2.

6
CLASSIFICATION OF CEREBRAL
PALSY AND PATTERNS OF
GAIT PATHOLOGY
Sylvia Õunpuu, Pam Thomason, Adrienne Harvey and H. Kerr Graham

A classification is the grouping together of a number of individuals that share common

attributes related to a specific disease process. Classification is necessary to define pathology
at all levels from etiology, presentation, severity of involvement and functional abilities.
With carefully defi ned classifications, we can better communicate among professionals
about patients, estimate prognosis, make the most appropriate treatment decisions and
realize the best outcomes. While there has been general consensus on the definition
of cerebral palsy (CP) (Stanley et al. 2000, Rosenbaum et al. 2006), a wide variety of
classifications have been put forward. Clover and Sethumadhavan (2003) have provided a
very comprehensive history of how classification of CP has changed since the original
description by Little in 1843 (Rang 1966) (Table 2.6.1). The following chapter will provide
a brief description of a few classification systems used to define CP with a focus on
functional classifications, which are the final stage at which treatment related to functional
outcomes decisions must take place.

Why classification?
Before discussing a few of the many classifi cation schemes of cerebral palsy that have been
put forward, it seems necessary to review the reasons why classification is necessary. Bax
et al. (2005) provided four primary reasons for the need to classify CP. These include the
following: (1) to provide a description that provides a level of detail that can delineate the
nature of the problem and its severity, (2) to provide prediction of both current and future
service needs for an individual, (3) to provide comparison so that groups of patients with
CP at one institution can be compared with those at another, and (4) to evaluate change so
that one individual with CP can be evaluated at various times and change can be documented.
These authors felt that further classification is needed, because the definition of CP is so
broad. Classification systems have traditionally focused on the distribution of affected limbs,
for example diplegia or hemiplegia, with an additional modifier to identify the type of
muscle tone, for example spastic. Because of the complexity of presentation of individuals
with CP a more in-depth classification system is needed to improve understanding and
ultimately management of this disorder.

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 TABLE 2.6.1
Comprehensive history of classification schemes for cerebral palsy since 1843

Reference Year Classification

Little 1862 Hemiplegic rigidity
Paraplegic rigidity
Generalized rigidity
Disordered movements without rigidity
Sachs and 1890 Paralysis of intrauterine origin Diplegia
Petersen Paraplegia
Hemiplegia
Birth palsies Diplegia
Paraplegia
Hemiplegia
Diataxia (ataxia)
Acute acquired palsies Hemiplegia
Paraplegia
Diplegia
Choreo-athetoid
Freud 1893 Unilateral disorders - hemiplegia Right or left
Bilateral disorders - diplegia Generalized rigidity
Paraplegic rigidity
Bilateral hemiplegia
Choreo-athetosis
Others
Wyllie 1951 Congenital symmetric diplegia
Congenital paraplegia
Quadriplegia or bilateral hemiplegia
Hemiplegia with additional qualifications Choreo-athetoid cerebral palsy
referring to all categories
Mixed forms of cerebral palsy
Ataxic cerebral palsy
Atonic diplegia
Minear 1956 A. Physiological Spasticity, athetosis, rigidity, ataxia,
tremor, atonia, mixed unclassified
B. Topographical Monoplegia, diplegia, paraplegia,
hemiplegia, triplegia, quadriplegia
C. Aetiological Prenatal, natal anoxia, postnatal, cause
described
D. Trauma Cause described
E. Supplemental Psychological evaluation
Physical status, convulsive seizures,
posture and locomotive behavior pattern,
eye-hand behavior pattern, visual status,
auditory status, speech disturbances
F. Neuroanatomical
G. Functional capacity Class I-IV
H. Therapeutic Class I-IV

Neurology Extent Severity

Ingram 1955 Hemiplegia Right or left Mild
Moderate
Severe
Double hemiplegia Mild
Moderate
Severe

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 TABLE 2.6.1 (continued)
Comprehensive history of classification schemes for cerebral palsy since 1843

Reference Year Classification

Diplegia
Hypotonic Paraplegia Mild
Dystonic Triplegia Moderate
Rigid or spastic Tetraplegia Severe
Ataxia
Cerebellar Unitaleral Mild
Vestibular Bilateral Moderate
Severe
Ataxia diplegia
Hypotonic Paraplegia Mild
Spastic Triplegia Moderate
Tetraplegia Severe
Dyskinesia
Dystonic Monoplegia Mild
Choreoid Hemiplegia Moderate
Athetoid Triplegia Severe
Tension Tetraplegia
Tremor
Other
Little Club 1959 Spastic cerebral palsy Hemiplegia
Diplegia
Double hemiplegia
Dystonic cerebral palsy
Choreo-athetoid cerebral palsy
Mixed forms of cerebral palsy
Ataxic cerebral palsy
Atonic diplegia

(From Clover and Sethumadhavan 2003, Table 1, p.287, by permission.)

Classifications of cerebral palsy

Minear (1956) has provided the most comprehensive classification system for CP which
includes the following categories: (1) physiological (motor), (2) topographical (distribution
of involvement), (3) etiological, (4) supplemental (patient capabilities from intellectual to
visual), (5) neuroanatomical (brain lesion), (6) functional capacity (severity) and (7)
therapeutic (level of treatment). The physiological classification refers to the motor aspects
of impairment, which are categorized as follows: spastic, athetotic, rigid, ataxic, tremor,
mixed and unclassified. The motor presentation of CP is defined in more detail in Chapters
2.3 and 2.4. The topographical classification refers to the anatomical location of involvement
and is categorized as follows: monoplegia (one lower limb is principally involved); diplegia
(both lower limbs are involved with minimal involvement of upper limbs); hemiplegia
(ipsilateral involvement with the upper extremity more involved than the lower); triplegia
(ipsilateral hemiplegia with contralateral monoplegia); quadriplegia (all four limbs involved
– lower > upper); and double hemiplegia (all four limbs involved – upper > lower). The
etiological classification represents several categories of cause: hereditary, acquired in utero,

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natal and postnatal. The etiology of CP was defined in more detail in Chapter 2.1. The
supplemental categories include the other systems that can be involved in CP including:
psychological, visual, auditory, posture, seizures and physical status. The neuroanatomical
classification is dependent on comprehensive imaging capabilities, which will be discussed
in Chapter 3.2. Even more than 50 years after Minear proposed the classification, the
correlation of lesion presentation obtained by imaging and patient function is still not well
understood. Finally Minear finishes with function and therapeutic classifications. The
functional classifications defined the level of severity. Four levels were proposed: Class 1:
patients with no practical limitation of activity; Class 2: patients with slight to moderate
limitation of activity; Class 3: patients with great limitation of activity; and Class 4: patients
who are unable to carry on any useful physical activity. These four levels, which were
proposed in 1956, are similar to the newer five-level GMFCS Classification, which will be
discussed later in this chapter. Minear further defined CP into therapeutic classifications:
Class A: requiring no treatment; Class B: requiring minimal bracing and therapy; Class
C: requiring bracing and treatment from a CP team; and Class D: requiring long-term
institutionalization and treatment. In general, his classification has stood the test of time.
A simpler standardized classification scheme for CP was proposed more recently by Bax
et al. (2005). This group proposed four major dimensions of classification: (1) motor
abnormalities, (2) associated impairments, (3) anatomical and radiological fi ndings, and
(4) causation and timing (Table 2.6.2). The primary difference between the proposed
classification and others is the proposal to eliminate the terms diplegia and hemiplegia due

TABLE 2.6.2
List of the major components of the classification of cerebral palsy as described by Bax et al. (2005)

Motor abnormalities
Nature and typology of the motor disorder: the observed tonal abnormalities assessed on examination (e.g.
hypertonia or hypotonia) as well as the diagnosed movement disorders present, such as spasticity, ataxia,
dystonia, or athetosis
Functional motor abilities: the extent to which the individual is limited in his or her motor function in all
body areas, including oromotor and speech function

Associated impairments
The presence or absence of associate non-motor neurodevelopmental or sensory problem, such as seizures,
hearing of vision impairments or attentional, behavioral, communicative and/or cognitive deficits, and the
extent to which impairments interact in individuals with CP

Anatomic and radiological findings

Anatomic distribution: the parts of the body (such as limb, trunk or bulbar region) affected by motor
impairments or limitations
Radiological findings: the neuroanatomic findings of computed tomography or magnetic resonance imaging,
such as ventricular enlargement, white matter loss, or brain anomaly

Causation and timing

Whether there is a clearly identified cause, as is usually the case with postnatal CP (e.g. meningitis or head
injury) or when brain malformations are present, and the presumed time frame during which the injury
occurred, if known.

From Bax et al. 2005; reproduced by permission of Mac Keith Press.

150
to the substantial inconsistency in definition and imprecise use of these terms in both clinical
practice and research. The authors recommend that the termsunilateral and bilateral be used
in conjunction with a description of the motor disorder and functional motor classification
in both the upper and lower extremities.

Classification of function using functional assessment scales

Since Minear’s proposed classification in 1956 there have been a variety of efforts to
improve the classification of function for persons with CP. The most commonly used
classification of gross motor function in children with CP is the Gross Motor Function
Classification System (GMFCS).

THE GROSS MOTOR FUNCTION MEASURE (GMFM)

Classification and measurement of gross motor function in CP are essential steps because
they guide the family and the multidisciplinary management team to the natural history, and
long-term prognosis of the condition. When planning treatment of gait problems,
classification of gross motor function also guides decision-making towards appropriate
management. The GMFM is the crierion for the measurement of gross motor function in
children with CP, and has been shown to be valid, reliable and responsive to change (Russell
and Rosenbaum 1989, Nordmark et al. 1997, 2000, Bjornson et al. 1998a, b, Russell et al.
2000, Russell and Leung 2003, Russell and Gorter 2005).
There are two versions of the GMFM. The original version consisted of 88 items, which
were grouped into five dimensions of gross-motor function: lying and rolling, sitting,
crawling and kneeling, standing and walking, and running and jumping (Russell and
Rosenbaum 1989). A more recent version, which consists of 66 items, is computer scored,
and features item maps. Because it has 22 fewer items, it is faster to administer. Since many
of the 22 items that were removed from the GMFM-88 came from the lower end of the
mobility scale, however, it is potentially limited for children who are very young or very
severely involved (Russell and Leung 2003). In either case, measurement of GMFM requires
specific training, an experienced physical therapist, and will take between 45 and 60 minutes
on average to perform. Consequently, it should be considered to be an essential research
tool: for example, in clinical outcome trials.

THE GROSS MOTOR FUNCTIONAL CLASSIFICATION SYSTEM (GMFCS)

The five gross motor curves (Fig. 2.6.1) which translate into the Gross Motor Functional
Classification System (GMFCS) were introduced by Palisano and Rosenbaum (1997). This
has now evolved into the GMFCS (Rosenbaumet al. 2002).
The gross motor curves are a useful matrix for identification of where a child is at a
specific point in time in relation to their age and gross motor function. This is very useful
in the prediction of future change. The vertical lines on the gross motor curves indicate the
point at which 90% of final gross motor function is likely to be achieved and is much younger
than often considered by clinicians. There are different descriptors for five different age
bands and in general, the GMFCS becomes more reliable in older age groups at least up to
the 6–12 age band (Nordmarket al. 1997). The child who is between 2 and 4 years old may

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Fig. 2.6.1 Gross motor curves. Curves provide information about the predicted average development
in groups defined by the Gross Motor Function Classification System levels. (Reproduced from
Rosenbaum et al. 2002, Fig. 3, p 1361, by permission.)

be on the up swing of their gross motor curve, the child who is 6–12 years old may be on a
stable plateau of gross motor function, and the youth between 12 and 18 years may be on
a descending curve of gross motor function. These issues are highly relevant to manage -
ment and clinical research. For example a child with spastic diplegia aged 2 years, GMFCS
level II, who receives injections of botulinum toxin A (BoNT-A) for spastic equinus may
make rapid gains in gross motor function and quickly move from walking only with
assistance to walking independently. It is tempting for both the clinician and the parent to
attribute the rapid gain in gross motor function solely to the effects of the injections of
BoNT-A. Reference to the appropriate gross motor curve, however, indicates that such a
child is following a curve with a rapid upward trajectory with or without intervention. For
this reason, the reporting of clinical trials involving physiotherapy, the use of orthoses and
injections of BoNT-A, in younger children with CP, must include an appropriate control
group.

THE FUNCTIONAL MOBILITY SCALE (FMS) AND FUNCTIONAL ASSESSMENT

QUESTIONNAIRE (FAQ)
Several groups have developed simple categorical scales for the assessment of functional
ability and functional mobility in children with CP to be used as a longitudinal measure.
These scales were designed to be responsive to change and can be used to document the

152
serial attainment of mobility scales and functional abilities, the deterioration or improvement
in these skills after intervention, or other changes consequent on growth and development.
The FMS is a 6-level ordinal scale that rates the mobility of children with CP over three
distances according to their need for assistive devices (Graham et al. 2004). The three
distances of 5, 50 and 500 meters represent mobility in the home, school and wider
community settings respectively. The scale is clinician administered through parent or child
report and should reflect performance rather than capability, i.e. what the child actually
does do rather than what they can do. For each of the three distances a rating of 1–6 is
assigned. Figure 2.6.2 displays the FMS where 6 represents children who walk
independently on all surfaces, 5 those who walk on level surfaces only, 4 those who use
single point sticks, 3 the use of crutches, 2 the use of a walker and 1 represents wheelchair
mobility. ‘C’ represents crawling and ‘N’ is for ‘does not apply’ and is assigned when
children do not go anywhere for long distances using any of those mobility devices. The
FMS is reliable and valid and has been shown to detect both deterioration and improve-
ment in mobility that occurs in the rehabilitation period following single event multilevel
surgery (Graham et al. 2004, Harvey et al. 2007).
The walking scale of the Gillette FAQ (Novacheck et al. 2000) is a 10-level parent-
report walking scale encompassing a range of walking abilities from non-ambulatory
to ambulatory in a variety of community settings and terrains (Fig. 2.6.3). It is a good
measure of parental perspective and covers a wide variety of activities of daily living. Both
the FMS and FAQ will be described in more detail in terms of case examples and treatment
outcomes in Chapter 6.1.

Classification of function using motion measurement techniques

Optimum physical management of the child with CP requires comprehensive measurement
of both function and gait. Three dimensional motion analysis techniques have facilitated the
classification of gait function at both the joint level and in relation to patterns of movement
across multiple joints. When proposed treatments impact the joint level, gait analysis provides
the optimal information with which to make treatment decisions (such as orthopaedic surgery
or bracing) and to evaluate treatment outcomes. Therefore any classification system being
used to define treatment for the ambulatory person with CP, must consider measuring gait
function at the individual joint level. Several strategies have been proposed for the
classification of gait function based on joint kinematics in hemiplegia (Winters et al. 1987,
Rodda and Graham 2001) and diplegia (Sutherland and Davids 1993, Rodda and Graham
2001, Rodda et al. 2004). Prior to this, gait patterns were described based on observational
analysis alone (Rang 1990). Gait patterns have also been described using statistical techniques
such as cluster analyses to describe gait patterns in CP (Wong et al. 1983, O’Malley et al.
1997, O’Byrne et al.1998). However, the lack of direct correlation of these analyses to joint
level understanding of function has limited their use as clinical tools.

Classification of unilateral involvement (hemiplegia)

The first attempt at classification of gait patterns with instrumented gait analysis in persons
with hemiplegia was by Winters et al. (1987), who described a classification system using

153
Fig. 2.6.2 Functional Mobility Scale (FMS). The purpose of the FMS is to measure a child’s current
performance. Visual cues are provided along with descriptions to assist in defining current level of
performance. (Reproduced from Harvey 2008, Fig. 4.1, p 112, by permission.)

154
Fig. 2.6.3 Gillette Functional Assessment Questionnaire: Functional Walking Scales. The parent is
expected to check one of the ten options that best reflects their child’s typical ability to walk, and
check boxes in list for other physical activities the child can do. (Reproduced by permission of the
questionnaire’s author, Dr Tom Novacheck.)

155
sagittal-plane kinematics for the ankle, knee, hip and pelvis. These patterns from type 1
through type 4 reflected increasing levels of involvement. Although the patterns present
some overlap and blend into each other, they do provide a guide for surgical management.
Type 1 represents a patient with a drop foot in swing related to triceps surae over activity
and/or anterior tibialis weakness (Fig. 2.6.4a). Since a true contracture is not present, the
only management required is an orthosis to control the drop foot during swing phase. Type
2 represents a drop foot in swing as well as restricted ankle dorsiflexion in stance secondary
to contracture of the plantarflexors. However, there is relative sparing of the knee and hip
(Fig. 2.6.4b). Management of the patient with type 2 hemiplegia may require a procedure
to obtain increased ankle dorsiflexion during stance, which might include a lengthening of
the triceps surae and/or tibialis posterior. Type 3 represents a patient with the characteristics
of types 1 and 2 as well as spasticity/contracture of the biarticular muscles crossing the
knee. It usually features increased knee flexion at initial contact and stance as well as reduced
and delayed peak knee flexion in swing (Fig. 2.6.4c). Appropriate management of a patient

(a) (b) (c) (d)

Fig. 2.6.4 Sagittal plane patterns for hemiplegia type 1 (a), 2 (b), 3 (c) and 4 (d) for the trunk, pelvis,
hip, knee and ankle. Multiple gait cycles from an individual child for each type are plotted in relation
to typical motion (grey band).

156
with type 3 hemiplegia requires similar management of the ankle (plantarflexors) as for
type II as well as appropriate treatment of the muscle problems at the knee (hamstrings and
rectus). Finally, type 4 represents a patient with the characteristics of types 1–3 as well as
hip involvement with limited hip extension in terminal stance and increasing anterior pelvic
tilt in stance (Fig. 2.6.4d). Management of the type 4 patient will require appropriate
treatment of muscles crossing all three joints (ankle, knee and hip) (Stout et al. 2004).
A limitation of the Winters classification system is that no mention of common
transverse-plane kinematic abnormalities was included and there was no inclusion of knee
hyperextension which is a common pattern in hemiplegia. Rodda and Graham (2001)
proposed a more comprehensive classification system. This included an additional sagittal-
plane pattern of knee hyperextension in combination with excessive equinus in stance and
swing, as well as transverse plane abnormalities of internal hip rotation (both of which are
likely to occur in the more involved person with CP). Management of the type 4 pattern
in the Rodda classification might include femoral derotation osteotomy and possible
adductor lengthenings at the hip; hamstring lengthenings and rectus femoris transfer at the
knee; and appropriate lengthening of the posterior calf to improve ankle motion. The Rodda
classification is presented diagrammatically in Figure 2.6.5.

Classification of bilateral involvement (diplegia)

The classification systems for patients with diplegia are more complex, as bilateral
involvement is present; and, in many cases, involvement is not symmetrical with different
patterns on one side in comparison to the other. Rodda et al. (2004) recognized the issues
related to asymmetry must be addressed in a classification system and included five sagittal-
plane classifications, the final of which (type 5) recognizes the common presentation of
asymmetrical involvement. A diagrammatic representation of this classification is presented
in Figure 2.6.6. Group 1 represents patients with true equinus, Group 2 represents patients
with jump gait with real equinus as well as knee and hip flexion, Group 3 represents apparent
equinus with knee and hip flexion, Group 4 represents crouch with excessive ankle
dorsiflexion and knee and hip flexion; and Group 5 represents asymmetric gait with a
combination of issues, for example apparent equinus and jump gait. This classification
system helps to define gait pathology, potential causes and ultimately a treatment strategy.

Classification by knee kinematic patterns

There are so many possible combinations of joint function in a patient with CP that some
authors have chosen to study function at the joint level instead of across multiple joints. In
a classic paper, Sutherland and Davids (1993) classified knee function in children with CP
into four sagittal-plane patterns. Although they recognized the relationship between the
function of one joint and its impact on adjacent joints, they felt that it was possible to define
certain primary disorders at a single joint. The four primary patterns at the knee were titled
jump knee, crouch knee, stiff knee and recurvatum knee. Each pattern was described by the
sagittal-plane motion as defined by three-dimensional motion analysis (Fig. 2.6.7) as well
as associated physical examination parameters and muscle activity. The identification of
these patterns on an individual basis can lead to a more specifi c treatment plan as each

157
Fig. 2.6.5 Gait patterns: spastic hemiplegia. A visual representation of the gait patterns during mid-stance phase are illustrated for types 1 through 4.
Suggested treatment options for the specific type are listed below. Additional patterns are identified which include subdividing type 2 into A typical and B
recurvatum knee. A description of the transverse plane rotations of the pelvis and hip is acknowledged in type 4. AFO, ankle–foot orthosis; RF, rectus
femoris; GRAFO, ground reaction ankle–foot orthosis. (Reproduced from Rodda and Graham 2001, Fig. 1, p 100, by permission.)
Fig. 2.6.6 Gait patterns: spastic diplegia. A visual representation of the gait patterns during mid-stance phase is illustrated for types I through V. The
dominant problematic muscle groups and related treatment options are listed below each pattern. Asymmetrical gait patterns are also addressed as indicated
in type V which is a combination of types I and IV. (Reproduced by permission and copyright (©) of the British Editorial Society of Bone and Joint
Surgery; from Rodda et al. 2004, Sagittal gait patterns in spastic diplegia. J Bone Joint Surg Br 86: 251–8.) AFO, ankle–foot orthosis; RF, rectus femoris;
GRAFO, ground reaction force ankle–foot orthosis.
Fig. 2.6.7 Sagittal-plane knee patterns. The sagittal-plane knee kinematic patterns are plotted for the
(a) jump, (b) crouch, (c) stiff and (d) recurvatum knees. These patterns are defined by stance or stance
and swing phase characteristics. Multiple gait cycles from an individual patient for each type are
plotted in relation to the typical motion (grey band).

pattern is consistent with a unique set of clinical and muscle function findings, as defined
by dynamic electromyography, which can aid in guiding treatment.
Lin et al. (2000) described similar classifications for the knee with the inclusion of joint
kinetic data. However, they described the ‘stiff’ knee classification as a ‘mild’ knee. Rodda
and Graham (2001) took classification to the next step and described four sagittal-plane
patterns which included the pelvis, hip, knee and ankle for patients with cerebral palsy.

Classification by joint kinetic patterns

Classification of gait in CP is now starting to go beyond kinematic patterns to focus on a
combination of specific kinematic and kinetic patterns (Õunpuu 2002, Adolfsen et al. 2007).
Joint kinetic patterns suggest a specific outcome of a combination of issues related to
joint contracture, muscle strength, control and weakness. With these classifi cations, it is
not so important whether the patient is defined as having hemiplegia or diplegia, since the
classifications themselves provide one of the most important components for making
treatment decisions that impact at joint level. This is because they represent thenal
fi outcome
of all systems, which with the supporting information (passive range of motion, muscle
strength and tone) allow treatment decisions to be made on the basis of function. The position
of the trunk has substantial impact on lower extremity joint kinetics, however, and must
always be taken into account when interpreting joint kinetic data. Joint kinetic patterns have
been identified and discussed in the literature and in the previous edition of this book
(Õunpuu 2004). A few sagittal-plane kinematic and kinetic patterns are described below to

160
further clarify their importance in defining function as it relates to level gait. It should be
stressed that these represent an example of just a few of many possible combinations of joint
kinematic and kinetic patterns, which in the future may lead to a more comprehensive and
useful method of classifying gait problems in CP. Other joint kinetic patterns also have
been identified and characterized. These include the hip-extensor moment pattern and the
hip-adductor moment pattern (abductor avoidance) (Õunpuu 2004). Patterns such as these
assist in the joint level classification of gait, which is ultimately needed for defining treatment
and evaluating the outcomes of those treatments.

DOUBLE BUMP ANKLE MOMENT PATTERN

This ankle moment pattern is characterized by the shape of the internal ankle plantar flexor
moment which is ‘double bump’ (Fig. 2.6.8). This is the one kinetic pattern that has been
connected to a particular treatment protocol (Rose et al. 1993). The double bump ankle
moment pattern is found in persons who have spasticity in their plantarflexors and who have
a toe- or foot-flat initial contact during gait (for example, a child with ‘jump gait’).
Essentially, it represents a double firing of the triceps surae, usually as a result of
gastrocnemius contracture and/or spasticity. The characteristics of the typically associated
ankle joint kinematics and kinetics are described below.

Joint kinematic
• Neutral or excessive plantarflexion at initial contact
• Rapid dorsiflexion during loading response which results in a quick stretch of the
spastic ankle plantarflexors that respond by contracting and producing premature
plantarflexion
• Repeat dorsiflexion followed by plantarfl exion in last half of stance (using a similar
mechanism as above)
• Less than typical dorsiflexion from mid-stance through toe off.

Joint moment
• Plantarflexor moment 100% stance
• Absence of a dorsiflexor moment in loading response with development of a premature
plantarflexor moment
• Followed by rapid decrease, increase and decrease in plantarflexor moment (double
bump)
• Associated with dominant and continuous ankle plantarflexor contraction throughout
stance.

Joint power
• Excessive power absorption in early stance (eccentric contraction of ankle plantar-
flexors)
• Premature power generation in mid-stance (concentric contraction of ankle plantar-
flexors)
• Inappropriate power generation in mid-stance drives body up, not forward

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 Fig. 2.6.8 Double bump ankle
pattern. The ankle kinematic,
moment and power for the double
bump ankle moment pattern is
plotted for the sagittal plane.
Multiple gait cycles from an
individual patient are plotted in
relation to the typical motion (grey
band). The net internal ankle
moment is plantarflexor throughout
the stance phase indicating a toe
initial contact and toe or forefoot
contact through out stance.
Increased ankle power absorption is
noted in loading response and
increased power generation is noted
in mid-stance indicating an
inefficient gait pattern.

• Second power absorption and generation in second half of stance

• Second power generation peak may be within or less than typical.

KNEE-EXTENSOR MOMENT PATTERN

The knee-extensor moment pattern is defined by the internal knee moment which is extensor
through out the majority of stance phase (Fig. 2.6.9). For example in a child with crouch
gait, inadequate hip-extensor and ankle-plantarflexor moments lead to excessive knee
flexion or crouch and/or knee-flexion contractures, which in turn demand a compensatory
knee-extensor moment pattern (Õunpuu 2002) (see Chapter 5.11). The knee-extensor
moment pattern is characterized by continuous coactivity of the quadriceps and hamstrings.
However, there is a net knee-extensor dominant moment, required to prevent collapse. The
characteristics of the typically associated knee-joint kinematics and kinetics are described
below.

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 Fig. 2.6.9 Knee-extensor moment
pattern. The knee kinematic, moment
and power for the knee-extensor
moment pattern are plotted for the
sagittal plane. Multiple gait cycles
from an individual patient are plotted
in relation to the typical motion (grey
band). The knee moment is extensor
throughout the stance phase which is
consistent with a crouch gait pattern
and requires continuous quadriceps
activity during stance to prevent
collapse.

Joint kinematic
• Greater than normal knee flexion at initial contact
• Continued excessive knee flexion during 100% stance
• Minimal knee sagittal-plane range of motion in stance.

Joint moment
• Rapid development of extensor moment during loading response
• Knee-extensor moment 100% stance phase
• Associated with dominant and continuous quadriceps contraction throughout
stance.

Joint power
• Typically minimal and varies depending on knee range of motion in stance.

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KNEE-FLEXOR MOMENT PATTERN
The knee-flexor moment pattern is defined by an internal knee moment that is primarily
flexor through out the stance phase (Fig. 2.6.10). This pattern is found in individuals with
full knee extension or knee hyperextension on passive range of motion, plantarflexor
spasticity contributing to an excessive plantarflexion/knee-extension couple and more often
than not a forward trunk lean. The characteristics of the typically associated knee joint
kinematics and kinetics are described below.

Fig. 2.6.10 Flexor moment pattern. The knee

kinematic, moment and power for the knee-flexor
moment pattern are plotted for the sagittal plane.
Multiple gait cycles from an individual patient
are plotted in relation to the typical motion (grey
band). The knee moment pattern is primarily
flexor throughout the stance phase, which is
consistent with knee hyperextension or extension
with a forward trunk position.

Joint kinematic
• Greater than typical knee flexion to full knee extension at initial contact
• Rapid knee extension after initial contact
• Usually prolonged knee extension or hyperextension in mid to terminal stance.

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Joint moment
• Rapid development of a knee-flexor moment during loading response
• Excessive knee-flexor moment during the majority of stance
• Associated with dominant and continuous knee-flexor activity; however, joint support
may be provided by muscular contracture or ligamentous restrictions of further motion
• Variable knee moment in pre-swing.

Joint power
• Increased power absorption during period of rapid knee extension in stance
• Associated eccentric contraction of the knee flexors and/or stretching of the soft-tissue
structures on the posterior aspect of the knee.

Summary
The classification of cerebral palsy is necessary for a variety of reasons. In the clinical
setting, classification is needed to assist in optimal communication among medical
professionals and between medical professionals and patients/families. It is needed to
determine prognosis and define treatment options. In the research setting, classification is
required to define homogeneous patient groups, to communicate effectively research results
and to more clearly define and connect appropriate treatments with the ‘right’ patient.
Standard and reproducible methods are needed in order for any classification system to be
applicable in both the clinical and research environments. Moving forward, it will be
important to establish consistency among medical professionals in both the defi nitions and
classification systems used when treating persons with CP. In Chapter 6.1 the classification
tools described above will be described in terms of their input for treatment decision-making
and evaluation of persons with CP.

REFERENCES

Adolfsen SE, Õunpuu S, Bell KJ, DeLuca PA (2007) Kinematic and kinetic outcomes after identical multilevel
soft tissue surgery in children with cerebral palsy. J Pediatr Orthop 27: 658–67.
Bax M, Goldstein M, Rosenbaum P, Leviton A, Paneth N (2005) Proposed defintion and classification of
cerebral palsy. Dev Med Child Neurol 47: 571–6.
Bjornson KF, Graubert CS, Buford VL, McLaughlin J (1998a) Validity of the gross motor function measure.
Pediatr Phys Ther 10: 43–7.
Bjornson KF, Graubert CS, McLaughlin J, Kerfeld CI, Clark EM (1998b) Test retest reliability of the gross motor
function measure in children with cerebral palsy. Phys Occup Ther Pediatr 18: 51–61.
Clover AF, Sethumadhavan T (2003) The term diplegia should be abandoned.Arch Dis Child 88: 286–90.
Graham HK, Harvey A, Rodda J, Nattrass GR, Pirpiris M (2004) The functional mobility scale (FMS). J Pediatr
Orthopaed 24: 514–20.
Harvey A, Graham HK, Morris ME, Baker RJ, Wolfe R (2007) The functional mobility scale: ability to detect
change following single event multilevel surgery. Dev Med Child Neurol 49: 603–7.
Harvey A (2008) The Functional Mobility Scale for Children with Cerebral Palsy. Gait CCRE Thesis Series,
vol. 6. Melbourne, Austtralia: University of Melbourne. p 112.
Lin CJ, Guo LY, Su FC, Chou YL, Cherng RJ (2000) Common abnormal kinetic patterns of the knee in grait
in spastic diplegia cerebral palsy. Gait Posture 11: 224–32.
Minear WL (1956) A classification of cerebral palsy. Pediatrics 18: 841–52.
Nordmark E, Hagglund G, Jarnlo GB (1997) Reliability of the gross motor function measure in cerebral palsy.
Scand J Rehabil Med 29: 25–8.

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