How a landmark redefinition transformed understanding, classification, and treatment of cerebral palsy
For decades, the medical community's understanding of cerebral palsy (CP) was fragmented. Clinicians, researchers, and families often used different definitions and classification systems, creating confusion and hindering optimal care. By 2006, this changed profoundly. An international workshop of experts convened to redefine cerebral palsy, culminating in a landmark report that would reshape clinical practice, research, and the lives of those with CP and their families 1 .
International workshop held in Bethesda, MD, bringing together leaders in preclinical and clinical sciences 1 .
Publication of the landmark report on the Definition and Classification of Cerebral Palsy 1 .
Widespread adoption of new definition and functional classification systems in clinical practice worldwide.
"A group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain" 6 .
Moved beyond describing physical signs to focusing on how those signs limit daily activities.
Explicitly recognized that motor disorders are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior 6 .
Perhaps the most significant advance in 2006 was the full embrace of functional classification systems. Moving beyond traditional categories based solely on the type of movement disorder or limb topography, the new framework prioritized how a person functions in their daily life 7 .
This shift was aligned with the World Health Organization's International Classification of Functioning, Disability and Health (ICF), which emphasizes the importance of focusing on the functional consequences of health conditions 7 .
| Classification System | Abbreviation | Function Classified | Core Purpose |
|---|---|---|---|
| Gross Motor Function Classification System 6 7 | GMFCS | Mobility & Self-initiated movement | Classifies severity based on sitting, walking, and need for assistive devices. |
| Manual Ability Classification System 6 7 | MACS | Hand use & Object manipulation | Classifies how children use their hands to handle objects in daily activities. |
| Communication Function Classification System 7 | CFCS | Effectiveness of communication | Classifies performance of everyday communication. |
| Eating and Drinking Ability Classification System 7 | EDACS | Safety & Efficiency of eating/drinking | Classifies functional eating and drinking abilities. |
Level I: Walks without limitations.
Level II: Walks with limitations, particularly on uneven surfaces or for long distances.
Level III: Walks using a hand-held mobility device (e.g., a walker).
Level IV: Self-mobility with limitations; often uses a power wheelchair.
Level V: Is transported in a manual wheelchair, requiring extensive assistance.
A pivotal study that underpinned this new functional era was the landmark prospective longitudinal study by Rosenbaum et al. in 2002. This research provided the first reliable evidence for predicting the trajectory of gross motor function in children with CP, leading to the creation of motor development curves 6 .
The study successfully created a set of gross motor development curves for children with CP, stratified by their GMFCS level.
The curves demonstrated that a child's GMFCS level is a strong predictor of their long-term motor development 6 .
| GMFCS Level | Typical Gross Motor Function Achieved |
|---|---|
| I | Walks without limitations. |
| II | Walks with limitations, particularly on uneven surfaces or for long distances. |
| III | Walks using a hand-held mobility device (e.g., a walker). |
| IV | Self-mobility with limitations; often uses a power wheelchair. |
| V | Is transported in a manual wheelchair, requiring extensive assistance. |
Source: Adapted from Palisano et al., 1997, and Rosenbaum et al., 2002 6 .
| GMFCS Level | Probability of Walking Without Devices | Probability of Walking With/Without Devices |
|---|---|---|
| I & II | 100% | 100% |
| III | 0% | 100% |
| IV | 0% | ~50% (for short distances) |
| V | 0% | 0% |
Source: Conceptual summary based on Rosenbaum et al., 2002 6 .
The scientific importance of this work was monumental. It gave clinicians and families a powerful, evidence-based tool for prognosis and setting realistic goals. It also showed that motor development in CP is not static but follows predictable patterns, which helped in planning timely interventions 6 .
The advances in defining and classifying CP relied on a suite of reliable tools and concepts. The table below details some of the essential "research reagents" that became fundamental to the field after 2006.
| Tool/Concept | Function & Explanation |
|---|---|
| Brain MRI 1 |
Function: Identifies the location and nature of the brain injury or malformation. Importance: Sheds light on etiology and correlates with clinical type (e.g., periventricular leukomalacia often linked to spastic diplegia). |
| Gross Motor Function Measure (GMFM) 6 |
Function: A standardized evaluative tool to measure change in gross motor function over time. Importance: Served as the primary outcome measure for creating the motor development curves and is vital for assessing intervention efficacy. |
| Family-Centered Service (FCS) 2 6 |
Function: A service delivery model that views families as collaborators and experts on their child. Importance: Acknowledges that optimal child functioning occurs within a supportive family and community context, leading to better outcomes and satisfaction. |
| Multidisciplinary Team 2 3 |
Function: A team of professionals from various disciplines working collaboratively. Importance: Provides holistic, individualized care plans that address the multifaceted needs of the child and family. |
The year 2006 marked a definitive step forward in the world of cerebral palsy. The revised definition and the embrace of functional classification systems created a common international language that improved communication, research, and clinical care.
Standardized terminology for global use
Shifted emphasis to functional abilities
Enabled evidence-based prognosis
By shifting the focus from mere description of motor signs to a holistic view of a person's function, abilities, and overall well-being, the 2006 framework ensured that care could be better tailored to help individuals with CP achieve their fullest potential. The development of tools like the GMFCS and the research it enabled empowered families with realistic prognoses and solidified a care model that was not only scientifically rigorous but also profoundly human-centered.