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Definition and classification of cerebral palsy

Article in Developmental Medicine & Child Neurology April 2007
DOI: 10.1111/j.1469-8749.2007.00166.x Source: PubMed

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Robert W. Armstrong
Aga Khan University Hospital, Nairobi
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The Executive Committee for the Definition of Cerebral Palsy

(CP) produced an excellent redefinition of CP in 2005 for
us to consider.1 They challenged us to think differently and
more broadly about how we define and describe CP. There is,
however, opportunity to provide more clarity by distinguishing between what is included in the definition and what is
included in the classification. With this clarification there can
be an orderly evolution of the classification as our knowledge
advances, while the definition can remain fairly constant.
The central elements of the definition are captured in the
first sentence: a group of 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. This defines the cohort of individuals who have a commonly recognized phenotype we know
as CP, as captured in the International Classification of Diseases
(ICD)-10 code (G80). The definition alone would not address
the concerns of Baxter and Rosenbloom2 that developmental
coordination disorder (DCD) might now be considered to be
CP. However, it is quite feasible, and happens in other circumstances, to exclude DCD from this definition and define the
set of tools that should be used to differentiate DCD from CP.
We do know from a number of cohort studies across the world
that CP can be defined reliably using the right set of tools and
that this can identify an appropriate cohort which can be followed over time.3,4
The difficulty with the definition comes with the second sentence. This should be removed entirely and replaced with a sentence such as the following: A full description of the individual
with CP requires classification of the motor abnormalities,
associated impairments, anatomic findings, and definition of
function according to the World Health Organization (WHO)
International Classification of Function. This is a linking sentence and is not actually part of the definition. The linkage is to
the more extensive classification system which is well presented by the Executive Committee, although clearly needing more
work as described by Blair and Love.5
The issue of age at the time of the disturbance is not
resolved by this definition and does need to be addressed. In
the current ICD-10 there is now the ability to use dagger and
asterisk symbols in order to link different ICD-10 codes. This
approach has been suggested for use within the neurological
adaptations of ICD-106 where a general disease or condition
may be identified elsewhere in ICD-10. For example, tuberculous meningitis has its dagger code (A17.0) in the chapter
for infectious and parasitic diseases and its asterisk code
(G01*) in the nervous system chapter. This approach might
be of value in differentiating postnatal etiologies of CP, and

166

Developmental Medicine & Child Neurology 2007, 49: 166166

Commentary

Definition and
classification of
cerebral palsy

offer greater clarity and broader inclusion within the definition

of the fetal or infant brain.
An additional important issue is the apparent disconnection of the Executive Committee process to define and classify
CP from the WHO procedures for developing and refining the
ICD-10. Other international groups have recognized the importance of working within the framework of the WHO Family of
International Classifications (2004), of which the ICD-10 and the
International Classification of Functioning, Disability and Health
are central to this effort to define and classify. There is a specific
extension of the ICD-10 to incorporate an expanded classification for neurology and ongoing work in preparation for revisions
based on changes in the field as a result of advances in diagnosis,
etiopathogenesis, genetics, nosology, and classification.7
A similar approach should be taken with respect to the definition and classification of CP so that we see the process as evolving
with the advancement of knowledge, while at the same time
retaining the group of disorders that reflect the phenotype.
The phenotype is important and families, clinicians, teachers,
and researchers will continue to value the term CP for what it is.
For the clinician and family the term initiates the discussion of an
important condition that has many potential implications for the
child and for the family. Despite the shock of the diagnosis, over
time we come to capture the details within this broader term and
doing so supports a language of discourse and identity that is
very important. However, very clearly, the use of the term CP
should not distract us from pushing hard for greater clarity using
all the tools we have available to improve our understanding of
this group of disorders.
Robert W Armstrong
References
1. Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N, Dan B,
Jacobsson B, Damanio D. (2005) Proposed definition and classification
of cerebral palsy, April 2005. Dev Med Child Neurol 47: 571576.
2. Baxter P, Rosenbloom L. (2005) CP or not CP? Dev Med Child Neurol
47: 507. (Editorial)
3. Surveillance of Cerebral Palsy in Europe (SCPE) working group.
(2000) Surveillance of cerebral palsy in Europe: a collaboration of
cerebral palsy surveys and registers. Dev Med Child Neurol
42: 816824.
4. Mutch L, Alberman E, Hagberg B, Kodama K, Perat MV. (1992)
Cerebral palsy epidemiology: where are we now and where are
we going? Dev Med Child Neurol 34: 547551.
5. Blair E, Love S. (2005) Definition and classification of cerebral palsy.
Dev Med Child Neurol 47: 510. (Commentary)
6. Van Drimmelen-Krabbe JJ, Bradley WG, Orgogozo JM, Sartorius N.
(1998) The application of the International Statistical Classification of
Diseases to neurology: ICD-10 NA. J Neurol Sci 161: 29.
7. World Health Organization Family of International Classifications.
(2004) http://www.who.int/classifications/en/ (Accessed June 2006)