This study was a single centred cross-sectional observational study, conducted in the Department of Physical Medicine and Rehabilitation (PMR) at Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India, from August 2015 to December 2016 after taking approval from Institutional Ethical Committee (IEC/Oct/2015). Patients were screened from the Outpatient Department of PMR. Baseline demographic data and detailed history were recorded, and physical and neurological examination was carried out. The CP was diagnosed according to a standard clinical definition as stated above [2]. Cases were enrolled in the study after satisfying the inclusion criteria and exclusion criteria.

Inclusion and Exclusion criteria: Diagnosed cases of CP within age group of 2-12 years were included and any case with congenital anomalies of upper and lower limb, musculoskeletal abnormalities of upper and lower limb, or with metallic implants were excluded.

Sample size calculation: On the basis of previous study, prevalence of CP was 2 to 2.5 per 1000 live birth [1]. Taking this value as reference, the minimum required sample size with 2% margin of error and 5% level of significance was 24 patients. To reduce margin of error, total sample size taken was 50.

Informed consent was taken from parents or guardians. Selected patients were advised neuroimaging (MRI).

For the motor function all the patients were assessed using Gross Motor Function Classification System (GMFCS) scale [9] and MACS [10].

Magnetic Resonance Imaging (MRI) was done with 1.5 T Philips InteraAchieva MR scanner. T1weighted, T2 weighted, T2 Fluid Attenuation Inversion Recovery (FLAIR) sequences were obtained in axial plane. T2 weighted imaging were done in sagittal and coronal plane. The MRI was analysed by the Radiologist for lesion changes and grading. The lesions were described as:

For grading of MRI [11] we had used the scoring system of sub-component like:

Size of lateral ventricles

White Matter (WM) abnormal signal intensity

WM reduction

Cysts

Size of subarachnoid space

Corpus callosum

Cortical grey matter

Grade-1 was considered normal having score 7-11, grade-2 was mild having score 12-16 and grade-3 was severe with score of 17-21.

In the statistical analysis, categorical variables were presented in number and percentage (%) and continuous variables were presented as mean±SD and median. Normality of data was tested by Kolmogorov-Smirnov test. If the normality was rejected then non-parametric test were used. Qualitative variables were correlated using Chi-Square test/Fisher’s-exact test. A p-value of ≤0.05 was considered statistically significant. The data were entered in MS EXCEL spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0.

Patients with CP in the study ranged from 2-12 years with mean age of 5.43 (±2.58) years. Out of 50 cases, 30 (60%) were in the age group of 2-5 years, 17 (34%) were in the age group of 6-10 years and 3 (6%) were in the age group of 11-12 years. Thirty two (64%) were males and 18 (36%) were females. The Male: Female ratio was 1.78:1. Maximum number of cases 14 (28%) were of GMFCS level 3 and least number of cases were of GMFCS level 5 in 4 (8%) cases. Maximum number of cases, 15 (30%) were of MACS 2 and least number of cases, 3 (6%) were of MACS level 5 [Table/Fig-1]. The most common type of brain lesion present was type E (Periventricular leukomalacia) seen in 45 (90%) cases [Table/Fig-2].

[Table/Fig-1]:

Distribution of Cases according to a) GMFCS level; and b) MACS level (N=50).

Type F (Porencephaly) was present mostly in GMFCS level 3 and in few cases of GMFCS levels 4 and 5 which was statistically significant (p-value=0.04) [Table/Fig-3]. Type F (Porencephaly) brain lesion was seen in MACS level 3, 4 and 5 with p-value=0.018. Type G (Border zone infarction) and H (Thin corpus callosum) were seen in all MACS level [Table/Fig-4].

Eleven (35.48%) patients in GMFCS level 1 had brain MRI grade 1 (normal) which was statistically significant (p-value=0.003). In GMFCS 4 predominant MRI grade was 2 (mild) which is statistically significant finding (p-value=0.013) [Table/Fig-5]. In MACS level 1 and 2 majority of cases were of MRI grade 1 and in MACS level 4 and 5 all the cases were of MRI grade 2 only [Table/Fig-6].

Cerebral palsy is a disorder that is most noticeably characterised by a motor disorder causing physical disability in human development, mainly in areas of body movement and posture. Study of motor status and its severity is vital for optimal therapy and rehabilitation. Motor function is affected by different type and extent of brain lesion [12].

Age distribution of patients in study population was in range of 2-12 years, with mean age of 5.43 (±2.58) years. Maximum number was in age group of 2-5 years. Among study population gender ratio was observed to be 1.78:1(M:F) showing male predominance which was comparable to a study done by Pharaoh PO et al., which shows male to female ratio of 1.4:1 with hemiplegic children, 1.2:1 for diplegic children and 1.5:1 for quadriplegic children [13].

In our study we observed most the patients belong to GMFCS class 1 and class 2 which corresponds to previous study [14,15]. Similarly most of the patients were of MACS level 1 and level 2 which also corresponds to study done by Himmelmann K et al., in 186 children. They found that Forty per cent of the children were in level 1 of the MACS and 19% were in level 2 [16].

In the present study, it was found that type E (Periventricular leukomalacia) brain lesion was most common lesion. It was observed consistently in all GMFCS level 1 (90.91%), 2 (80%), 3 (85.71%), 4 (100%) and 5 (100%) cases. Type D (Enlargement of lateral ventricle), type H (Thin corpus callosum) and type G (Border zone infarction) were next most common types of brain lesions. Two (20%) cases in GMFCS level 2 and 2 (14.29%) cases in GMFCS level 3 did not show any lesion on MRI brain. Numata Y et al., in their study on 86 patients found that 36 cases had normal brain MRI finding in all GMFCS levels. Fifty cases had abnormal MRI finding, type E (Periventricular leukomalacia) was found in 12 (14%), type D (Enlargement of lateral ventricle) in 12 (14%), type F (Porencephaly) 6 (7%), type A (Hypomyelination) five (5.8%), type B (Cerebral atrophy) four (4.7%), type C (Malformation) 3 (3.5%), type G (Border zone infarction) three (3.5%), type I (Cerebellar atrophy) 2 (2.3%), type H (Thin corpus callosum) 1(1.1%) and two cases had unclassified lesion [17].

It was found that in GMFCS level 1 only MRI grade 1 (normal) was seen, in GMFCS level 2 and 3 predominant MRI grade was 1 (normal) and in GMFCS level 4 and 5 predominant MRI grade was 2 (mild). With increasing GMFCS levels, MRI grade was also increasing. A Study by Robinson MN et al., has shown the similar results. However, MRI grade 3 lesions were not seen in any cases included in the present study [12].

Like GMFCS, in MACS level 1and 2 predominant MRI grade was 1 (p-value=0.008, 0.026), in MACS level 3 predominant MRI grade was 2 (p-value=0.201) and in MACS level 4 and 5 only MRI grade 2 lesion was seen (p-value=0.001, 0.049). There was direct association of MACS level with MRI grading. However, MRI grade 3 lesions were not seen in any MACS level. Our results are comparable with finding of earlier report by Kwong KL et al., who analysed the MRI of brain in 122 children with spastic CP and found that MRI findings for patients with spastic CP were closely related to types of CP and gestation at birth [18].

As this study was a time bound study on a limited number of cases, further studies are recommended with bigger sample size and longer time duration.

The present study highlighted that there was association between type and extent of brain lesion and type of CP and motor functions (GMFCS and MACS levels). Type and extent of brain lesion helps clinician to understand functional motor outcome and application of rehabilitation strategies in CP rehabilitation. However, brain lesion is not present in MRI in some cases. Hence, proper clinical evaluation and analysis along with MRI findings are recommended in diagnosis and planning optimal rehabilitation interventions in CP.