CLASSIFICATION OF SPASTIC HEMIPLEGIC CEREBRAL PALSY IN CHILDREN

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CLASSIFICATION OF SPASTIC HEMIPLEGIC CEREBRAL
PALSY IN CHILDREN
Jacques Riad, MD, Yvonne Haglund-Akerlind MD PhD,
Freeman Miller, MDDepartment of Orthopaedic
Surgery, Alfred I. duPont Hospital for
Children Wilmington, DE, USA and Department of
Woman and Child Health, Karolinska Institutet,
Stockholm, Sweden.
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Classification of spastic hemiplegic cerebral
palsy in children

• Background

Classification systems can be useful for
prognostic reasons and to help in establishing
treatment strategies.
Winters classification of spastic hemiplegic
cerebral palsy, based on sagittal kinematic data
from three-dimensional gait analysis is widely
used.
In Winters study the patients had a large age
variation, including adults. Not all patient were
diagnosed with spastic cerebral palsy, since some
had adults stroke and traumatic brain injury.
The role of the Winter classification is
difficult to define and not all patients fit into
one of the four groups described.
Winter 1987
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Classification of spastic hemiplegic cerebral
palsy in children

• Goal 1.

Investigate how well children can be classified
using Winters criteria.
Goal 2.
Investigate if patients move between
classification groups over time and/or with
surgical intervention.
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Classification of spastic hemiplegic cerebral
palsy in children

• Method

Spastic hemiplegic CP is defined as unilateral
neurological involvement registered on the
physical examination with the typical upper and
lower extremity positioning, as well as gait
deviations found in the kinematics and kinetic
data in GA. Independent ambulators without
assistive devices or previous surgery were
included. In the second part of the study when
comparing the Winter classification groups over
time, with or without surgery, patients with two
gait analysis were included. The gait analysis
was performed with a Motion analysis video
capture system and all the data was reduced using
Orthotrak (Motion Analysis Corp Santa Rosa,
California). Multiple gait cycles were collected,
typically between 10 and 25 cycles, and were time
dilated. A mean cycle with standard deviation was
calculated. The patient walked at a self-selected
speed.
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Classification of spastic hemiplegic cerebral
palsy in children

• Method

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Classification of spastic hemiplegic cerebral
palsy in children

• Results 1.

The mean age for the whole study group was 8.1
years of age (range 3.6-19.8 years) at the
GA. Sixty-eight boys and 44 girls.
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Classification of spastic hemiplegic cerebral
palsy in children

• Results 1.

Classified groups on the hemiplegic side and
normal values, for the pelvis, hip, knee and
ankle joints in 112 patients with spastic
hemiplegic cerebral palsy. Mean values, solid
line, and standard deviations, gray area.
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Classification of spastic hemiplegic cerebral
palsy in children

• Results 1.

An independent samples t-test of the sagittal
plane kinematic data was performed. The groups
were compared to each other in the following
order Group 0 was compared to group 1, group 1
to 2, group 2 to 3 and group 3 to 4. Several
significant differences were found. See tables.
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Classification of spastic hemiplegic cerebral
palsy in children

• Results 2.

Re-classified patients. Age, in years, at first
gait analysis (GA 1). Time between gait analysis
1 and 2. Patients classification group.The
change into different groups over time for
patients that had no surgery and for those that
had surgery.
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Classification of spastic hemiplegic cerebral
palsy in children

• Conclusion

The Winter classification failed to classify 23
(26/112) of our spastic hemiplegic cerebral palsy
children. We suggest that the classification be
complemented with the less involved group 0. In
this way all patients can be classified and
further divided into ankle, knee and hip
involvement. Treating physicians should be aware
of the possibility that patients may move into
another classification group over time.