Various treatments used in complementary and alternative medicine.
\r\n\tHowever, despite the positive outlook and trends in routing protocol design, there are still several open or unresolved challenges that researchers are still grappling with. Providing adequate responses to those challenges is essential for next-generation networks in order to maintain its reputation and sustain its preponderance in cyber and physical security. Some of the challenges include, but are not limited to, the following:
\r\n\t• Robustness and reliability of routing protocol
\r\n\t• Reduced dependencies on heterogeneous networks
\r\n\t• Security of routing protocols
\r\n\t• Dynamic Adhoc routing Protocols
\r\n\t• Routing in 5G Networks
\r\n\t• Routing IoT enabled networks
\r\n\t• Scalable and dependable routing system architectures
\r\n\t• QoS and QoE Models and Routing Architectures
\r\n\t• Context-Aware Services and Models
\r\n\t• Routing Mobile Edge Computing
\r\n\tThe goal of the book is to present the state of the art in routing protocol and report on new approaches, methods, findings, and technologies developed or being developed by the research community and the industry to address the aforementioned challenges.
\r\n\tThe book will focus on introducing fundamental principles and concepts of key enabling technologies for routing protocol applied for next-generation networks, disseminate recent research and development efforts in this fascinating area, investigate related trends and challenges, and present case studies and examples.
\r\n\tThe book also investigates the advances and future in research and development in Routing Protocols in the context of new generation communication networks.
The social and sexual communication roles of hair as well as its protective function have absolutely undeniable for both sexes for many years [1, 2]. Although the loss of hair is not a life-threatening condition, the loss of hair at an early age or sudden onset hair loss may cause serious psychological distress, thus it may directly affect the quality of life negatively [1, 3]. For this reason, patients with suffering from hair loss should be considered finically in order to distinguish ordinary hair shedding from pathologic hair loss. A loss of 100 or less hair falling per day should not be considered as pathological hair loss. But in case of hair loss more than 100 per day, a pathological condition should be mentioned [3].
\nHair loss is a common dermatological problem that has been estimated to affect between 0.2 and 2% of the world’s population. There are several factors leading to hair loss including major physical-emotional stress, chemotherapy, genetic predisposition, dihydrotestosterone (DHT), excessive sebum, cardiovascular diseases, smoking, and endogenous substances [3]. The common hair diseases that dermatologists are often faced in daily practice are androgenetic alopecia (AGA), alopecia areata (AA), telogen effluvium, anagen effluvium, and traumatic alopecia such as trichotillomania and traction alopecia [1]. AGA, known as male pattern hair loss in men and as female pattern hair loss in women, is the most common form of hair loss in adults [1, 4, 5]. Approximately 60% of males between the ages 30 and 50 years and 17% of women under 50 years of age suffer from AGA [4]. The role of DHT which is reduced from testosterone by enzyme 5α-reductase is clearly known in the mechanism of AGA [6]. In early stage, the process begins with shortening of the anagen phase and continuous miniaturization of sensitive follicles [1]. During this process, terminal hairs are replaced by vellus hairs which are shorter, finer and nonpigmented in the frontal and vertex regions of the scalp [3, 4]. Year after year, permanent baldness occurs at the site of miniaturized hair [1]. AA is a common, chronic inflammatory disease that is characterized by non-scarring alopecic patches on the scalp. It affects approximately 2% of the United States (US) population [7, 8]. Although the mechanism of AA is exactly unknown, it is thought that a necessary secondary event or cofactor such as febrile illness, pregnancy, or a major life crisis in addition to genetic predisposition [8, 9]. Even though AA may regress spontaneously, the disease may remain stable or even may spread to the entire scalp (known as alopecia totalis) or body (known as alopecia universalis). Telogen effluvium is a disease that occurs as a result of passing of a portion of hair from anagen phase to telogen phase. It is characterized by diffuse hair shedding. While trichotillomania is an impulse control disorder, traction alopecia is association with patients’ hairstyle. These two diseases that occur after recurrent and chronic trauma are frequently seen in females than males. Both of them can result with permanent scarring [9].
\nIn recent years, complementary and alternative medicine (CAM) is becoming increasingly popular all over the world. In fact, CAM is still the only option to cure and treat some diseases in some regions of Africa, Asia, and South America [10]. Alternative medicine refers to the use of CAM in place of conventional medicine, while complementary medicine refers to the use of CAM along with conventional medicine [11]. According to The National Center for Complementary and Alternative Medicine (NCCAM) in the United States, CAM is defined as ‘a group of diverse medical and health-care system, practices, and products that are not presently considered to be a part of conventional medicine’ [12]. In some countries like Korea, oriental medicine has been officially approved and has gained support from legal system using the licensing system [13]. The number of visits to alternative care practitioners increased by about 1.5 times in 7 years (from 427 billion in 1990 to 629 billion in 1997) in the United States [14]. The National Health Interview Survey estimated that in 2007 alone, 38% of adults in the United States used CAM [15].
\nCAM is separated by NNCAM into four categories: alternative medical systems, biologically based therapies, manipulative and body-based therapies, and mind-body therapies. The details of these therapies are shown in Table 1 [16]. In a survey study conducted in the United Kingdom (UK) in 2010, the most popular CAM therapies were reported as acupuncture, hypnotherapy, and chiropractic, while the least preferred CAM were noted as aromatherapy, reflexology, and medical herbalism [17]. The annual expenditure on CAM is about $30 billion in the United States and £1.6 billion in the UK [18, 19].
Alternative medical system | Acupuncture |
Ayurveda | |
Homeopathy | |
Naturopathy | |
Biologically based therapies | Chelation |
Folk medicine | |
Nonvitamin nonmineral natural products | |
Diet-based therapies | |
Megavitamin therapy | |
Manipulative and body-based therapies | Chiropractic care |
Massage | |
Mind-body therapies | Biofeedback |
Relaxation techniques | |
Hypnosis | |
Yoga | |
Tai Chi | |
Qi Gong | |
Healing rituals | |
Energy healing | |
Reiki |
Various treatments used in complementary and alternative medicine.
Similarly, using of CAM is quite often among patients suffering from dermatologic disorders such as acne, atopic dermatitis, psoriasis, dermatophytes, actinic keratosis, vitiligo, hair loss, cosmetic indications, melanoma, and lupus erythematosus [20–27]. A survey data from UK indicated that 35–69% of patients who have various skin diseases have used CAM in their lifetime [27]. The prevalence of CAM use by dermatology patients were 25.7 and 41% in Singapore [28] and Taiwan [29], respectively, while it ranges from 33.5 [30] to 43.7% in Turkey [31]. As the most frequently complementary medicines used by patients to treat their dermatological diseases have been reported as homeopathy, herbalism, diets, and food supplements in the UK [19, 27], the most used types of CAM have been recorded as herbal remedies, special diet, and megavitamin in Taiwan [29]. In one study, positive feedbacks from patients using CAM, especially herbal therapies, were noteworthy for both skin-related and non-skin-related conditions. Approximately 85% of patients with skin-related conditions, many of those with chronic diseases such as acne and eczema, noted improvement with CAM use [32]. To treat hair loss, the first two groups shown in Table 1 are more preferred than the others.
\nIdeal treatment of hair loss should include the drugs that have both 5α-reductase inhibition effect and hair growth promoter substances, together. The most used conventional treatments are topical minoxidil, finasteride, dutasteride, combination of cyproterone acetate and estrogen, spironolactone, flutamide, topical progesterone, cimetidine, zinc sulfate, topical niacin, topical aminexil, topical ketoconazole, and cyclosporine-A [2]. In particular, minoxidil and finasteride are widely used for treating hair loss. But adverse effects of all of these agents have limited to their usage [1, 2]. Hence, patients suffer from hair loss have begun to turn to alternative therapies, even though there is little scientific evidence to prove their effectiveness.
Herbal medicine is extremely popular since ancient times in Ayurveda, Siddha, Chinese, and Unani systems of medicine [3, 33]. Many plants and/or their extracts have been used to prevent hair loss and treat alopecia. These plants and their properties are summarized in Table 2.
Botanical name | Family | Possible mechanisms of action |
---|---|---|
Thuja orientalis | Cupressaceae | Inhibition of 5α-reductase enzyme |
Citrullus colocynthis | Cucurbitaceae | Antiandrogenic effect |
Rosmarinus officinalis | Lamiaceae | Increasing the circulation of the scalp |
Camellia sinensis | Theaceae | Inhibition of 5α-reductase enzyme |
Asiasari radix | Aristolochiaceae | Inducing early telogen-to-anagen conversion |
Allium cepa L. | Liliaceae | Unknown |
Polygonum multiflorum | Polygonaceae | Proliferation of dermal papilla cells, expression of FGF-7, up-regulating Shh and β-catenin expression |
Allium tuberosum Rottler ex Spreng | Liliaceae | Stimulating expression of IGF-1 |
Cucurbita pepo | Cucurbitaceae | Inhibition of 5α-reductase enzyme |
Serenoa repens | Arecaceae | Inhibition of 5α-reductase enzyme, decreasing DHT uptake by hair follicle, decreasing the binding of DHT to androgenetic receptors |
Panax ginseng C.A. Meyer | Araliaceae | Expression of VEGF, antiapoptotic activity |
Eclipta alba | Asteraceae | Anagen phase induction, reducing level of TGF-β1 |
Zizyphus jujuba | Rhamnaceae | Unknown |
Allium sativum | Liliaceae | Unknown |
Avicennia marina | Acanthaceae | Inhibition of 5α-reductase enzyme |
Phyllanthus niruri | Euphorbiaceae | Inhibition of 5α-reductase enzyme |
Oryza sativa | Inhibition of 5α-reductase enzyme | |
Sophora flavescens Aiton | Leguminosae | Inhibition of 5α-reductase enzyme, vasodilator and antiandrogen effects |
Chrysanthemum zawadskii var. latilobum | Asteraceae | Anti-inflammatory effect |
Scutellaria baicalensis | Lamiaceae | Inhibiting nuclear translocation of the androgen receptor, enhance proliferation of human dermal papilla cells |
Cuscuta reflexa Roxb | Convulvulaceae | Inhibition of 5α-reductase enzyme |
Pueraria thomsonii | Leguminosae | Inhibition of 5α-reductase enzyme |
Curcuma aeruginosa | Zingiberaceae | Inhibition of 5α-reductase enzyme |
Hura crepitans | Euphorbiaceae | Inhibition the neurotrophin (NT)-4 activation |
Tobacco leaves | Solanaceae | Inhibition of 5α-reductase enzyme |
Tectona grandis Linn | Verbinaceae | Unknown |
Boehmeria nipononivea | Urticaceae | Inhibition of 5α-reductase enzyme |
Some plants used for hair loss and their properties.
Thuja orientalis (T. orientalis, family Cupressaceae), also known as T. occidentalis in Eastern or Arbor vitae or white cedar, is a plant that is widely distributed in East Asia [34, 35]. In addition to grown as an ornamental tree in Europe, it has been used to treat various diseases concerning respiratory system, skin disorders, and urinary system. Nowadays, it is often used in homeopathy and evidence-based phytotherapy [35]. It has also been traditionally used to promote hair growth in the oriental medicine. Although T. orientalis has a strong 5α-reductase inhibitor effect, the exact mechanism of hair-promoting effect of T. orientalis is still unknown. In the literature, there are few studies investigating the association between T. orientalis and hair growth. In animal studies, it was demonstrated that topically application of T. orientalis extract induced an earlier anagen phase and prolonged the mature anagen phase. In immunohistochemistry analysis, it was also shown that the expression levels of β-catenin and sonic hedgehog (Shh) were upregulated in T. orientalis extract-treated group at 14 days, compared to those in the control or 1% minoxidil-treated group. In mice treated with T. orientalis, authors observed an increase in both the number and size of hair follicles [34, 36]. Even, cubosomal suspension of T. orientalis extract was found to be more effective due to increased skin penetration of the T. orientalis [37].
Citrullus colocynthis (C. colocynthis) Shrad (family Cucurbitaceae), known as Indrayan, is one of the numerous herbal drugs recommended by the traditional system of medicine for hair growth promotion in India [38, 39]. It contains β-sitosterol, campesterol, stigmasterol, α-spinasterol, and cucurbitacin glycosides. It has several pharmacological effects such as immunostimulating, antiandrogenic, antibacterial, and hypoglycaemic in addition to hair-promoting effect [39]. There are few animal studies evaluating hair growth-promoting activities of the C. colocynthis. Roy et al. reported that topical application of C. colocynthis plant, especially petroleum ether extracts, had an astonishing effect on hair growth initiation time, complete hair growth, and the length of hair follicle in albino rats. In qualitative studies, hair growth was initiated in the denuded area on the 4th day and 5th day with 5 and 2% ointment of petroleum ether extract of C. colocynthis, respectively. But, hair growth initiation was noted on the 6th day and the second week in minoxidil-treated standard group and in control group, respectively. Complete hair growth was recorded on the 16th, 18th, 19th, and 24th days in the 5% petroleum ether extract group, 2% petroleum ether extract group, minoxidil group, and control group, respectively. In quantitative studies, at 30 days after treatments with extracts of C. colocynthis, anagenic population were recorded as 67 and 47% in the minoxidil group and control group, whereas it was noted as 75 and 72% in the 5 and 2% petroleum ether extract groups, respectively. In both 2 and 5% petroleum ether extract groups, approximately 50% of hair population had length of 0.5 mm and above at 30 days after treatment [38]. In another study, Dhanotia et al. evaluated the hair growth-promoting activities of the petroleum ether extract from the fruit of C. colocynthis on albino mice using a testosterone-induced alopecia model. As a result of both qualitative and quantitative studies on hair growth, they suggested to present the inhibition of androgenic activity and altered anagen/telogen ratio and follicular density [39]. Polyherbal formulation including C. colocynthis was also shown to present hair growth-promoting activity on rats. Hair growth initiation time was markedly reduced to one-third on treatment with the prepared formulation compared to control group. The time required for complete hair growth was also reduced by 32%. Quantitative analysis of hair growth cycle after treatment with formulations and 2% minoxidil solution (positive control group) exhibited greater number of hair follicles in anagenic phase compared with control [40].
Rosmarinus officinalis (R. officinalis), commonly known as Rosemary, is a plant that belongs to family Lamiaceae and naturally grows in all Mediterranean countries [41, 42]. It has antiandrogenic effect and hair growth-promoting activity apart from antioxidative, anti-inflammatory, antibacterial, and antitumor effects [43]. In CAM, R. officinalis is often used in aromatherapy to treat anxiety-related conditions and increase alertness, although it has occasionally been used to stimulate hair growth [41]. The exact mechanism of hair growth is still unclear, but it is believed to act by increasing the circulation of the scalp. Murata et al. showed that topical administration of R. officinalis extracts solution (2 mg/day/mouse) improved hair regrowth in the testosterone-treated C57BL/6NCrSIc mice. They also showed significant promotion of hair growth after 16 days of topical administration. Among the some constituents of R. officinalis [i.e., rosmarinic acid, ursolic acid, 12-methoxycarnosic acid (12-MCA)], it was demonstrated that inhibitory activity of 12-MCA on 5α-reductase was higher than rosmarinic acid and ursalic acid (82.4, 14.2, and 2.5% inhibition at 200 μg/ml, respectively) [43].
Green tea (Camellia sinensis, family Theaceae) is a well-known plant since ancient times, especially in China. It has been regarded to possess numerous pharmacological effects such as antimetastatic, anticancer, hepatoprotective, antidiabetic, antiobesity, anti-atherosclerotic, antibacterial, antiviral, anti-inflammatory, and antioxidant effects. It has been preferred in various dermatological diseases due to its mentioned beneficial effects worldwide. Human papilloma virus (HPV)-induced cervical cancer, genital warts, acne, rosacea, wound healing, atopic dermatitis, and keloids are diseases that green tea is commonly used. Apart from these diseases, it can be used to prevent or treat AGA by selectively inhibiting 5α-reductase activity. Catechins, a group of very active flavonoids, are a major component of green tea representing 60–80% of all polyphenols [44, 45]. There are four major catechins in green tea: epigallocatechin-3-gallate (ECGC), epigallocatechin (EGC), epicatechin gallate, and epicatechin [46, 47]. ECGC is the most highly bioactive catechin among these constituents [45]. In a study, EGCG was found to cause significant human hair follicle elongation ex vivo. Indeed, it was also shown proliferative and antiapoptotic effects of ECGC on dermal papilla cells through the upregulations of phosphorylated Erk and Akt and by an increase in the ratio of Bcl-2/Bax ratio [48]. Esfandiari et al. also reported that 33% of the mice that received 50% fraction of polyphenol extract from dehydrated green tea in their drinking water had significant hair regrowth within a period of 6 months compared with control group received regular drinking water [49].
Asiasari radix (A. radix, family Aristolochiaceae) or the radix of Asiasarum heterotropoides var. mandshuricum F. Maekawa usually grows in Korea, Japan, and China. A. radix is also called as ‘seshin’ in Korea, as ‘saishin’ in Japan, or Chinese wild ginger in English [50, 51]. It is used to treat various oral mucosal diseases such as aphthous stomatitis, gingivitis, local pain, and toothache apart from hair loss. A study from Korea showed its potent hair growth effect in mice. Though A. radix had not inhibitory effect on 5α-reductase enzyme, authors suggested that the extract of the plants induced early telogen-to-anagen conversion. They also demonstrated expression of vascular endothelial growth factor (VEGF) in human dermal papilla cells cultured in vitro [52].
Onion juice (Allium cepa L., family Liliaceae) may be used in patients with AA because of garlic-like activity. Both herbal medicines have similar chemical constituents, especially Allicin. The exact mechanism of onion juice in the treatment of AA is still unknown [53, 54]. In the study by Sharquie and Al-Obaidi, at 4 and 6 weeks after topical application of onion juice twice a day, hair regrowth was observed as 73.9 and 86.9% of patients with AA, respectively. Patients should be informed about skin irritation on the skin surface in contact with the onion juice [53].
Polygonum multiflorum (P. multiflorum, family Polygonaceae) is a very popular plant that has been widely used to treat various diseases in traditional Chinese medicine due to its different pharmacological effects such as antiaging, immunomodulating, antihyperlipidemia, hepatoprotective, anticancer, and anti-inflammatory. Besides these pharmacological effects, some studies have been reported related to hair growth promotion activity and hair-blacking effect [55, 56]. An active component of P. multiflorum, known as 2,3,5,4′-tetrahydroxystilbene-2-O-β-
Allium tuberosum Rottler ex Spreng (ATRES, family Liliaceae) is one of the Allium species like Allium tuberosum and Allium cepa L. It is widely distributed in East Asia and has been used for treating abdominal pain, diarrhea, hematemesis, and asthma in traditional medicine. Choline acetyltransferase activity of ATRES was also reported [54, 59]. In the first study, evaluating the hair growth-promoting activity and its mechanism of action, ATRES has strong hair-promoting activity through stimulating expression of insulin-like growth factor-1 (IGF-1). Especially, the n-butanol extract of ATRES was found to have most hair growth-promoting activity among the other compared groups including minoxidil, ethanol, n-hexane, distilled water groups on telogenic C57BL6/N mice [59].
Pumpkin seed oil (PSO, family Cucurbitaceae) has been used for treating symptomatic benign prostatic hyperplasia through its inhibitory effect on 5α-reductase and antiandrogenic effect [60, 61]. In a randomized, double-blind, placebo-controlled study, self-rated improvement score, and self-rated satisfaction scores in the PSO-treated group were higher compared with the placebo group after oral administration of PSO at dosage of 400 mg/day for 24 weeks. At 24 weeks, mean hair count was recorded as increase of 40 and 10% in the PSO-treated group and placebo group, respectively. But, there was no significant difference in hair thickness between groups [60].
Serenoa repens (S. repens, family Arecaceae) is a native plant in West India and is grown in large quantities on the Atlantic southeast coast of North America. Saw palmetto is extracted from the berries of this plant. It is one of the herbal medicines that have inhibitory effect on both types 1 and 2 of 5α-reductase enzyme. In addition to inhibitory effect on 5α-reductase, S. repens may also decrease DHT uptake by hair follicle and decrease the binding of DHT to androgenetic receptors [62, 63]. Anti-inflammatory effect has been demonstrated with a composition containing saw palmetto, carnitine, and thioctic acid in hair follicle keratinocytes [64]. Both oral and topical use of S. repens could be effective for treating androgen-induced alopecia in both sexes [63]. In an open label study, 50 male patients with mild to moderate AGA were treated with S. repens 320 mg/day for 24 months. After this period, only 38% of patients had an increase in hair growth. But, this improvement was lower than the group treated with finasteride (68% of patients) [62]. Satisfactory results were also observed after application of topical products containing S. repens extract for 24 weeks in male patients with AGA [65]. Recommended dose is 320 mg/day orally [63]. Side effects of S. repens are minimal. The most known side effects are related to gastric symptoms, although contact dermatitis, feeling of coldness, mild burning sensation, undesirable smell, itching, and acne are the reported adverse events after topical application [63, 65, 66].
Ginseng (family Araliaceae) is traditionally used as an important herbal medicine in East Asian countries such as China, Korea, and Japan. It is divided into three categories: fresh ginseng, red ginseng, and white ginseng [67, 68]. Red ginseng is extracted from the steamed root of Panax ginseng C.A. Meyer, or known as Korean ginseng, and has various effects such as antiaging, antidiabetic, immunoregulatory, anticancer, neuroregulation, lipid-regulating and antithrombotic activities, and wound- and ulcer-healing activity [68, 69]. In addition to these properties, it has also been used for treating numerous hair diseases such as AGA and AA due to its promoting hair growth activity [70, 71]. There are very important chemical constitutes such as polysaccharides, ginsenosides (or known as saphonins), alkaloids, glucosides, and phenolic acid in ginseng [68]. Ginsenosides are the major pharmacologically active ingredients of ginseng. To date, approximately 70 ginsenosides have been isolated from ginseng. In a study, it has been demonstrated that ginsenoside Rg3 had upregulated the expression of VEGF in human dermal papilla cells and mouse hair follicles [72]. Antiapoptotic activity of fructus panax ginseng was also shown in human dermal papilla cells [73].
Eclipta alba (L.) Hassk. (E. alba, family Asteraceae) is a medicinal plant commonly used for treating gastrointestinal disorders, respiratory tract disorders, fever, liver disorders, skin disorders, spleen enlargement, and cuts and wounds as well as hair loss and graying of hair. Numerous pharmacological activities including hepatoprotective, hair growth-promoting activity, antidiabetic, analgesic, anti-inflammatory, neuropharmacological activities, antioxidant, antimicrobial, antimalarial, cardiovascular effects, immunomodulatory, antiepilepsy, anticancer, antiulcer, and antihelmintic activities have been demonstrated. E. alba phytoconstituents including wedelolactone, eclalbasaponins, α-amyrin, oleanolic acid, ursolic acid, luteolin, and apigenin are responsible from main medicinal effects [74]. Hair growth-promoting activity has been investigated on animals. The methanol extract of E. alba has been tested for its efficacy for hair growth in pigmented C57/BL6 mice. While the transition of telogen phase to anagen phase of hair growth was observed in approximately 87.5% animals treated with 3.2 mg/15 cm2 of methanol extract of E. alba, 50% of the animals treated with 1.6 mg/15 cm2 of methanol extract of E. alba was observed transition from telogen phase to anagen phase of hair growth. The rate of anagen induction was dependent on concentration of methanol extract of E. alba [75]. The petroleum ether extract of E. alba was also investigated for its hair growth stimulatory effects in nude mice. This fraction of E. alba significantly reduced the levels of transforming growth factor-β1 (TGF-β1) expression during early anagen and anagen-catagen transition, so that authors suggested that the duration of terminal differentiation was extended [76]. Roy et al. also reported that the petroleum ether and ethanol extracts of E. alba (incorporated into ointment base in concentration of 2 and 5%, respectively) significantly reduced the time taken for hair growth initiation and completion in albino rats treated with the extracts [77].
The plant, Zizyphus jujuba (Z. jujuba, family Rhamnaceae), is a widely distributed both in the Mediterranean regions and in the tropical and subtropical region of Asia and America. It can be used for several diseases such as diabetes, diarrhea, skin infections, liver complaints, urinary disorders, obesity, fever, pharyngitis, bronchitis, anemia, insomnia, and cancer [78]. There is no sufficient data related to its hair growth-promoting effect. In a study by Yoon et al., a greater effect on length of hair was reported in mice treated with 1 and 10% of Z. jujuba essential oil after 21 days of treatment as compared to control group. Although the length of hair was measured as 9.96 mm with 1% of oil and 10.02 mm with 10% of oil, respectively, the length of hair was measured as 8.94 mm in the control group [79].
Allium sativum (family Liliaceae), known as garlic, is one of the most popular herbal medicine and can be used in the treatment of various dermatologic conditions such as psoriasis, AA, keloid scar, wound healing, cutaneous corn, viral and fungal infection, leishmaniasis, and skin-aging and rejuvenation. Constituents of garlic include enzymes (e.g., alliinase), sulfur-containing compounds (e.g., alliin), compounds produced enzymatically from alliin (e.g., allicin), arginine, oligosaccharides, flavanoids, and selenium [80]. In a double-blind randomized-controlled study, Hajheydari et al. reported that combination of topical garlic gel and betamethasone valerate cream was more effective than betamethasone valerate cream alone in patients with localized AA at the 3rd month. The number of total and terminal hairs in the group treated with garlic gel was significantly higher than those of the control group at the third months [81].
Avicennia marina (A. marina), also known as grey or white mangrove, is a traditional herbal plant belonging to family of Acanthaceae. However, it is traditionally used to treat various skin diseases in Egypt, antiandrogenic activity of A. marina and a compound, avicequinone C, isolated from the hearthwood of A. marina was firstly reported by Jain et al. [82]. The results revealed that A. marina was a potent 5α-reductase type 1 inhibitor, reducing the 5α-DHT production by 52% at the final concentration of 10 μg/mL [82]. Moreover, among the thirty different extracts, the highest inhibitory activity was observed from the crude extract of A. marina at a final concentration of 10 g/ml through the reduction in 5α-DHT formation by more than 50% [83].
Phyllanthus ninuri (P. niruri, family Euphorbiaceae) is a widely used plant of genus Phyllanthus in traditional medicine. It is also known as ‘chanka piedra,’ ‘bhuiamlki,’ ‘zhuzicao,’ ‘dukung anak,’ ‘quebra-pedra,’ and ‘chanca piedra.’ P. niruri usually grows in tropical and subtropical regions in Central and South American countries, India and East Asia and has several biologic activities such as antidiabetic, analgesic, wound healing, and immunomodulatory effects. It is traditionally used to cure of jaundice, fever, malaria, stomachache, urolithiasis, vaginal candidiasis, varicella, and tuberculosis by people living in these countries [84, 85]. Newly, inhibitory activity of petroleum ether extract of P. niruri on 5α-reductase type 2 enzyme was shown, and it has been suggested to be useful in the treatment testosterone-induced alopecia [85].
It has been believed that rice bran extract, which is produced by milled rice (Oryza sativa), has antioxidant, anticancer, and antihyperlipidemic effects as well as 5α-reductase inhibitory activity [86]. The compounds having antioxidant activity are phenolic acids, flavonoids, anthocyanins, proanthocyanidins, tocopherols, tocotrienols, γ-oryzanol, and phytic acid [87]. Very few studies exist to support the claims of the efficacy of rice bran. The hair growth-promoting activity of rice bran supercritical CO2 extract (RB-SCE) and its two components (linoleic acid and γ-oryzanol) were shown using real-time reverse transcriptase-polymerase chain reaction in C57BL/6 mice by Choi et al. [86]. In a double-blinded randomized-controlled study, dermal application of 0.5% of RB-SCE (8 ml/day) to the head skin significantly increased hair density and hair diameter in male patients with alopecia for 16 weeks [88].
Sophora flavescens Aiton (S. flavescens, family Leguminosae) is one of the important plants used in traditional Chinese medicine [89, 90]. It has been used for treating viral hepatitis, cancer, viral myocarditis, heat dysentery, hemafecia, jaundice, anuresis, leucorrhoea with reddish discharge, vulval swelling, pruritus vulvae, eczema, and trichomonas vaginalis [90, 91]. It is a strong inhibitor of 5α-reductase enzyme in addition to its vasodilatory and antiandrogen effects. Despite lack of proper clinical trials to support its efficacy for hair loss, the mechanism of affect on hair loss treatment is thought to be through these activities. It was demonstrated that the isolated two pterocarpans, L-maackiain and medicarpin, promoted the proliferation of human hair keratinocytes [89].
Laminaria japonica (L. japonica) is a kind of brown algae and called as ‘kombu’ in Japanese, ‘dashima’ in Korean, and ‘haidai’ in Chinese. The most consumed countries of L. japonica are Far Eastern countries such as Korea, Japan, and China. L. japonica is believed to have beneficial effects for health; however, the mechanism of beneficial effects is not fully understood [92, 93]. The combination of L. japonica extract and Cistanche tubulusa extract has the potential to promote hair growth. Oral administration of both L. japonica extract at dosage of 54 mg/kg and Cistanche tubulusa extract at dosage of 162 mg/kg exhibited an excellent hair regrowth activity on mice. It has been thought that anti-inflammatory activities of the both plant extracts could play an important role to prevent hair loss and improve alopecia [94].
Chrysanthemum zawadskii var. latilobum (C. zawadskii, family Asteraceae) has been used for the treatment of pneumonia, bronchitis, cough, common cold, pharyngitis, bladder-related disorders, gastrointestinal disorders, and hypertension in traditional medicine for ages. Essential oil of the plant contains 27 hydrocarbons, 12 alcohols, 7 ketones, 4 esters, 1 aldehyde, 1 amine, and 3 miscellaneous components [95, 96]. Although recent studies have expressed anti-inflammatory effect and protective effects from liver damage of C. zawadskii, there is little experimental evidence suggesting that the extract stimulates hair growth in humans and animals. In mice study, topical methanol extract of C. zawadskii was more effective compared to minoxidil-treated group. In the C. zawadskii-treated and minoxidil-treated groups, while the maximum hair scores in the first hair-growth generation were recorded as 2.5 ± 0.29 and 2.5 ± 0.28, hair coverage scores in the second hair-growth generation were noted as 2 ± 0.41 and 1.5 ± 0.29, respectively. Rapid hair loss seen in minoxidil-treated mice was not observed in C. zawadskii-treated group after the first hair growth generation [95].
Scutellaria baicalensis (S. baicalensis, family Lamiaceae), also known as Huang Qin, mostly grows in China, Japan, Korea, Mongolia, and Russia [97, 98]. S. baicalensis is likely to have hair growth-promoting effect by means of its active substances. It has been reported that the compound possessing this activity is an active flavonoid isolated from S. baicalensis named ‘Baicalin’. In recent years, it has also suggested that both the extract of S. baicalensis and baicalin inhibit nuclear translocation of the androgen receptor stimulated by DHT in human dermal papilla cells and enhance proliferation of human dermal papilla cells in vitro [98].
Cuscuta reflexa Roxb. (C. reflexa, family Convulvulaceae) is a parasitic plant that is used as herbal medicine. It is also known as ‘Tukhm-e-Kasoos (dodder),’ ‘Aftimoon,’ or ‘Kasoos’ in Unani Tibbi, ‘Akashabela,’ or ‘Amarabela’ in Hindi, ‘Swarnalata’ in Bengali, and ‘Akakhilata’ in Assamese, in vernacular [99, 100]. It commonly grows on different host plants, mostly thorny herbs in all geographical regions of India [99, 101]. Many pharmacological activities such as relaxant and spasmolytic action, positive inotropic and cardiotonic activities, cholinergic action, anti-HIV, antioxidant, anti-steroidogenic, antibacterial, hepatoprotective, hypoglyceamic, diuretic, anticonvulsant, anti-inflammatory and anticancer activities as well as hair growth activity have been previously reported [100]. A number of experimental observations have indicated that C. reflexa has hair growth-promoting and 5α-reductase inhibitory activities. Hair growth was shown after treatment of the petroleum ether extract solution (250 mg/kg, orally) of C. reflexa and the ethanolic extract solution (250 mg/kg, orally) of C. reflexa in male albino rats with cyclophosphamide-induced alopecia at 19 days [99]. In another animal study by Pandit et al. suggested that petroleum ether extract of C. reflexa reversed androgen-induced alopecia by inhibiting conversion of testosterone to DHT [101]. Polyherbal formulation including C. reflexa was also shown to present hair growth-promoting activity on rats. Hair growth initiation time was markedly reduced to one-third on treatment with the prepared formulation compared to control group. The time required for complete hair growth was also reduced by 32%. Quantitative analysis of hair growth cycle after treatment with formulations and 2% minoxidil solution (positive control group) exhibited greater number of hair follicles in anagenic phase compared with control [40].
Ishige sinicola (I. sinicola) is a brown alga that has antibacterial and anti-inflammatory effects against acne. In 2013, a study firstly demonstrated that I. sinicola extract and its component, octaphlorethol A, have the potential to promote hair growth via the proliferation of dermal papilla cells followed by the activation of β-catenin pathway, and the 5α-reductase inhibition [102].
G. elliptica is the edible seaweed in some Asian countries. Although it is thought that potential anticancer activity, there is no enough evidence investigating the protective effect against hair loss and hair growth-stimulating effect of G. elliptica [103, 104]. Possible mechanisms including the proliferation of dermal papilla cells, inhibition of 5α-reductase enzyme, increase in prostaglandin E2 (PGE2) production, decrease in pro-inflammatory cytokine production, and inhibitory activity against Pityrosporum ovale (P. ovale) have been shown in the prevention of hair loss. A study showed that G. elliptica extract promoted the proliferation of dermal papilla cells by 169.5% at the concentration of 100 μg/ml compared with the vehicle-treated control group. The study also indicated that G. elliptica extract inhibited 5α-reductase enzyme and this activity increased with dosage [104].
Puerariae flos (the flowers of Pueraria thomsonii, family Leguminosae) extract (PF-ext) has inhibitory activity on testosterone 5α-reductase. The two major compounds, soyasaponin I and kaikasaponin III, are responsible for this inhibitory activity. In addition to inhibitory activity on testosterone 5α-reductase of both compounds, soyasaponin I possesses hepatoprotective, sialyltransferase inhibitory, and renin inhibitory activities, while kaikasaponin III possesses anti-hepatotoxic, hypoglycemic, hypolipidemic, and anti-herpes virus activities [105, 106]. Inhibitory activity of PF-ext on 5α-reductase is stronger than Puerariae Radix extract (PR-ext). In testosterone-sensitive male mice, hair regrowth was improved after the application of PF-ext solution in a dose-dependent manner via antiandrogenic activity. PF-ext can stimulate the induction of the hair cycle to anagen phase, but this mechanism has not been proven definitely [105].
Curcuma aeruginosa (C. aeruginosa, family Zingiberaceae) is a native plant of India and Southeast Asia. The rootstock of C. aeruginosa has long been used in traditional medicine for various indications such as dysmenorrhea, exanthemas and fungal infections. The oils derived from this plant consist of 1,8-cineole, curserenone, furanogermenone, camphor, (Z)-3-hexenol, zedoarol, furanodienone, curcumenol, isocurcumenol, β-alemene, curzerene, and germacrone, among others. C. aeruginosa hexane extract effects by inhibiting 5α-reductase activity, consecutively impairing the conversion of testosterone to DHT [107, 108]. Pumthong et al. investigated the effect of C. aeruginosa hexane extract on male-pattern baldness with a randomized, double-blind, placebo-controlled study. The study has shown that 5% hexane extract of C. aeruginosa especially combined with 5% minoxidil increased hair growth and decreased hair shedding [107].
Hura crepitans (H. crepitans, family Euphorbiaceae) has been used as a traditional medicine to treat some diseases such as Hansen’s disease and syphilis in the Amazon region. A compound in H. crepitans, daphne factor F3, can play an effective role the mechanism of the hair growth. But, interestingly, the amount of daphne factor F3 is very important for hair growth. While H. crepitans from Peru possesses hair regrowth activity, H. crepitans from Brazil is not affect hair growth. Because, the daphne factor F3 content of H. crepitans from Peru is about 30 times more than H. crepitans from Brazil [109, 110]. It has been suggested that H. crepitans inhibits the retardation of hair regrowth by DHT through inhibition the neurotrophin (NT)-4 activation induced by DHT [109].
Tobacco leaves (family Solanaceae) are used in traditional medicine for promoting of hair growth. The leaves also used to treat bronchitis, asthma, skin diseases, headache, etc. Alkaloid nicotine is the main constituent of tobacco leaves. Alkaloids such as nicotine, nicotianin, nicotinine, nicoteine, and nicoteline, which are the constituent parts of tobacco leaves, selectively inhibit 5α-reductase activity. The microbial bio transformed extract of tobacco leaves in cow urine has been investigated to treat AGA, and it has been found that it promotes hair growth at concentration dependent manner. The study confirms that 30% concentrated lotion treatment is at par with 2% minoxidil treatment in potentiating hair growth promotion in male albino Wister rats [111, 112].
Tectona grandis Linn. (T. grandis, family Verbinaceae) (teak tree) has been used to cure many diseases in traditional Indian medicine. T. grandis is called as ‘saka’ in Sanskrit, ‘sagun’ in Hindi, ‘sagwan’ in Marathi, and teak tree in English. It has also been used as a hypoglycaemic agent. According to the traditional Indian medicine, T. grandis roots are useful in anuria and urinary retention. The flowers have used to treat bronchitis, biliousness, and urinary discharge. The oil from the seeds is useful in scabies. The wood is used to relax and sedate the gravid uterus, heal headache and burning pains, cure liver problems, and even dysentery. T. grandis has been investigated in some studies for its anti-inflammatory and wound healing effects and is used as a topical treatment for burn wounds [113, 114]. Jaybhaye et al. investigated the effect of petroleum ether extract of T. grandis Linn. seeds on hair growth activity of albino mice. According to this study, topical application of the petroleum ether extract of T. grandis induced hair growth initiation and was superior to standard therapy with minoxidil 2% solution. The combination of the petroleum ether extract (5%) with 2% minoxidil has the strongest effect on hair growth initiation [113].
Boehmeria nipononivea (B. nipononivea, family Urticaceae) is a Japanese plant and the use of acetone extract derived from this plant has been investigated for treatment of androgen-dependent alopecia. One study indicates that the acetone extract of B. nipononivea has 5α-reductase inhibitory activity. The acetone extract derived from B. nipononivea was investigated on mice for its hair growth effect, and it resulted with a significant hair regrowth starting on 15th day and continues until 22th day. The 5α-reductase inhibitory activity of the acetone extract of B. nipononivea is attributed to fatty acids contains such as α-linolenic acid, palmitic acid, oleic acid, elaidic acid, and stearic acid. The study reveals that both the acetone extract of B. nipononive and three fatty acids (α-linolenic, elaidic, and stearic acids) have 5α-reductase activity and stimulates hair regrowth [115].
Acupuncture is an ancient holistic system of Chinese medicine and has been practiced there so many years. China had the cultural and traditional exchange with its neighbors, and therefore, it spread to all over the world in time. Today, it is one of the most frequently used forms of complementary medicine [116].
\nAcupuncture aims to bring a complete cure, not only managing the outstanding symptom but to heal the whole body. Even though various acupuncture techniques are available, the fundamental techniques are needling, moxibustion, cupping, suction, and acupressure. Over the centuries, acupuncture has been used to treat a wide variety of diseases including skin disorders such as acne, alopecia, eczema and dermatitis, pruritus, pityriasis, psoriasis, rosacea, systemic lupus, urticaria, herpes zoster, chicken pox, impetigo, leprosy, and vitiligo. The exact mechanism of action of acupuncture treatment in skin disorders is not clear but investigations revealed that acupuncture stimulation effects on three key points: the hypothalamus-pituitary-adrenal axis, the autonomic nervous system, and brain-derived neurotrophic factor. There may be an increase on serum levels of cortisol by the effect of acupuncture. It has also been demonstrated by functional MRI that manual needle acupuncture distinctively activates the hypothalamus-limbic system [116].
\nDegranulation of mast cells significantly increases in autoimmune diseases such as AA and chronic inflammation. A mouse model for AA study has shown that severe mast cell degranulation and accumulation around the anagen hair follicle cause a self-attack of the hair follicle cells by migration of the inflammatory cells. This attack induces the hair matrix cell phase to the telogen phase that results with hair loss. Acupuncture treatment reduces T1-cell attacks on hair bulb and activates blood circulation by warming the local collaterals; therefore, it may help to reduce hair loss. The same mouse study indicated that electro-acupuncture reduces mast cell degranulation in the dermis. It is reported that may be the cause of the pathological changes causing AA but reliable evidence is not yet available [117, 118].
\nEven though acupuncture treatment in dermatological diseases is safe and inexpensive, improperly performed acupuncture can cause potentially serious adverse effects such as vasovagal events, local infections, damage to internal organs, pneumothorax, spinal cord injury, and hepatitis B infection [116].
The hypnotic phenomenon has been used over thousands of years, and it is a form of trance induction. Recently, the use of hypnotic therapy in somatic medicine has been supported by the British Medical Association in 1955 and the American Medical Association in 1958. A hypnotic trance can be described as an altered state of consciousness with “inward focus.” It can be differed from other states of consciousness by electroencephalography (EEG) and imaging modalities. A hypnotic state can be induced by a therapist or an individual can induce hypnotic trace in himself or herself (self-hypnosis) [119, 120].
\nHypnosis has been used for several indications such as induction of anesthesia or to heal irritable bowel syndrome and psychosomatic diseases as well as a variety of skin disorders including AA and trichotillomania. Nowadays, medical hypnosis is performed by physicians whom have received appropriate training in many countries all over the world. For some selected skin disorders, with proper training and selection of appropriate patients, medical hypnosis can relieve symptoms and in some cases can cure the illness [119, 120].
\nHypnosis is a cost-effective and nontoxic therapy and can be used in dermatological treatment especially in patients with psychosomatic component [119, 120]. In a preliminary study, hypnotic sessions including relaxing suggestions and symptoms-oriented suggestions were held as a complementary or the only treatment once every 3 weeks in patients with severe AA, alopecia totalis, or alopecia universalis. Twelve of 21 patients showed significant improvement after 4–13 (mean 5.5) sessions of hypnosis, while treatment success could not be achieved in 9 patients. But also, minimal relapses were observed in all patients responded well [121]. In another prospective cohort study, it has been suggested that hypnosis had no significant contribution on hair regrowth in patients with refractory AA [122].
\nDespite confusing conclusions have been reported about the efficacy in the treatment of AA, hypnosis seems to be salubrious in the treatment of both children and adolescents with trichotillomania. Cohen et al. reported that complete resolution of their complaints was seen in two children after 7–8 weeks and in one child after 16 weeks. Even if just a recurrence was observed in one patient during follow-up, the patient completely recovered again with hypnotic retreatment [123]. Iglesias A observed that three pediatric cases completely disappeared to their trichotillomania behavior after 7 or less hypnotic sessions [124]. In addition to children, hair pulling was significantly reduced with imaginative techniques in adolescents with trichotillomania [125]. According to these results, hypnotherapeutic approach can be considered as a quite effective and preferred option in both children and adolescents with trichotillomania.
The side effects reported after CAM is often minimal. Contact dermatitis was reported with onion juice in patients with AA, thus patients should be informed about skin irritation on the skin surface in contact with the onion juice (Figure 1) [53]. S. repens that can be used as both orally and topically may cause undesirable adverse effects such as mild stomach discomfort, contact dermatitis, feeling of coldness, mild burning sensation, undesirable smell, itching, and acne [63, 65, 66]. Vasovagal events, local infections, damage to internal organs, pneumothorax, spinal cord injury, and hepatitis B infection are some of the side effects that can be encountered after acupuncture therapy [116]. Prurigo nodularis also reported on extremities of a patient shortly after acupuncture [126].
Contact dermatitis developed after topical application of onion and garlic on face of a patient with AA.
In recent years, although the increasingly widespread use of CAM, scientific data are still not enough. The observed results with herbal medicine are promising in the treatment of hair loss, especially AGA and AA. According to acceptable results, hypnosis may be an effective and safe alternative option in patients with hair loss, especially AA and trichotillomania. Even so, there is need for more scientific data proving its effectiveness and reliability.
The categorization of children with cerebral palsy (CP) into clinical groups remains a challenge, hence the presence of so many classifications that are not comprehensive and the continued search for a holistic classification [1]. The clinical manifestations of CP are heterogeneous as rightly pointed out in the most current definition of CP [1, 2]. This implies that children with CP differ clinically in many aspects. Therefore, different groupings (classifications) are possible [1]. These classifications (groups) differ in the characteristic(s) used and their individual uses or purposes. A classification may be used for describing the nature of the disability, for predicting current and future management needs, comparing cases in different areas and assessing change following an intervention [1]. Generally, it is desirable that any classification used should be reliable, valid, quantitative, and objective and most importantly assist management [1].
\nBesides early identification and intervention, the current trend in neurodevelopmental pediatrics is a focus on functional effects of different states of health [3, 4]. This is the outcome of the recent WHO International Classification of Functioning, Disability and Health (ICF) which in the field of CP led to the development of newer measures of functional abilities (functional scales) [3, 4]. There are functional scales for a number of functions impaired in CP. It is widely accepted that the functional classification remains the best classification for a patient with CP because it guides management [1, 5, 6].
\nSome factors that influence the clinical classification of CP are the age of a child, reliability of the medical history, and extent of diagnostic investigations [1]. This means that the same child may be classified differently at different times (due to changes in peripheral manifestations with age), by different people (due to variable historical data from maternal recall or case notes), and in different regions (due to differences in availability and affordability of neuroimaging and metabolic studies). Therefore, Bax et al. [1] in 2005 proposed that all classification results should indicate these factors at the time of classification.
\nChildren with CP differ clinically in the following characteristics: type/nature of motor disorder, distribution of motor impairment, etiology, presence/number of accompanying impairments, structural brain abnormalities on neuroimaging, degree of severity of impairments, and individual therapeutic needs. These clinical variables form the basis of the traditional classifications of CP. In 1956, Minear [7] and the Nomenclature and Classification Committee of the American Academy for cerebral palsy classification put forward an early classification system that presented seven classification axes based on the aforementioned features.
\nSubsequent classification systems originated from the Minear classifications and are either a combination or an expansion of the categories. Such classification systems based on multiple variables include the Swedish classification system [8], Edinburgh classification [9] and classification by the Surveillance for Cerebral Palsy in Europe (SCPE) [10].
\nThe current emphasis on the functional consequences of different health states increased interest and research on the functional classification of CP [1, 3, 4]. The result is an evolution of newer measures (functional scales) that objectively and reliably measure and quantify functional abilities. A number of these functional scales have been validated by multiple studies [11, 12, 13, 14, 15, 16]. They include Gross Motor Function Classification System (GMFCS) [11] (functional mobility/ambulatory function), Manual Ability Classification System (MACS) [14] (hand and arm function/manual dexterity), Communication Function Classification System (CFCS) [16] (speech/communication function) and Eating and Drinking Ability Classification System (EDAC) [17] (eating and drinking/oropharyngeal function). They are mainly used for predicting current and future management needs of children with CP, and their use agrees with current thinking in management of CP.
\nAdvances in management of CP including the biopsychosocial method of service delivery that recommends liberal use of assistive devices require additional characteristics or variables to be added to traditional classifications in order to assist management and satisfy other important purposes like clinical description and research [1, 4, 5]. Such a classification would be called holistic, comprehensive or standardized. A consensus on what characteristics/components such holistic classification should incorporate is yet to be reached by experts in the field of CP.
\nThe traditional classifications of CP are basically the Minear [7] classifications in seven axes namely:
Physiological
Topographic
Supplemental
Aetiologic
Neuroanatomic (radiologic)
Therapeutic
Functional
This is based on the type/nature of motor or movement disorder (quality and changes in tone) and classifies CP into two types: spastic (pyramidal) and non-spastic (extrapyramidal). Generally speaking, neuromotor findings in spastic CP are consistent and persistent while variability is the rule in extrapyramidal CP [6, 18, 19].
\nThe clinical features of spastic CP are as follows [6, 18, 19]:
Tone is invariably increased (hypertonia), that is, persistently increased with little or no variation in the awake (movement, tension and emotion) or sleep states. This is further confirmed by asking caregivers whether their child feels stiff when touched or held most times of the day even during sleep. The answer is usually a “yes.”
The quality of the increased tone is described as “clasp-knife” spasticity and is elicited clinically by a rapid passive movement at a joint (as rapidly as the time taken to say “one thousand and one”). This produces the classic “clasp-knife” resistance followed by a sudden “give.” Spasticity refers to hypertonia due to a velocity-dependent increase in tonic spinal stretch reflex.
Deep tendon reflexes are markedly increased (more commonly grade 3+ or 4+)
A positive Babinski sign (extensor planter response), that is, lightly stroking the lateral aspect of the sole and across the foot pads/ball of the foot, results in extension/dorsiflexion of the hallux (up-going big toe) and fanning out/spreading of the other toes.
Sustained ankle clonus, that is, when the ankle is briskly dorsiflexed on a flexed knee, a rhythmic contraction is observed.
Non-positional contractures (due to persistent hypertonia)
Decreased movement
Localization/limb distribution of neuromotor impairment varies from one child to another and so spastic CP can be further classified topographically.
In contrast, the clinical features of extrapyramidal (non-spastic) CP are [6, 18, 19]:
Tone is variably increased (varies from hypertonia to hypotonia) depending on the state, that is, tone is increased by activity, agitation, tension, and emotions like crying, but tone is decreased in sleep and when relaxed. Caregiver usually tells the clinician that their child limbs feel normal when asleep or quiet.
The quality of the increased tone is “lead pipe” rigidity or “candle wax” type and is elicited clinically by a slow passive flexion and extension of a limb. The increased resistance to this passive movement is felt all through the movement. Besides, extrapyramidal hypertonus can be diminished by repetitive movement and this is called “shaking it out.”
Deep tendon reflexes are usually normal or mildly increased (grade 1+ to 3+).
A negative Babinski sign.
Unsustained ankle clonus.
Positional contractures (the variable tone is protective against contractures and so contractures like hip/knee flexion contracture only occur after prolonged periods on a wheelchair).
Movement is disordered. Thus, extrapyramidal CP is also called dyskinetic CP.
There is a four-limb functional impairment that precludes further topographic classification. However, extrapyramidal or dyskinetic CP is further subdivided based on the different manifestations of abnormal/involuntary movements (dyskinesia) and tone. The subtypes are choreathetoid CP—characterized by excessive and rapid movements involving the proximal body parts (trunk) (chorea) combined with slow writhing movements of the distal parts of the body (extremities) (athetosis) and usually with reduced tone. This is the commonest type of extrapyramidal CP. Dystonic CP is characterized by extrapyramidal hypertonia and decreased movement (hypokinesia). Dystonia occurs when there is simultaneous contraction of both agonist and antagonist muscles. Ataxic CP occurs when there are signs of incoordination and hypotonia caused by damage to the cerebellum. This is a rare form of CP [6, 18, 19].
One merit of the physiological classification is that it can suggest the areas of brain damage and possible etiological factors. For instance, spasticity would suggest damage to the cortical neurons (pyramidal cells) due to hypoxic ischemic encephalopathy (HIE) from severe perinatal asphyxia and postnatal central nervous system (CNS) infections like meningitis [19]. In addition, dyskinetic CP points to damage to the basal nuclei by bilirubin encephalopathy and severe perinatal asphyxia at term [19]. Therefore, the physiological classification is still clinically useful.
\nHowever, the physiological classification is not reliable [6, 18, 20]. The terms spastic (pyramidal) and extrapyramidal CP are strictly incorrect [6, 18, 20]. It is more accurate to refer to these as “predominantly spastic” and “predominantly non-spastic.” Due to the complex interactions of the upper motor neuron system (the pyramidal, extrapyramidal, and cerebellar pathways) with the anterior horn cells to control posture and movement, lesions causing CP in real life usually involve both pyramidal and extrapyramidal pathways [21]. Strictly speaking, pyramidal lesions induce spasticity as a result of concomitant damage to extrapyramidal pathways [21]. This explains the clinical combination of motor/movement abnormalities, for example, spasticity and dystonia, and spasticity and choreoathetosis. This is the so-called mixed CP subtype. From the explanation above, this CP subtype should actually be very common but from published studies [22, 23], spastic CP remains the commonest type thereby exposing the subjectivity and imprecision in assessment of patients based on this classification. Additionally, the physiological classification does not aid therapy or inform management of patients with CP, and this inability to indicate functional abilities remains a major drawback [6, 18, 20].
\nThis classification relies on the localization/limb distribution of neuromotor impairment in spastic CP [19]. It subdivides spastic CP into: quadriplegia (symmetric/equal and severe spasticity of all four limbs), diplegia (involvement of the four limbs but greater spasticity and weakness in the lower limbs) and hemiplegia (involvement of the upper and lower limbs on one side of the body) [19]. Other types of spastic CP such as tripegia (three-limb spasticity) and monoplegia (one-limb spasticity) are rare, and double hemiplegia (four extremity involvement with greater spasticity of the upper limbs) is no longer in use [6, 20].
\nAn advantage of this classification is that these topographical subtypes can be linked to some etiological factors. For instance, diplegia suggests periventricular leukomalacia due to prematurity/low birth weight; hemiplegia suggests perinatal stroke, periventricular hemorrhagic infarction or neonatal cortical infarction while quadriplegia suggests severe perinatal asphyxia at term, postnatal infection (bacterial meningitis) and metabolic/genetic disorders [19]. However, the descriptive terms in the topographic classification cannot be used reliably [6, 20]. One notable source of confusion is distinguishing spastic diplegia from quadriplegia. This distinction is highly subjective since it is unclear how much upper limb spasticity is needed to separate a diplegia from a quadriplegia [6, 20]. Recall that there is involvement of the four limbs in both subtypes. The arm and leg naturally perform different functions, and assessing the relative severity of involvement is difficult [1]. Moreover, the imprecise use of these terms in clinical practice has been reported by Gorter et al. [24] Many experts agree that the use of these terms in classification should be stopped [1]. Furthermore, the topographic classification does not consider functional abilities and so does not aid therapy or inform management of these children [6, 20]. Therefore, the topographic and physiological classifications share similar merits and demerits.
\nThis is an additional grouping that comprises the accompanying impairments in CP and their association with the physiological and topographic classifications [6, 20]. The accompanying physical, mental or physiological impairments in CP include epilepsy, cognitive (intellectual), speech, visual and hearing impairments, behavioral problems and secondary musculoskeletal abnormalities (hip dislocation/subluxation, contractures) [1, 2]. The purpose of linking these supplemental disorders to the physiological and topographic classifications was to identify syndromes with a common etiology that would lead to prevention [6, 20]. Unfortunately, the supplemental disorders correlated poorly with the two earlier classifications. This means that it was only in a few examples like bilirubin encephalopathy that such a link between supplemental disorders, physiology and etiological factor could be established. For instance, the combination of accompanying impairments—vertical gaze palsy, sensorineural deafness and enamel dysplasia—is associated with choreoathetoid CP (physiology) from damage to the basal nuclei by bilirubin encephalopathy (etiological factor) [6, 20].
\nThough these associations were limited and the aim of the supplemental classification defeated, supplemental disorders (accompanying impairments) remain pertinent to the current management of CP because their presence strengthens the need for multidisciplinary management. This means that the accompanying impairments need to be taken into consideration in planning service delivery. Moreover, the accompanying impairments may cause more functional limitation than the primary motor dysfunction (the core feature of CP) and thus must be addressed to achieve a positive functional outcome. Furthermore, the most recent definition of CP [2] highlights the importance of these accompanying impairments by incorporating them as part of the definition of CP since CP rarely occurs without them. It is generally recommended that the presence or absence of these impairments and the extent to which they interfere with function be recorded in addition to the classifications used [1]. Currently, it is recommended that at least the presence/absence of epilepsy be recorded and intellectual function (IQ), vision and hearing be assessed [1].
\nThe categorization based on the actual cause (etiology) and timing of insult was aimed at prevention, and the association of erythroblastosis fetalis with choreoathetoid CP was the paradigm for this classification [6, 20]. The etiology of CP is multifactorial, and the causal pathways are (mechanisms) multiple and complex. The Collaborative Perinatal Project [25] identified the associated risk factors for CP. Due to the fact that much of the data in these epidemiological studies [25, 26] are still correlational, “risk factors” are more appropriate than etiology. These risk factors or associated etiological factors in CP include genetic abnormalities, cerebral dysgenesis, multiple gestation, intrauterine/congenital infection (TORCHS), maternal infection (UTI), prematurity, low birth weight, perinatal asphyxia (HIE), bilirubin encephalopathy, postnatal CNS infections, etc. [19, 25, 26]. These associated etiological factors can be classified according to the timing of insult as prenatal (commonest), perinatal and postnatal [6, 19, 20].
\nIdentifying both the disturbances or events and causal pathways or processes that led to the damage to the developing motor system remains a challenge [6, 20]. This is compounded by the fact that most of these factors are prenatal in timing. Therefore, the etiological classification was severely limited and failed in addressing prevention [6, 20].
\nThis classification correlates specific radiologic findings (brain structural alterations) with types of CP [6, 20]. This implies categorizing CP patients based on neuroradiologic findings. Thus, the neuropathologic classification relies on neuroimaging studies such as magnetic resonance imaging (MRI) and computed tomography scan (CT scan).
\nNeuroimaging contributes significantly to the understanding of the etiology and pathology of CP and the timing of insults [1, 6, 20]. In a systematic review of neuroimaging for cerebral palsy, Korzeniewski et al. [27] classified abnormal radiological findings and diagnoses into five categories namely: malformations, gray matter damage, white matter damage, ventriculomegaly, atrophy or CSF space abnormalities and miscellaneous findings.
\nThough the correlations between the neuropathologic substrates and clinical types have been weak and inconsistent, recent advances such as diffusion tensor imaging, magnetic resonance spectroscopy, functional magnetic resonance imaging and fast spin echo imaging have improved greatly the possibility of a comprehensive radiologic classification [6, 20, 27]. A recent study by Hou et al. [28] continues to correlate neuropathologic findings with different clinical types of CP. For example, dyskinesia correlated with lesions detected by MRI in the thalamus and putamen due to HIE and in the globus pallidus and hypothalamus due to kernicterus.
\nThere are also difficulties in estimating the timing of insults in CP using neuroimaging findings. It was initially assumed that the presence of neuronal migrational disorders meant that the insult occurred in the first half of pregnancy while the presence of a glial response indicated insults around the second half of pregnancy [27]. However, there is evidence that cell migrational disorders can occur in the last 2–3 months of pregnancy [27]. Nevertheless, malformations are more likely to occur earlier in gestation, and thus, neuroimaging confirmation of their presence can help establish that the cause of CP is unrelated to perinatal events [27].
\nCategorizing patients with CP based on neuroradiologic findings implies that neuroimaging studies be carried out on all patients. Therefore, it will be difficult to apply such classification in resource-poor countries where neuroimaging facilities are not readily available or affordable and the professional expertise needed may be lacking. Despite this, the American Academy of Neurology (AAN) recommends neuroimaging studies on all children with CP whenever possible [27]. The bottom line is that neuroimaging can be used to identify the neuropathologic substrates of the various etiologic and risk factors of CP, possibly provide information about timing of insults and detect cerebral dysgenesis or malformations but, at present, a comprehensive neuropathologic classification is still in the pipeline.
\nThis scheme categorizes CP cases based on treatment needs into four groups namely: non-treatment, modest treatment, need for a CP treatment team, and pervasive support groups [6, 20]. Parents/caregivers want their children to receive treatments that will improve their condition, so any classification that is implicative of treatment is important to the patients and their caregivers and relevant to clinical practice. There is a consensus in the literature that the therapeutic and functional classifications are the most important to the patient [1, 6, 20].
\nHowever, the therapeutic classification simply identifies how much treatment or the extent of interventions a given child requires without specifying what is actually needed to improve function. This explains the little emphasis on the therapeutic classification.
\nFunctionally, CP is classified into levels of severity based on functional (motor) abilities and/or limitation of activity [1, 6, 20]. Currently, the emphasis on the functional classification is due to its important role in the management of CP. So there is a rekindled interest in this scheme.
\nThe functional classification remains the best classification of CP because it is a useful guide to providing care for patients appropriate for their functional level and helps clinicians set and discuss with parents/caregivers realistic rehabilitation goals [1, 4, 5, 11, 12]. The functional classification satisfies the needs of patients and parents/caregivers by informing the current and future service needs of children with CP [5]. It provides information that will permit comparison of CP cases in different locations. It provides information that will allow evaluation of change at different points in time in the same patient such as after an intervention [1].
\nHowever, it falls short of giving full descriptive information about a child with CP that clearly delineates the nature of the problem. It does not indicate the nature of the motor abnormality, the topography, the etiology, or neuropathologic substrates which in their own respects are important descriptive information. Besides, it does not indicate supplemental disorders that are necessary for assessing the service delivery needs of patients with CP.
\nIloeje and Ogoke [29] in 2017 reported that the type of CP (physiology and topography), etiological factors and the number of accompanying impairments (supplemental disorders) were positively associated with the severity of gross motor dysfunction and walking ability of children with CP. In that study [29], children with spastic quadriplegic type, bacterial meningitis as etiological factor or many (five or six) accompanying impairments all had severe gross motor dysfunction and were non-ambulatory. Therefore, the other classifications may suggest functional abilities in children with CP.
\nThese are the Swedish classification [8], Edinburgh classification [9] and Surveillance for Cerebral Palsy in Europe (SCPE) classification [10].
\nCP subtypes based on the Swedish classification (1989) [8] are spastic (hemiplegic, tetraplegic, and diplegic), dyskinetic (dystonic and athetotic), ataxic and unclassified/mixed. It is immediately obvious that this classification combines the Minear’s Physiologic and Topographic schema. Thus, it shares the same merits and demerits as the physiological and topographic classifications as earlier discussed.
\nAccording to the Edinburgh classification [9], there are six subtypes of CP namely hemiplegia, bilateral hemiplegia, diplegia, ataxic, dyskinetic and other forms of CP including mixed forms. This classification is a combination of classifications based on topography and physiology and so has the same advantages and shortcomings as the topographic and physiologic classifications.
\nThe SCPE [10] classifies CP into the following four subtype groups: spastic (bilateral and unilateral), dyskinetic (dystonic and choreoathetotic), ataxic, and non-classifiable. This grouping also combines the physiological and topographic classifications. The classification tree of the SCPE for subtypes of CP is shown in Figure 1.
\nClassification tree for sub types of CP by SCPE.
Due to the lack of reliability of the terms used in Minear’s topographic classification, SCPE [10] introduced two new terms to replace quadriplegia, diplegia, and hemiplegia. These terms are bilateral and unilateral used to describe involvement of both sides and one side of the body, respectively. By this classification, spastic quadriplegia and spastic diplegia are classified as bilateral spastic CP (BS-CP) while spastic hemiplegia is termed unilateral spastic CP. This classification is easy to apply and is more reliable than the earlier traditional classifications. Therefore, by improving the reliability of the terms used in the topographic component of this classification, the SCPE currently seems to be the best traditional classification for description of patients with CP.
\nHowever, the SCPE classification [10] does not include functional abilities and so does not aid therapy for patients with CP. Hence, this classification currently has not had a similar level of advocacy as the functional classifications.
\nCurrently, functional classification of each case of CP is internationally advocated due to its important role in management. Thus, current classifications of CP are functional scales for various functions impaired in CP such as communication, gross motor, fine motor, and oromotor/oropharyngeal functions. They are basically ordinal scales to categorize functional abilities or severity of limitation of activity and are not used as outcome measures, tests or assessments [14, 30]. They are simple and easy to apply both by healthcare professionals and care givers and are good for clinical use and patient stratification for research purposes [5, 11, 30]. They have been validated by studies [12, 13, 15] and shown to be objective and reliable clinical classification systems for CP. They have replaced previously used imprecise and subjective functional classifications of CP into mild, moderate and severe.
\nTheir development resulted from the paradigm shift from a focus on body structure and function (impairment-based assessments and treatments) to current emphasis on activity or participation (function and social engagement) [3, 4, 5]. These concepts are contained in the ICF [3]. The ICF is a new classification system for health and disease that is universal (for everybody not only people with disabilities) [3]. It is a new way to consider health conditions and posits an interactive relationship between health conditions and contextual factors (environmental and personal factors) in which all components are linked together [3, 4]. It represents a coherent view of health from biological, individual and social perspectives (a biopsychosocial approach to health, functioning and disability) [4]. The ICF model has been used to guide clinical thinking and service delivery to patients with CP [4]. This conceptual change introduced by the ICF is topical.
\nThe functional classifications are analogous and when used together complete the description of daily functional activities in CP at the activity or participation level of the ICF [3, 30]. They include
Gross Motor Function Classification System (GMFCS) [11]
Manual Abilities Classification System (MACS) [14] & Mini—MACS [31]
Communication Function Classification System (CFCS) [16]
Eating & Drinking Ability Classification System (EDACS) [17]
There are other functional scales like the Functional Mobility Scale (FMS), Bimanual Fine Motor Function (BFMF), Functional Assessment Questionnaire (FAQ), the Pediatric Orthopaedic Society of North America Outcomes Data Collection Instruments (PODCI), etc.
\nHowever, the first four are more commonly used and will be discussed here.
\nThis is the most widely used clinical functional classification of CP [1]. It is an ordinal scale that categorizes a child’s mobility/ambulatory or lower limb function in five levels ranging from walking without restrictions (level I) to inability to maintain antigravity head and trunk postures (level V) [11]. The first version of GMFCS was published in 1997 by Palisano et al. [11] and described gross motor functional abilities and limitations in children aged less than 12 years. The upper limit of 12 years (before end of adolescence) was a limitation of the first version, and the GMFCS was revised and expanded in 2007 by Palisano et al. [32] to include an age group for youths 12–18 years. This current version of GMFCS [32] emphasizes the concepts inherent in the WHO’s International Classification of Functioning, Disability and Health (ICF). The GMFCS—ER [32] is shown in Figure 2. A summary of the criteria for the GMFCS [11, 32] is as follows:
Level I—Walks without limitations.
Level II—Walks with limitations.
Level III—Walks using hand-held mobility device.
Level IV—Self mobility with limitations; may use powered mobility.
Level V—Transported in a wheelchair.
Gross Motor Function Classification System—Expanded & Revised (GMFCS—E & R). Reproduced with permission.
These general headings or titles for each level represent the method of mobility or highest level of mobility that a child with CP is expected to achieve after 6 years of age [11].
\nCurrent management of CP involves a liberal use of adaptive/augmentative equipment in addition to impairment-based treatment approaches to achieve independence [5]. A major goal in the management of CP is to ambulate the children and enable independent living; this gave birth to the changing concepts and the GMFCS. So, how GMFCS is a useful guide to providing care appropriate for the functional level and age of a child with CP?
\nA child on GMFCS level I will walk independently and so requires no adaptive mobility equipment but appropriate stimulation. The child on level II may need hand-held mobility device when first learning to walk (younger than 4 years) and eventually walks with limitations (after 6 years). Thus, a hand-held mobility device may be provided initially for the child on level II. Therefore, the management of patients on GMFCS levels I and II would focus on appropriate stimulation, preventing complications from occurring and treatment of accompanying impairments. The child on GMFCS level III will require adaptive equipment for low back support for floor and chair sitting and at about 6 years, a hand-held mobility device for walking indoors and a self-propelled manual wheelchair for mobility outdoors and in the community. The management is multidisciplinary depending on the nature and number of accompanying impairments. It is important to note that the child on GMFCS level III may be added to children on levels I and II (walking at least indoors) or to children on levels IV and V (wheeled mobility at least in the community). Nevertheless, GMFCS level III is usually classified as ambulatory because the child is independently mobile in some settings irrespective of the need for assistive mobility device. This need or use of adaptive mobility equipment is acceptable (current thinking) [5]. In addition to multidisciplinary care, the child on GMFCS level IV requires initially a body support walker that supports the pelvis and trunk for floor and chair sitting and later powered mobility and a manual wheelchair for transportation outdoors, at school, and in the community. The management of a child on GMFCS level V involves pervasive supports and a manual wheelchair for transportation in all settings (physical assistance at all times) [11].
\nThe MACS [14] and the mini-MACS [31] are five-level scales for classifying arm and hand function (manual abilities/manual dexterity) in children with CP aged 4–18 years and 1–4 years, respectively. They classify children’s usual performance in handling objects with two hands (not best use or individual hand function) in important daily activities (Figures 3 and 4).
\nThe Manual Ability Classification System (MACS). Reproduced with permission [14].
The mini-Manual Ability Classification System (mini-MACS). Reproduced with permission.
The MACS, developed in 2006 by Eliasson et al. [14] and modeled on the GMFCS, has been shown by various studies to be valid and reliable. However, a study in 2009 by Plasschaert et al. [33] reported lower inter-rater reliability of the MACS when used in children aged 1–5 years (linear weighted Kappa (k) of 0.67 and 0.55 for 2–5 years and 2 years, respectively). Thus, the MACS was adjusted in 2016 by Eliasson et al. [31] to obtain the mini-MACS which was shown to have excellent inter-observer reliability. The adjustments were simply to obtain descriptions that are applicable to children less than 4 years of age. The mini-MACS differs from the MACS due to the need for assistance in handling objects in children 1–4 years and the nature of the objects they are expected to handle.
\nThe MACS is used to ascertain the child’s needs and inform management decisions such as choosing an appropriate upper limb intervention. That is, they are used like the GMFCS to guide functional intervention. For instance, children on MACS levels I and II handle objects independently and do not require any adaptive device to handle objects. The children on level III require some assistance and sometimes adaptive equipment for independent handling of objects. Children on level IV require continuous assistance and adaptive equipment while those on level V need total assistance. Eliasson et al. [31] posited that the mini-MACS is probably not sensitive to changes and should therefore not be used to evaluate development or intervention, but rather to categorize how suspected CP affects the manual abilities of children 4 years and younger.
\nThe CFCS was developed and validated by Hidecker et al. [16] in 2011. It classifies everyday communication performance of an individual with CP into five levels ranging from effective communication in all settings (level I) to ineffective communication even with familiar partners (level II). The categorization of the effectiveness of current communication is based on the performance of sender and receiver roles, the pace of communication, and the type of conversational partner. In ascertaining the current level of communication, the CFCS aptly considers and includes use of all methods of communication. This implies that it describes both use of normal verbal and non-verbal communication (speech, gestures, behaviors, eye gaze, and facial expressions) and use of augmentative and alternative communication systems (AACs) (manual sign, pictures, communication books, communication boards and talking devices such as speech generating devices and voice output communication aids) [16]. The CFCS level identification chart is shown in Figure 5.
\nThe Communication Function Classification System (CFCS). Reproduced with permission [16].
The EDACS was developed by Sellers et al. [17] in 2014 and comprises two ordinal scales that describe eating and drinking ability in people with CP from 3 years of age. The five-level scale classifies the safety and efficiency of eating and drinking while the three-level scale classifies level of assistance required to bring food and drink to the mouth. The five-level scale is based on the range of food textures eaten, the presence of cough and gag when eating or drinking, and the control of movement of food and fluid in the mouth. The three-level scale is categorized into independent, requires assistance, and dependent for eating and drinking. Thus, the EDACS ranges from independent ability to safely and efficiently eat and drink like peers on a wide range of textures (level I) to total dependence for eating and drinking and reliance on tube feeding (level V) [17]. The EDACS algorithm is shown in Figure 6.
\nEating and Drinking Ability Classification System (EDACS) algorithm. Reproduced with permission [17].
The final goal of a managing doctor and the final hope of a patient and his family is an ambulatory self-dependent individual. Using the functional classifications to guide management helps the pediatrician, the occupational therapist, the physiotherapist, the speech and language therapist and all involved in the care of children with CP to achieve this goal. For instance, the GMFCS is used to ascertain the requirements for ambulation appropriate for the age of the child and gross motor functional abilities while the MACS helps ascertain appropriate upper limb interventions for independent performance of activities of daily living. The CFCS by classifying communication effectiveness in CP is useful in service delivery. It helps identify those that will require augmentative and alternative communication systems to improve their communication. The EDACS assists in identifying the appropriate food texture to give a particular child, need for assistance, the risks involved in eating and drinking and the appropriate method of feeding (oral/tube feeding). Therefore, in simplistic terms, these current classifications tell us what to do to the child with CP. A summary of all groups of classifications is shown in Tables 1, 2, 3.
\nClassification axis | \nCriterion/characteristic used | \nInter rater/inter observer reliability | \nSuitability for research (description, comparison/stratification) (on a scale of 1–5) | \nIndication of functional abilities | \nAiding/guiding current management | \n
---|---|---|---|---|---|
Physiological | \nType of motor/movement abnormality (quality and changes in tone) | \nPoor | \n++ | \nNo | \nNo | \n
Typographic | \nDistribution/localization of motor impairment | \nPoor | \n++ | \nNo | \nNo | \n
Supplemental | \nAccompanying impairments | \nNot reported | \nNot reported | \nNo | \nYes | \n
Aetiologic | \nActual cause and timing of insult | \nNot available | \nNot available | \nNot available | \nNo | \n
Neuroanatomic | \nBrain structural alterations on neuroimaging | \nNot available | \nNot available | \nNot available | \nNo | \n
Therapeutic | \nIndividual treatment needs | \nNot reported | \nNot reported | \nNo | \nNo | \n
Functional | \nDegree of severity/activity limitation | \nGood | \n+++ (good) | \nYes. Its major advantage | \nYes. Its strength | \n
Comparison of traditional (Minear’s) classifications based on single variables.
Classification | \nMinear’s classifications combined | \nCriteria/characteristics used | \nInter rater/inter observer reliability | \nSuitability for research (on a scale of 1–5) | \nIndication of functional abilities | \nAiding/guiding current management | \n
---|---|---|---|---|---|---|
Swedish classification | \nPhysiological and topographic | \nType of motor abnormality + localization of motor impairment | \nPoor | \n++ | \nNo | \nNo | \n
Edinburg classification | \nPhysiological and topographic | \nType of motor abnormality + localization of motor impairment | \nPoor | \n++ | \nNo | \nNo | \n
SCPE Classification | \nPhysiological and modified topographic | \nType of motor abnormality + localization of motor impairment as unilateral and bilateral only. | \nFair | \n+++ | \nNo | \nNo | \n
Comparison of traditional classifications based on multiple variables.
Classification | \nCriterion/characteristic used | \nInter rater/inter observer reliability | \nSuitability for research | \nIndication of functional abilities | \nAiding/guiding current management | \nAge range included (year developed) | \nNature of scale(s) | \n
---|---|---|---|---|---|---|---|
GMFCS | \nGross motor/ambulatory/lower limb function (current gross motor abilities/activity limitations) | \nGood | \nYes (valid and reliable) | \nYes | \nYes | \nGMFCS (birth–12 years) (1997) GMFCS-E&R (birth–18 yreas) (2007) | \nOrdinal (5-level) | \n
MACS | \nManual dexterity/upper limb function (usual performance in handling objects with two hands). | \nGood | \nYes (valid and reliable) | \nYes | \nYes | \nMACS (4–18 years) (2006) Mini-MACS (1–4 years) (2016) | \nOrdinal (5-level) | \n
CFCS | \nCommunication function (everyday communication performance) | \nGood | \nYes (valid and reliable) | \nYes | \nYes | \n≥3 years. (2011) | \nOrdinal (5-level) | \n
EDACS | \nEating & drinking ability/oropharyngeal/swallowing function (safe and efficiency of eating and drinking and level of assistance required) | \nGood | \nYes (valid and reliable) | \nYes | \nYes | \n2–12 years. (2014) | \nTwo ordinal scales (one 5-level, one 3-level) | \n
Comparison of current (functional) classifications.
The development of a standardized or holistic classification of CP is topical and in tandem with advances in understanding of CP, imaging techniques and quantitative motor assessments [1]. Bax et al. [1] in 2005 proposed a standardized CP classification scheme with four major components namely:
Motor abnormalities (a. nature and typology of motor disorder and b. functional motor abilities)
Associated impairments
Anatomic and radiologic findings
Causation and timing.
Currently, there are obvious limitations with categorization of neuroimaging findings and identifying specific causes of CP. Therefore, as we await comprehensive and acceptable neuroanatomic and etiologic classifications, the minimum acceptable multiaxial classification of CP for both developed and developing countries should include:
Classification of motor abnormalities according to SCPE.
Accompanying impairments
Functional classification levels for: gross motor/ambulatory function (GMFCS), manual abilities (MACS), communication, (CFCS) and eating and drinking ability (EDACS).
This implies that only the first two components of the standardized classification proposed by Bax et al. [1] are applicable currently. The classification by SCPE provides enough clinical descriptive information about children with CP while the supplemental and functional classifications are useful for management and service delivery. The use of the functional scales in clinical context (to aid management) and in research is in accordance with current thinking and the reconceptualization of the management of CP.
\nEach classification system used in CP has its merits and shortcomings. Therefore, the clinical classification of CP needs to use many axes to be comprehensive. Currently, it must include the functional scales so as to guide management.
\nThe neuropathologic classification is being awaited, and due to its contribution to the assessment of etiological factors and timing of insults in CP, it is critical to the development of a holistic or standardized classification of CP.
\nI am grateful to Professor Sylvester O. Iloeje for his assistance and extend my thanks to all staff of Mother Healthcare Diagnostics & Hospital, 5B Okigwe Road, Owerri and department of Paediatrics, Federal Medical Centre, Owerri. Thanks too to my beautiful wife Mrs. Linda Chigozie Ogoke for all her support during the period of writing up of this book chapter.
\nNone.
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\\n\\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by, and construed in accordance with, the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
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\n\nAUTHOR'S GRANT OF RIGHTS
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\n\nMISCELLANEOUS
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\n\nEntire Agreement: This Publication Agreement constitutes the entire agreement between the parties in relation to its subject matter. It replaces all prior agreements, draft agreements, arrangements, collateral warranties, collateral contracts, statements, assurances, representations and undertakings of any nature made by or on behalf of the parties, whether oral or written, in relation to that subject matter. Each party acknowledges that in entering into this Publication Agreement it has not relied upon any oral or written statements, collateral or other warranties, assurances, representations or undertakings which were made by or on behalf of the other party in relation to the subject matter of this Publication Agreement at any time before its signature (known as the "Pre-Contractual Statements"), other than those which are set out in this Publication Agreement. Each party hereby waives all rights and remedies which might otherwise be available to it in relation to such Pre-Contractual Statements. Nothing in this clause shall exclude or restrict the liability of either party arising out of any fraudulent pre-contract misrepresentation or concealment.
\n\nWaiver: No failure or delay by a party to exercise any right or remedy provided under this Publication Agreement, or by law, shall constitute a waiver of that or any other right or remedy, nor shall it preclude or restrict the further exercise of that or any other right or remedy. No single or partial exercise of such right or remedy shall preclude or restrict the further exercise of that or any other right or remedy.
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\n\nNo partnership: Nothing in this Publication Agreement is intended to, or shall be deemed to, establish or create any partnership or joint venture or the relationship of principal and agent or employer and employee between IntechOpen and the Author or any Co-Author, nor authorize any party to make or enter into any commitments for, or on behalf of, any other party.
\n\nGoverning law: This Publication Agreement and any dispute or claim, including non-contractual disputes or claims arising out of, or in connection with it, or its subject matter or formation, shall be governed by, and construed in accordance with, the law of England and Wales. The parties submit to the exclusive jurisdiction of the English courts to settle any dispute or claim arising out of, or in connection with, this Publication Agreement, including any non-contractual disputes or claims.
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