are more involved able to the American than the legs. These are usually spastic in Academy for Cerebral type.” (Cerebral Palsy-Its Individual & 1 . Tension Palsy to date. For outline 2. Non-tension Community Problems, edited by William M. of 12-types of athetosis 3.