Document Type : Literature Reviews
Authors
1 Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran (https://orcid.org/0000-0001-6413-927X)
2 Department of Exercise and Sports Sciences; Charles Sturt University, Australia. Pediatric Neurorehabilitation Research Center, Tehran, Iran.
3 Department of Occupational Therapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
Abstract
Background: Cerebral palsy is one of the most prevalent physical disabilities in childhood. Children afflicted with this condition face a myriad of challenges and potential disabilities, which complicate treatment efforts. Integrating scales with other diagnostic instruments is increasingly crucial for accurately assessing these children and devising effective treatment strategies. This study primarily aims to review functional classification systems based on the International Classification of Functioning, Disability, and Health (ICF) for children with cerebral palsy and explore the relationships among these systems.
methods: This study was designed to review the ICF-based functional classification systems. A comprehensive search was conducted across multiple databases, including Google Scholar, PubMed, ERIC, OVID, ProQuest, Scopus, Web of Knowledge, and OTseeker. Search terms related to cerebral palsy and various aspects of body function, activity, and participation were utilized. The search was conducted until September 2022 to gather relevant literature for analysis.
Results: The analysis of the reviewed articles revealed the existence of five valid and reliable classification systems. In most studies, the correlation among these systems was moderate. Owing to their simplicity and comprehensiveness, these classification systems have significantly impacted the depiction of the functional status of children with cerebral palsy and the quality of their care. However, additional classification systems remain needed to address other overlooked functions and complete the overall description.
Conclusion: The outcomes of this review indicated the development of classification systems for certain functions in children with cerebral palsy. In conjunction with the classifications above, creating additional new systems for overlooked functions could offer a comprehensive and integrated understanding of children with cerebral palsy's crucial functional capacities and performances.
Highlights
azade riyahi:googel scholar
Afsoon Hassani Mehraban:googel scholar
Keywords
- Cerebral Palsy
- Communication Function Classification System (CFCS)
- Disability
- Eating and Drinking Ability Classification System (EDACS)
- Gross Motor Function Classification System (GMFCS)
- International Classification of Functioning
- and Health (ICF)
- Manual Ability Classification System (MACS)
- Visual Function Classification System (VFCS)
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- Sellers D, Mandy A, Pennington L, Hankins M, Morris C. Development and reliability of a system to classify the eating and drinking ability of people with cerebral palsy. Developmental Medicine & Child Neurology. 2014;56(3):245-51.
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|
Health Condition (Disorder/disease) |
|
Activities (Activity limitation) |
|
Body Structures and Functions |
|
Participation (Participation restriction) |
|
Environmental Factors |
|
Personal Factors |
Figure 1: WHO International Classification of Function, disability and health and showing the relationship between its components
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Table 1: The method of development and validation of functional classification systems and psychmetric properties |
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|
Year of publication |
Authors |
Subject of study
|
Population of study
|
Study method
|
Study Results
|
|
2019
|
Giovanni Baranello et al.
|
Construction and validation of a visual function classification system (VFCS) |
The reliability study included 29 specialists, 39 parents and an overall sample of 160 children with CP (mean age 6 years and 6 months in the range of 1-19 years)
|
Includes four steps: (1) Draft five levels of literature review analysis and clinical experience (2) Validation of structures and revision of levels for conceptual significance using the nominal group process (3) Amended by the Delphi International Survey (4) Assessing the reliability between evaluators among specialists as well as caregivers, and the reliability of test-retest |
The absolute agreement between the evaluators was 86%. Test-retest reliability was high. Reliability between parents and professionals in 39 average children. As a final conclusion, they stated that VFCS is properly constructed and is a reliable system for classifying the visual abilities of children with CP in the clinic and research environment.
|
|
2016
|
Eliasson et al.
|
Development of Manual ability classification for children under four years (Mini-MACS)
|
A sample of 61 children with CP aged 12 to 51 months was scored by a parent and two therapists for a total of 64 assessments. |
Level 1: Drafting the classification system Level 2: Nominal group process Level 3: Delphi Survey Level 4: Reliability |
The ICC coefficient was 0.90 between parents and therapists and 0.97 between the two therapists. Moreover, this system seems to be applicable for children with CP 1-4 years. |
|
2014
|
Diane Sellers et al.
|
Establishing a system for classifying the eating and drinking ability (EDACS) of children with CP and evaluate its reliability
|
Reliability study consisting of 25 speech and language therapists and 48 parents and 129 children and people with CP (4-22 years and mean age 14 years) |
Level 1: Drafting the system Level 2: Nominal group process Level 3: Delphi Survey Level 4: Reliability |
Agreement and reliability between two groups of excellent therapists and between the parent group and the therapists, the agreement was moderate to substantial and the reliability was good to excellent. Finally, they concluded that the EDACS system is a valid and reliable system for classifying the ability to eat and drink in children with CP. Ø Determining the validity and reliability of the Farsi version of the EDACS system by Riyahi et al. in 2019.
|
|
2011 |
Mary Cooley et al. |
Establishing and validating a Communication Performance Classification System (CFCS)
|
Reliability between evaluators By 61 specialists and 68 parents / relatives and 69 children with CP 2 to 18 years
|
An 11-member development team developed comprehensive descriptions of CFCS levels and reviewed four nominal groups of 27 participants. In a Delphi survey, 112 respondents commented on the clarity and usefulness of CFCS. Reliability between evaluators was completed by 61 specialists and 68 parents / relatives who classified 69 children with CP. Test-retest reliability was completed by 48 specialists with a minimum interval of 2 weeks between classifications. |
Reliability between the two specialists was 0.66 and between the parent and the specialist was 0.49. Reliability among evaluators among specialists for classifying children over 4 years of age had reached 0.77. The reliability of the test-retest was 0.82. CFCS interpretation showed content validity and test-retest reliability very good. Reliability between good evaluators among experts and reliablity between average evaluators among parents/experts. Ø Determining the validity and reliabilty of the Farsi version of CFCS system by Soleimani et al. in 2015. |
|
2008 |
Rosenbaum et al.
|
Construction, validity and reliability of a large motor function classification system in children with CP
|
110 children with CP 2-18 years
|
Level 1: Drafting the system Level 2: Nominal group process Level 3: Delphi Survey Level 4: Reliability
|
In this study, the reliability between the evaluators as well as the reliability of the test repetition was high. The positive predictive validity of GMFCS for predicting gait from 1 to 2 years of age up to 12 years of age was 0.74. Ø Determining the validity and reliability of the Farsi version of the GMFCS system by Dehghan et al. in 2010 Ø Evaluation of validity and reliability of the test - Parental version retest and reliability between therapists' prescription and GMFCS parental prescription by Riahi et al. in 2012 |
|
2006 |
Eliasson et al.
|
Manual Ability Classification System (MACS) for children with CP, how valid and reliable
|
Reliability between therapists for 168 children aged 4-18 years and 25 parents and pediatricians
|
Its validity was based on the experience of a skilled group, a review of articles, and a comprehensive analysis of children in a range of practices, resulting in a consensus on structures as well as on the content of the five levels. Then parents and therapists were interviewed about the content, simplicity and ease, explanation and preference of each level. Reliability was also assessed between therapists for 168 children aged 4-18 years and 25 parents and pediatric therapists.
|
The results showed that MACS has good validity and reliability. The internal correlation coefficient between therapists was 0.97 and between parents and therapists was 0.96, which is a sign of excellent agreement.
Ø Determining the validity and reliability of the Farsi version of the MACS system by Riahi et al. in 2013 |
Table 2: Reliability of the Gross Motor Function Classification System
|
Source |
Type of Reliability |
Subject Age Range, y |
Reliability Statistics |
|
|
Palisano et al [34]
|
Inter-rater reliability |
|
ICC =0.96 |
|
|
Inter-rater reliability |
older than 2 years of age |
K=0.75 |
||
|
Inter-rater reliability |
under 2 years of age |
K=0.55 |
||
|
Randall et al [35] |
Inter-rater reliability |
4-11 |
0.98 |
|
|
Wood et al [36] |
Inter-rater reliability |
2-12 |
G=0.93 |
|
|
Test–retest reliability |
G=0.79 |
|||
|
Palisano et al [37] |
Inter-rater reliability |
under 2 years of age |
K=0.55 |
|
|
Inter-rater reliability |
2-12 |
K=0.75 |
||
|
Russell et al [38] |
Test-retest reliability |
over 12 months |
ICC =0.99 |
|
|
Bodkin et al [39] |
Interrater reliability |
younger than two years old |
K=0.55 |
|
|
Interrater reliability |
two to 12 years old |
K=0.75 |
||
|
El et al [40] |
|
12-18 |
ICC=0.97 |
|
|
Test-retest reliability |
ICC=0.94 |
|||
|
Papavasiliou et al [41] |
|
mean age 5.4 years |
K=0.80 |
|
|
Piscitelli et al [42] |
Inter- reliability |
|
K=0.97 |
|
|
Intra-rater reliability |
|
K=0.98 |
||
|
|
GMFCS by parents |
|||
|
Riyahi et al [43] |
|
2-12 |
ICC=0.92 |
|
|
|
K=0.61 |
|||
|
GMFCS by therapists And parents |
||||
|
|
2-12 |
ICC=0.88 |
||
|
|
K=0.68 |
|||
|
Dehghan et al [44] |
Interrater reliability (IRR) |
|
P<0.05 |
|
ICC: Intraclass correlation coefficient
K: kappa coefficient
GMFCS: Gross Motor Function Classification System
IRR: Inter-rater reliability
Table 3: Reliability of the Manual Ability Classification System
|
Source |
Type of Reliability |
MACS Version
|
Subject Age Range, y |
Reliability Statistics |
|
Eliasson et al [21] |
Interrater reliability |
Original version |
4-18 |
ICC = 0.97 |
|
Van Meeteren et al [45] |
Interrater reliability |
Original version |
18-24 |
ICC = 0.83 |
|
Plasschaert et al [46] |
Interrater reliability |
Original version |
1-5 |
Κ = 0.55 (younger than 2 y) |
|
κ = 0.67 (2-5 y of age) |
||||
|
Jang et al [47] |
Interrater reliability |
Korean version |
4-14 |
ICC = 0.92-0.96 |
|
Interrater reliability |
Korean version |
4-14 |
ICC = 0.96-0.98 |
|
|
Akpinar et al |
Interrater reliability |
Turkish version |
4-18 |
ICC = 0.89-0.98 |
|
Test retest reliability |
Turkish version |
4-18 |
ICC = 0.91-0.98 |
|
|
Riyahi et al [20] |
Interrater reliability |
Farsi version |
4-18 |
ICC = 0.96 |
|
Test retest reliability |
Farsi version |
4-18 |
ICC = 0.97 |
|
|
Morris et al [48] |
Interrater reliability |
Original version |
6-12 |
ICC = 0.7-0.9 |
|
Mutlu et al [49] |
Interrater reliability |
Turkish version |
4-18 |
ICC = 0.96 |
|
Randall et al [35] |
Interrater reliability |
Original version |
4-11 |
κ = 1 |
ICC: Intraclass correlation coefficient
K: kappa coefficient
MACS: Manual Ability Classification System
Table 4: Reliability of the Communication Function Classification System
|
Source |
Type of Reliability |
Subject Age Range, y |
Reliability Statistics |
|
|||||
|
Hidecker et al [50] |
Inter-rater reliability |
2-18 |
K = 0.82 |
|
|||||
|
Randall et al [35] |
Inter-rater reliability |
4-11 |
0.98 |
|
|||||
|
Soleymani et al [51] |
between speech and language pathologists and occupational therapists |
|
|||||||
|
inter-rater reliability |
2-18 |
0.81 |
|
||||||
|
between parents and occupational therapists |
|
||||||||
|
inter-rater reliability |
2-18 |
0.74 |
|
||||||
|
between parents and speech and language pathologists |
|
||||||||
|
inter-rater reliability |
2-18 |
0.88 |
|
||||||
|
for occupational therapists |
|
||||||||
|
test-retest reliability |
2-18 |
0.96 |
|||||||
|
for speech and language pathologists |
|
||||||||
|
test-retest reliability |
2-18 |
0.98 |
|
||||||
|
for parents |
|
||||||||
|
test-retest reliability |
2-18 |
0.94 |
|
||||||
|
Vander Zwart et al [52] |
between parents and SLTs |
|
|||||||
|
Interrater reliability |
range 2y 9mo–12y 10mo |
r=0.54 |
|
||||||
|
between SLTs |
|
||||||||
|
Interrater reliability |
range 2y 9mo–12y 10mo |
r=0.78 |
|
||||||
|
SLT |
|
||||||||
|
intrarater reliability |
range 2y 9mo–12y 10mo |
r=0.85 |
|
||||||
Table 5: Reliability measures associated with use of Eating and Drinking Ability Classification System (EDACS) by speech and language therapists (SaLTs)
|
Source |
Reliability of EDACS levels |
Subject Age Range, y |
Reliability Statistics |
|
Sellers et al [53] |
Reliability of EDACS levels I to V |
4-22 |
K = 0.72 |
|
ICC= 0.93 |
|||
|
|
Reliability of EDACS levels of assistance |
k=0.80 |
|
|
ICC= 0.92 |
|||
|
Tschirren et al [54] |
Interrater reliability of EDACS |
mean age 9y 7mo |
κ=0.94 |
|
|
Interrater Reliability of EDACS level of assistance |
κ=0.89 |
|
|
Reliability measures associated with use of EDACS by speech and language therapists and parents |
|||
|
Sellers et al [53] |
Reliability of EDACS levels I to V |
4-22 |
k=0.45 |
|
|
ICC=0.86 |
||
|
|
Reliability of EDACS levels of assistance |
k=0.64 |
|
|
|
ICC=0.77 |
||
|
Tschirren et al [54] |
Interrater reliability of EDACS |
mean age 9y 7mo |
κ=0.82 |
|
|
Interrater Reliability of EDACS level of assistance |
κ=0.89 |
|
EDACS: Eating and Drinking Ability Classification System
SaLTs: Speech and language therapists
K: Kappa coefficient
ICC: Intraclass correlation coefficient
GMFCS: Gross Motor Function Classification System
MACS: Manual Ability Classification System
Mini-MACS: Mini Manual Ability Classification System
CFCS: Communication Function Classification System
EDACS: Eating and Drinking Ability Classification System
|
Table 6: General summary headings for the GMFCS, MACS, Mini-MACS, CFCS, EDACS and VFCS |
|||||
|
Level 5 |
Level 4 |
Level 3 |
Level 2 |
Level 1 |
Scale |
|
Transported in a Manual Wheelchair |
Self-Mobility with Limitations; May Use Powered Mobility |
Walks Using a Hand-Held Mobility Device |
Walks with Limitations |
Walks without Limitations |
GMFCS (aged 0–18) |
|
Does not handle objects and has severely limited ability to perform even simple actions. |
Handles a limited selection of easily managed objects in adapted situations |
Handles objects with difficulty; needs help to prepare and/or modify activities. |
Handles most objects but with somewhat reduced quality and/or speed of achievement. |
Handles objects easily and successfully. |
MACS (aged 4–18) |
|
Does not handle objects and has severely limited ability to perform even simple actions. |
Handles a limited selection of easily managed objects in simple actions. |
Handles objects with difficulty. |
Handles most objects, but with somewhat reduced quality and/or speed of achievement. |
Handles objects easily and successfully |
Mini-MACS (aged 1–4) |
|
Seldom effectively sends and receives, even with familiar partners |
Inconsistently sends and/or receives even with familiar partners |
Sends and receives with familiar partners effectively, but not with unfamiliar partners |
Sends and receives with familiar and unfamiliar partners but may need extra time
|
Sends and receives with familiar and unfamiliar partners effectively and efficiency |
CFCS (aged 2–18) |
|
Unable to eat and drink safely – tube feeding may be considered to provide nutrition |
Eats and drinks with significant limitations to safety |
Eats and drinks with some limitations to safety; there may be limitations to efficiency |
Eats and drinks safely but with some limitations to efficiency |
Eats and drinks safely and efficiently |
EDACS
(aged 3–18) |
|
Does not use visual function even in very adapted environments |
Uses visual function in very adapted environments but performs just part of vision- related activities |
Uses visual function but needs some adaptations |
Uses visual function successfully but needs self- initiated compensatory strategies |
Uses visual function easily and successfully in vision- related activities |
VFCS |
VFCS: Visual Function Classification System
Table 7: Relationship between Functional Classification Systems in Cerebral Palsy
|
Riyahi et al. in 2022 [29]
|
MACS- GMFCS-CFCS-EDACS |
There is a moderate and significant relationship between the MACS and the EDACS, the MACS and the CFCS, and the CFCS and the EDACS in children with CP. |
|
Mutlu A et al. in 2018 [55] |
GMFCS-MACS-CFCS |
GMFCS levels showed a strong correlation with MACS levels (rs=0.78). MACS level was strongly correlated with CFCS levels (rs=0.73), particularly in quadriplegic children (rs=0.78). GMFCS levels were moderately correlated with CFCS levels (rs=0.71). |
|
Margarta et al. in 2017 [27] |
GMFCS-MACS-CFCS-EDACS |
A high correlation between the four classifications was found (r> 0.70, p < 0.01). |
|
Killian et al. in 2014 [26] |
GMFCS-MACS-CFCS |
There were moderate positive correlations between three FCS: GMFCS and MACS (T were no significant correlations between CFCS and the other FCS). |
|
Compagnone E et al. in 2014 [56] |
GMFCS-MACS-CFCS |
A strong correlation was found between the three classifications: Level V of the GMFCS-E&R corresponds to Level V of the MACS (rs=0.67, p=0.001); the same relationship was found for the CFCS and the MACS (rs=0.73, p<0.001) and for the GMFCS-E&R and the CFCS (rs=0.61, p=0.001). |
|
Oskoui et al. in 2013 [57] |
GMFCS–MACS |
The overall agreement between GMFCS and MACS Levels was moderate (kappa 0.457, standard error 0.034) with a strong positive correlation (Spearman rho of 0.820, standard error 0.023). |
|
Himmelman et al. in 2013 [58] |
CFCS-GMFCS-MACS |
CFCS correlated with the GMFCS, MACS and cognitive function (p < 0.01). |
|
Riyahi et al. in 2013 [20] |
GMFCS-MACS |
Correlation between GMFCS and MACS was also calculated, this demonstrated a moderate relationship (P=0.727). |
|
Heidecker et al. in 2012 [50] |
GMFCS–MACS |
GMFCS levels were strongly correlated with MACS levels (rs=0.69, p<0.001). |
|
Heidecker et al. in 2012 [50] |
MACS–CFCS |
MACS levels were moderately correlated with CFCS levels (rs=0.54, p<0.001). |
|
Heidecker et al. in 2012 [50] |
GMFCS–CFCS |
GMFCS levels were moderately correlated with CFCS levels (rs=0.47, p<0.001), |
|
Akpinar P. et al. in 2010 [30] |
GMFCS–MACS |
Total agreement between the GMFCS and the MACS occurred in only 45% of the children. |
|
Gunel MK et al. in 2009 [59] |
GMFCS–MACS- WeeFIM |
A good correlation between the GMFCS and MACS was found in all children (r=0.735, p<0.01). There was also a correlation between the GMFCS and WeeFIM subscales according to subtypes and all parameters were correlated at the level of p<0.01, the same as the MACS. |
|
Carnahan KD et al. in 2007 [60] |
GMFCS–MACS |
The overall agreement between GMFCS and MACS was poor (kappa value 0.35, 95% confidence interval 0.27–0.41). |
|
Eliasson AC et al. in 2006 [21] |
GMFCS–MACS |
Correlation between GMFCS and MACS was also calculated, this demonstrated a moderate relationship. |
MACS: Manual Ability Classification System
GMFCS: Gross Motor Function Classification System
CFCS: Communication Function Classification System
EDACS: Eating and Drinking Ability Classification System
WeeFIM: Functional Independence Measure
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