Kara Taylor, BS
Morgan Poole, BS
Speech-Language Pathology
University of Central Arkansas
Cerebral Palsy Definition
“describes a group of permanent disorders of the
development of movement and posture, causing
activity limitations, that are attributed to nonprogressive disturbances that occurred in the
developing fetal or infant brain.
The motor disturbances of cerebral palsy are often
accompanied by disturbances of sensation,
perception, cognition, communication, and
behaviour, by epilepsy, and by secondary
musculoskeletal problems” Rosenbaum, et al. (2007)
Functional Limitations in
Daily Activities
 Mobility Palisano et al., 1997
 Gross Motor Function Classification System (GMFCS)
www.canchild.ca/Portals/0/outcomes/pdf/GMFCS-ER.pdf
 Handling Objects Eliasson et al., 2006
 Manual Ability Classification System (MACS) for children
with cerebral palsy 4-18 years www.macs.nu/
 Communication Hidecker et al., under development
 Communication Function Classification System (CFCS)
www.cfcs.us/
 Eating/Drooling Sellers et al., under development Manchester U.K.
Comparison of Classification Tools
GMFCS
Mobility
MACS
Handling objects
CFCS
Level
Communicating
Effective sender/receiver
Walks without Handles objects easily
I.
with unfamiliar and
limitations.
and successfully.
familiar partners
Handles most objects
Effective but slower
Walks with
but with somewhat
sender/receiver with
II.
limitations.
reduced quality and/or
unfamiliar and familiar
spread of achievement.
partners
Handles objects with
Walks using
difficulty; needs help Effective sender/receiver
III.
a hand-held
to prepare and/or
with familiar partners
mobility device.
modify activities.
Self-mobility
Handles a limited
with limitations;
Inconsistent sender
selection of easily
IV.
May use
and/or receiver with
managed objects in
powered
familiar partners
adapted situations.
mobility.
Does not handle objects
Transported in
Seldom effective
and has severely limited
V.
a manual
sender/receiver even
ability to perform even
wheelchair.
with familiar partners
simple actions.
Few Communication
Measures in CP Studies
 Need: Better measures of speech,
language, and hearing within existing
CP epidemiological studies.
 Challenge: Quick, multidisciplinary
measure of communication
 Hope: More SLPs and audiologists will be
included on CP research teams
Cooley
Hidecker et
al., 2009
Cooley
Hidecker et
al., 2009
Cooley
Hidecker et
al., 2009
Current CFCS Draft
Cooley
Hidecker et
al., 2009
CFCS Level Identification Chart
Hidecker et al.
Please do not use without permission
Objectives
To analyze the communication of a
sample of children with CP by:
Communication modes
GMFCS (mobility classification)
MACS (hand use classification)
Cerebral palsy types
Comorbidities
Participants
 71 children with CP
 Ages 2 to 18 years
 Parent raters
If no parent rating, used
professional rating
Communication Methods
 41 of 71 used speech
 15 of 41 used ONLY speech
 56 of 71 were multi-modal
 Speech (n=26)
 Sounds (n=51)
 Eye gaze, facial expressions, gesturing, &/or pointing
(n=53)
 Manual signs (n=20)
 Communication books, boards, and/or pictures (n=19)
 Speech-generating devices or voice output devices (n=16)
CFCS & Communication Modes
Speech Speech,
No
No Speech
&
unaided
speech
unaided
CFCS Speech Unaided AAC &
unaided
AAC &
AAC aided AAC
AAC
aided AAC
Level Only
I
II
III
IV
V
7
5
2
1
0
1
6
4
3
0
1
4
4
3
0
0
2
2
4
8
0
1
1
9
3
SGD/VOCA by CFCS Level
 Speech-generating devices or voice
output devices (n=16)
CFCS Level I (n=1)
 CFCS Level II (n=2)
 CFCS Level III (n=3)
 CFCS Level IV (n=8)
 CFCS Level V (n=2)

GMFCS & MACS Levels
by CFCS Level
CFCS Level I
MACS
GMFCS
I
I
2
II
3
II
III
IV
V
Total
2
2
5
III
0
IV
0
V
Total
1
5
3
1
0
1
2
0
9
GMFCS & MACS Levels
by CFCS Level
CFCS Level II
GMFCS
MACS
I
II
I
1
3
II
1
3
III
IV
V
1
5
1
2
V
1
2
8
Total
4
1
IV
Total
III
3
2
1
2
4
1
2
16
GMFCS & MACS Levels
by CFCS Level
GMFCS
I
I
II
III
IV
V
Total
1
1
CFCS Level III
MACS
II
III
IV
1
1
3
1
1
1
2
1
5
4
2
V
0
Total
1
1
5
1
4
12
GMFCS & MACS Levels
by CFCS Level
GMFCS
I
I
II
III
IV
V
Total
1
1
CFCS Level IV
MACS
II
III
IV
4
1
2
1
7
1
3
4
7
V
1
2
3
Total
0
5
1
7
6
19
GMFCS & MACS Levels
by CFCS Level
GMFCS
I
I
II
III
IV
V
Total
0
CFCS Level V
MACS
II
III
IV
V
0
1
1
2
4
7
7
0
Total
0
0
1
1
9
11
Types of Cerebral Palsy and CFCS
 Types of CP
 Bilateral (n= 63)
 Hemiplegia (n= 13)
 Spastic (n= 62)
 Dyskinetic (n= 5)
 Dystonic (n= 27)
 Choreo-athetotic (n= 4)
 Ataxic (n= 10)
 CP type NOT a predictor of CFCS Level
Comorbidities and CFCS Levels
• developmental delay (85%)
• mild or severe cognitive impairment (56%)
• seizure disorder (52%)
• language disorder (45%)
• visual impairment not corrected by glasses
(44%)
• dysarthria (34%)
• apraxia of speech (27 %)
Key Findings
CFCS with GMFCS and MACS
provides a more complete view of
the functional abilities of children
with CP.
Speech was associated with more
effective communicators.
Clinical Implications
 Accessible, common tool that can be
used by both parents and professionals.
 Useful when talking with families and
other professionals.
 Support understanding among various
members of multidisciplinary teams.
Current research directions
Measure the CFCS stability across
the life span.
 Need research partners who serve
individuals with CP from age 2 to 21
 Will classify CFCS and collect additional
data over the course of 4 years
Current research directions
 CFCS to cerebral palsy registries’ data?
 Surveillance of CP in Europe (SCPE)
 Translate/validate CFCS in languages
 Currently underway
 Arabic
 Dutch
 Turkish
 Need Spanish partners
• Translation Interests
• ?????
Clinical Implications –
examples
 Knowing a person’s CFCS classification may suggest
a starting point for intervention
(we still need clinical research evidence)
 Level I – Any activity or participation limitations?
Decrease any residual speech sound errors?
 Level II – Any ways to speed up communication,
especially with unfamiliar partners? Can repair
strategies be improved? Can AAC
access/composing methods be faster?
Clinical Implications –
examples
 Level III – Increase communication partners? Improve
communication repair strategies? Add AAC?
 Level IV – Increase sender and/or receiver skills?
Add AAC?
 Level V – Improve partner recognition of gestures
and unconventional messages?
 Focus on communication partner training.
 Create a communication dictionary of these
unconventional message.
 Pair AAC message with unconventional message.
Future research directions
 Create a snapshot of a person’s functional
levels by reporting the CFCS in
conjunction with GMFCS & MACS.
 Correlate the CFCS level to quality of life
and/or participation measures.
Future research directions
 Validate the CFCS in other populations
including those with autism, Down
syndrome, and post-stroke.
 Study the possible effect of additional
AAC components and operational
competencies on CFCS Levels.
Acknowledgements
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Thank you to the individuals who participated:
In addition to those who chose to contribute anonymously,
Development Team: Sally Bucrek, Kipp Chillag, DO, Ann-Christin Eliasson, PhD, Maria S. French, PhD, Lisa
Herren, Rebecca Jones, PhD, Lena Krumlinde-Sundholm, PhD
Nominal Group: Deena Agree, George Baker, Lisa Bardach, Lehua Beamon, Susan Davenport, Denise
Fitzpatrick, Elizabeth A. Fox, Barb Galuppi, Jonathon Gold, Clare Jorgensen, Marilyn Kertoy, John Lawton,
Michael Livingston, Rhonda Massa, Jeanette Miller, Chris Morris, Nancy Novakoski, Krista Richardson, Cindy J.
Russell, Dianne Russell, Geraldine Schram, Dennis Schroeder, Becky Schroeder, Yakov Sigal, Nancy ThomasStonell, David VanDyke, Lynna M. Walta, Kristin J. Whitfield
Delphi Survey: Janet H. Allaire, Ilona Autti-Rämö, Rita L. Bailey, Simona Bar-Haim, David Bauer, Kristie
Bjornson, PhD, PT, Timothy J Brei, MD, Wendy Burdo-Hartman, MD, Megan Carter, Michael Collis, Cynthia
Cress, Diane L. Damiano, Pamela K. De Loach, Leo V. Deal, Shelley Deegan, Steven T DeRoos, MD, Cindy
DeYoung, Laura Drower M.S., SLP, Joseph R. Duffy, Stephanie Farnham OTR, James W. Fee, Jr., Iris Fishman,
Deb Gaebler, Gay L. Girolami, PT, MS, Jan Willem Gorter, MD PhD, Kate Himmelmann, Megan M. Hodge, Tara
Kehoe, Debora K. Kerr, Barbara A. Krampac, MS CCC/SLP-L, Nicole Lomerson, Mary Ann Lowe, Valerie
Maples, Jill Meilahn, D.O., Michael E. Msall, MD, Susan Murr, Dana Overhake, Robert J. Palisano, Carol Palk,
Lindsay Pennington, Judy Phelps, OTR, Matthew Phillips, Margaret R. Poore, SLP/AAC Specialist, Dinah
Reddihough, Tom J Reed, Dr. Gina Rempel, James M Renuk, Bernadette Robertson, Cheryl Robins, Sharon
Rogers, Lynn Rothman, Julie Scherz, Diane Dudas Sheehan, Kevin Vance, Candace Hill Vegter, Jo Watson, Ellen
Wood, Marilyn Seif Workinger, PhD, Marshalyn Yeargin-Allsopp, MD
Reliability Sites: BC Centre for Ability (Vancouver, British Columbia), Helen DeVos Children’s Hospital
(Grand Rapids, Michigan), Gillette Children’s Hospital (St. Paul, Minnesota), Marshfield Clinic (Marshfield,
Wisconsin), Seattle Children’s Hospital (Seattle, Washington), Rehabilitation Institute of Chicago (Chicago,
Illinois)
Research Team: Aliah Alsarraf, Megan Bigalke, Kenneth Chester, Mary Jo Hidecker, Stephanie Currier, Kristen
Darga, Julie Fisk, Kelly Gowryluk, Carly Hanna, Brenda Johnson, Ray Kent, Lauren Klee, Lauren Klier, Jenny
Koivisto, Lauren Michalsen, Nigel Paneth, Hye Sung Park, Sarah Parker, Tiffany Quast, Kristen Raabis, Peter
Rosenbaum, Marliese Sharp, Archie Soelaeman, Katie VanLandschoot, Lauren Werner, Jacqueline Wilson
This research is supported in part by an NIH postdoctoral fellowship (NIDCD 5F32DC008265-02) as well as
grants from the Cerebral Palsy International Research Foundation and The Hearst Foundation.
References
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5
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Contact us
 Mary Jo Cooley Hidecker
MJCHidecker@uca.edu
 CFCS Website
http://cfcs.us