Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 90974

AbstractMaterial and MethodsResultsDiscussionConclusionAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : January | Volume : 16 | Issue : 1 | Page : KC08 - KC12 Full Version

Factors Affecting Ambulatory Status in Children with Cerebral Palsy: A Cross-sectional Study


Published: January 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/48650.15882
Annie Mathew, Nonica Laisram

1. Postgaduate Student, Department of Physical Medicine and Rehabilitation, VMMC and Safdarjung Hospital, New Delhi, India. 2. Principal Consultant, Professor and Former Head, Department of Physical Medicine and Rehabilitation, VMMC and Safdarjung Hospital, New Delhi, India.

Correspondence Address :
Dr. Nonica Laisram,
Principal Consultant, Professor and Former Head, Department of Physical
Medicine and Rehabilitation, VMMC and Safdarjung Hospital, New Delhi, India.
E-mail: drnonica@gmail.com

Abstract

Introduction: Cerebral Palsy (CP) is one of the most common causes of physical disabilities in childhood. Most children with CP are facing limitations of walking and other physical activities. Limitation in ambulation presents potential barriers to activities of daily life, participation in physical, recreational, and social activities, which further hampers the quality of life. Thus, attainment of walking is an important goal for the children with CP, as well as doctors for optimum rehabilitation plan.

Aim: To study the ambulatory status in different types of CP and factors affecting ambulatory status in children with CP.

Materials and Methods: This observational, cross-sectional study was conducted in the Outpatient Department of Physical Medicine and Rehabilitation (PMR) of VMMC and Safdarjung Hospital, New Delhi, India, from November 2018 to April 2020. Total 100 children with CP of age group 2-18 years were enrolled in the study. The type of CP was determined based on tone pattern and limb involvement. Walking ability was assessed using Gross Motor Function Classification System (GMFCS), Functional Mobility Scales (FMS) and Gillette Functional Assessment Questionnaire (FAQ). Factors such as age of independent sitting, presence of accompanying impairments which may influence the walking ability were also studied. Quantitative variables were compared using Kruskal-Wallis test and qualitative variables were compared using Chi-square test.

Results: In the study population of 100 children with CP, 68 were males and 32 were females. Total 55% were independent ambulators, 14% were ambulatory with aids and 31% were non ambulators. 86% had spastic CP, 6% had dyskinetic CP, 6% had mixed CP and 2% had hypotonic CP. Among spastic CP (86), 56% had diplegia, 16.2% had quadriplegia, 24.4% had hemiplegia and 3.4% had triplegia. Children with spastic hemiplegia showed highest potential for independent walking. Among 100 children with CP, 56% achieved independent sitting by 2 years of age, 31% achieved independent sitting after 2 years of age and 13% did not achieve sitting. Total 82.14% of children who achieved independent sitting by 2 years of age were ambulatory without aids. Total 36% of total children had no impairments, 44% had one or two impairments and 20% had three or more impairments. Total 88.8% of children who had no impairments were ambulatory without aids, thus showed good walking potential. Where as 70% of children who had three or more impairments were non ambulators.

Conclusion: The spastic hemiplegia type of CP, achievement of independent sitting by 2 years of age and absence of accompanying impairments are good prognostic predictors of ambulation in children CP.

Keywords

Association, Prognosis, Type of cerebral palsy, Walking ability

The Cerebral Palsy (CP) is one of the most common causes of physical disabilities in childhood, which occurs with an overall prevalence rate of 2.11 per 1000 live births (1). Cerebral palsy is described “as a group of permanent disorders of development of movement and posture causing activity limitation that are attributed to non progressive disturbances that occurred in developing foetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, and behaviour by epilepsy and secondary musculoskeletal problems” (2).

Cerebral palsy can be classified into various types based on tone pattern and based on distribution of limb involvement. Based on tone pattern CP is classified as spastic, dyskinetic, hypotonic and mixed. Dyskinetic includes athetoid, choreiform, ballistic and ataxic types. Based on distribution of limb involvement CP is classified as diplegia (lower limbs affected more than upper limbs), hemiplegia (upper limb frequently more affected than lower limb), quadriplegia (bilateral upper limb and lower limb distribution), and triplegia (combination of diplegia and quadriplegia but with asymmetric upper limb involvement) (3),(4).

Various scales used for assessing functional level and motor development in CP are Gross Motor Function Classification System (GMFCS) (5), Functional Mobility Scales (FMS) (6) and Gillette Functional Assessment Questionnaire (FAQ) (7). There is no previous study which has simultaneously used GMFCS, FMS and Gillette FAQ to assess the ambulation. Study of walking ability based on number of accompanying impairments (rather than a specific impairment), is also particular to this study.

Early identification of ambulatory potential and knowledge of factors that might influence the maintenance of ambulatory capacity would favour the planning of realistic treatment goals.

Hence, present study was conducted to assess the ambulatory status in different types of CP and various factors affecting ambulatory status in children with CP. Three scales- GMFCS, FMS and Gillette FAQ were used simultaneously to assess ambulatory status. Study also highlights use of FMS and Gillette FAQ along with GMFCS as functional assessment scales for children with CP. Influence of age of independent sitting and increasing number of accompanying impairments on walking ability were also studied.

Material and Methods

This observational cross-sectional study was conducted in the Outpatient Department of Physical Medicine and Rehabilitation, of VMMC and Safdarjung Hospital, New Delhi, India, from November 2018 to April 2020. Due approval from the Institute Ethics Committee was taken (IEC/VMMC/SJH/Thesis/October/2018-48).

Inclusion criteria: Hundred children diagnosed with CP of both genders, belonging to age group 2-18 years were enrolled after obtaining written informed consent from the parents.

Exclusion criteria: Children with any co-existing neuromuscular disorders, metabolic disorders and genetic disorders were excluded from the study.

Sample size calculation: The study of Keeratisiroj O et al., observed 48.2% of children with CP were capable of ambulation (8). Taking this value as reference, the minimum required sample size with 10% margin of error and 5% level of significance is 96 patients. So, total sample size taken is 100. Formula used is:- N ≥{p(1-p)}/(ME/Zα)2;

Where, Zα is value of Z at two-sided alpha error of 5%, ME is margin of error and p is proportion of patients capable of ambulation.

Study Procedure

For each patient relevant history including antenatal, perinatal and postnatal periods and developmental milestones (gross motor, fine motor, language and social milestones) were recorded. Anthropometry including head circumference and body weight was recorded. Detailed age adjusted neurological examination was done and any abnormalities in tone, posture, movement and reflexes were recorded. Accompanying impairments including visual, auditory, speech and cognitive impairments were recorded. Children with CP were classified on the basis of tone pattern as spastic, dyskinetic, hypotonic and mixed. Spastic CP was classified based on limb involvement as diplegia, quadriplegia, hemiplegia and triplegia (3),(4).

Children, who walked a distance of atleast 20 feet with the help of walking aids or assistive devices (canes, crutches, walker, frames etc.,) were considered as ambulatory with aids and those who walked the same distance without any walking aids or assistive devices were considered as ambulatory without aids. Children who were completely dependent for ambulation or those required a manual wheel chair for ambulation were considered as non ambulatory (9).

Parameters: Walking ability of children with CP was assessed using GMFCS, FMS and Gillette FAQ.

• Gross Motor Function Classification System (GMFCS) (5) classified gross motor function on the basis of severity from level I (walks without restriction) to level V (very limited self-mobility, even with assistive technology).
• Functional Mobility Scales (FMS) (6) assessed mobility at 5 m (e.g., short distances in house), 50 m (e.g., mobility at school) and 500 m (long distances e.g., shopping centre). Ratings were given from highest score 6 (independent on all surfaces) to lowest score 1 (uses wheel chair). Children who crawled the distance was marked as C and who could not complete distance was marked as N.
• Gillette Functional Assessment Questionnaire (FAQ) FAQ (7) classified levels from 1-10. At level 1 child could not take any step at all, Levels 2-4 described limited house hold mobility. At level 5 and 6 child preferred walking for household mobility. From level 7 child walk community distances. Level 10 is the best where child is typically able to keep up with peers. Walking ability based on the above scales was correlated with type of CP based on tone pattern and limb involvement. Factors such as age of achievement of independent sitting and presence of accompanying impairments which may influence the walking ability of children with CP were also studied.

Statistical Analysis

All 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 was used. Quantitative variables were compared using Kruskal Wallis test (as the data sets were not normally distributed) between the groups. Qualitative variables were compared using Chi-square test. A p-value <0.05 was considered statistically significant. The data was entered in MS Excel spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0.

Results

Total 100 children belonging to age group 2-18 years participated in the study. Total 68 were males and 32 were females (male to female ratio 2.1:1). The mean age of the study population was 5.85±3.4 years. Out of 100, 86 of 100 (86%) had spastic CP, 6 of 100 (6%) had dyskinetic CP, 6 of 100 (6%) had mixed CP and 2 of 100 (2%) had hypotonic CP. Among children with spastic CP, 48 (56%) had diplegia, 14 (16.2%) had quadriplegia, 21 (24.4%) had hemiplegia and 3 (3.4%) had triplegia. The most common type of CP (based on tone pattern) was spastic type (86 of 100). Diplegia was the most common type of spastic CP (Table/Fig 1).

Out of 100 children, 55 were ambulatory without aids, 14 were ambulatory with aids (e.g., cane, crutches, walker) and 31 were non ambulatory. Among different types of CP, 90.48% of children with spastic hemiplegia were ambulatory without aids. Association of ambulatory status with type of CP was statistically significant (Table/Fig 2). Association of GMFCS (Table/Fig 3) with type of CP based on tone pattern (p-value=0.011) and distribution of limb involvement (p-value <0.0001) was statistically significant. Association of FMS (5 m, 50 m, 500 m) with type of spastic CP based on limb involvement was statistically significant (Table/Fig 4),(Table/Fig 5),(Table/Fig 6). Association of Gillette FAQ with type of spastic CP based on limb involvement was also statistically significant (Table/Fig 7). Among different types of CP, spastic hemiplegia showed the highest ambulation.

Total 87 of 100 children had achieved independent sitting, of which 56 achieved by 2 years of age. Total 82.14% of children who achieved independent sitting by 2 years of age were ambulatory without aids. Association of ambulatory status with age of independent sitting was statistically significant (Table/Fig 8). Out of 100 children, 36 had no accompanying impairments and rest 64 had atleast one impairment. Total 20 had only one impairment (speech impairment-6, visual impairment-12, cognitive impairment-2), 24 had two accompanying impairments (speech and cognition-14, vision and cognition-6, speech and vision-4) and 20 had three or more accompanying impairments (vision, speech and cognition-17, hearing, speech and cognition-1, vision, speech, cognition and hearing impairment-2). Total 88.88% of children who had no accompanying impairments were ambulatory without aids. The association of ambulatory status with number of accompanying impairments was statistically significant (Table/Fig 9).

Discussion

Out of 100 children, 86 (86%) had spastic CP, 6 (6%) had dyskinetic CP, 6 (6%) had mixed CP and (2%) had hypotonic CP. Among children with spastic CP, 48 (56%) had diplegia, 14 (16.2%) had quadriplegia, 21 (24.4%) had hemiplegia and 3 (3.4%) had triplegia. Similar to previous studies (10),(11),(12),(13) the present study also observed spastic type as the predominating type.

Out of 100 children with CP, 55% (55) were ambulatory without aids. This is similar to the findings from previous studies (14),(15),(16). However, Laisram N and Saha S and Keeratisiroj O et al., observed lesser number of independent ambulators (34.9% and 39.4%, respectively) (8),(17).

Majority (48 of 86; 55.8%) of children with spastic CP were ambulatory without aids. 4 (66.7%) children with dyskinetic CP were ambulatory without aids. Of 2 children with hypotonic CP, one was ambulatory without aids and other was non ambulatory. Four of 6 (66.7%) of children with mixed CP were ambulatory with aids. Total 48 of 86 (55.8%) children with spastic CP were ambulatory without aids. Among spastic CP hemiplegia showed highest potential for independent walking (19 of 21 children; 90.5%), whereas spastic quadriplegia showed lowest potential for independent walking (1 of 14; 7.1%). Twenty six of 48 (54.2%) of spastic diplegia and 2 of 3 (66.7%) of children with triplegia also showed independent ambulation. Laisram N and Saha S reported that 94.9% of hemiplegics were ambulatory without aids (17). Previous studies also observed similar findings (18),(19). Vasconcellos RLM et al., and Nordmark E et al., reported that spastic quadriplegic CP as predominantly non ambulatory, which is consistent with findings of present study (20),(21). The present study reinforces that spastic hemiplegics were the most successful ambulators.

Assessment of GMFCS in different types of CP showed, 80 (93%) children of spastic CP in level II-IV. All children with dyskinetic CP showed GMFCS levels between II-IV. All children with mixed CP were in between level I-III. Among spastic CP, 17 hemiplegics (80.95%) were at level II and rest 2 (9.5%) were at level I and showed highest ambulation. Total 13 (92.86%) children with spastic quadriplegia were at levels IV-V and showed lowest ambulation. Shevell MI et al., in their study observed similar findings (14).

Assessment of Functional Mobility Scales (FMS) 5 m showed, 50 (58%) spastic, 4 (66.6%) dyskinetic, 5 (83.3%) mixed CP walked independently with rating of 6 or 5. Among spastic CP, 19 (90.5%) hemiplegics, 28 (58.3%) diplegics, 2 (66.7%) triplegics and 1 (7.14%) quadrplegics walked independently at FMS 5 m with ratings 6 or 5. At FMS 50 metres, 46 (53.5%) spastic, 3 (50%) dyskinetic, 2 (33.3%) mixed CP walked independently. Among spastic CP, 1 (7.14%) quadriplegics, 18 (85.7%) hemiplegics completed 50 m independently. At FMS 500 m 32 (37%) spastic, 1 (16.7%) dyskinetic, 1 (50%) hypotonic and 1 (16.67%) mixed CP completed independently. Among spastic CP 15 (71%) hemiplegics walked FMS 500 m independently. None of quadriplegics could walk the distance independently. Two (9.5%) hemiplegics completed the distance with best rating of 6 and showed successful ambulation. Walking ability of spastic hemiplegic children at FMS distances were comparable with the findings of Rodby-Bousquet E and Hagglund G (22). Functional Mobility Scales (FMS) scores were seen to vary with subtypes of CP in the present study.

Gillette Functional Assessment Questionnaire assessment showed 40 (46.5%) children with spastic CP between VII-IX levels, 4 (66.7%) dyskinetic CP between V-VIII levels, 4 (66.67%) mixed CP between IV-VI levels. Among spastic CP, 15 (71.4%) hemiplegics showed successful ambulation (level VII-X), 24 (50%) diplegics between 7 to 9 levels, 14 (92.86%) children with quadriplegia at (levels I-III) and showed lowest ambulation. All children (3 of 3) with spastic triplegia were between VI-VIII levels.

In the present study, 69 (69%) children could walk with or without ambulatory aids. In overall, spastic CP showed favourable ambulatory potential. Children with spastic hemiplegia had the highest potential for independent walking. Children with spastic quadriplegia had poor ambulatory potential, and were more dependent on their care-givers. This is why they have poor ambulatory potential and functional ability. A 68.75% children with spastic diplegia were ambulatory with or without aids. All children with spastic triplegia were ambulatory with or without hand-held assistive devices. Children with mixed CP showed a better ambulation than children with dyskinetic CP. Children with hypotonic CP were very less in number (2 of 100) and therefore difficult to comment regarding their overall walking potential. It was observed that neurological subtype is a powerful predictor of functional status related to ambulation. Thus present study reinforces that the type of CP was a strong predictor for prognosticating ambulation in children with CP. Comparison of present study with contrast studies is summarised in (Table/Fig 10) (8),(14),(17),(18),(22).

Association of ambulatory status with age of independent sitting showed, 82% of children who achieved independent sitting by 2 years of age were able to walk independently. The present study findings were consistent with findings of Keeratisiroj O et al., and Laisram N and Saha S (8),(17). Montgomery PC (19) concluded that the best skill for predicting ambulation was sitting. Early gross motor milestones, especially sitting, are important for predicting walking since antigravity muscles for the trunk and postural control during sitting is necessary for the upright position development (23).

Strong association between ambulatory status and number of accompanying impairments was observed in the present study. Thirty six had no any accompanying impairments and rest 64 had atleast one impairment. Maximum of four accompanying impairments were observed simultaneously. Most common impairments observed were visual, speech, hearing and cognitive impairment. 88.88% of children who had no impairments were ambulatory without aids, whereas, 70% of children with three or more impairments were non ambulatory. Similar findings were observed by Iloeje SO and Ogoke CC (18) and Vasconcellos RLM et al., (18),(20). The study suggests that total number of accompanying impairments in a child with CP may give an indication of functional abilities of the child.

The present study shows that type of CP, age of independent sitting and presence of accompanying impairments affected walking ability in children with CP.

Limitation(s)

Few limitations noted in the present study include analysis of broad age groups together, comparatively small sample size and recall bias owing to the cross-sectional design of the study. Unequal distribution of cases with respect to age groups and subtypes of CP were also considered as limitation of study.

Conclusion

The present study highlights that spastic hemiplegia type of CP, achievement of independent sitting by two years of age and absence of accompanying impairments are good prognostic predictors of walking potential in children with CP. The study helps to assess ambulation in different types of CP and assists in planning for optimum rehabilitation interventions. Early interventions and awareness programs among parents and care givers are recommended to identify the influencing factors, to prognosticate walking potential and to improve walking ability of children with CP. Regular monitoring and follow-up is required to maintain and improve walking ability in children with CP.

Acknowledgement

Authors acknowledge the support provided by the doctors and staff of Department of PMR, VMMC and Safdarjung hospital to conduct this study. Authors also sincerely thank the children and families who participated in this study.

References

1.
Osuki M, Countinho F, Dykeman J, Jette N, Pringsheim T. An update on the prevalance of cerebral palsy: A systemic review and meta-analysis. Dev Med Child Neurol. 2013;55:509-19. [crossref] [PubMed]
2.
Bax M, Goldstein M, Rosenbaum P, Paneth N. Proposed definition and classification of cerebral palsy. Dev Med Child Neurol. 2005;47:571-76. [crossref] [PubMed]
3.
Oleszeck J, Davidson L. Cerebral palsy. In: Braddom RL, ed. Physical medicine and rehabilitation. 4th ed. Philadelphia: Saunders; 2011:1255. [crossref]
4.
Niedzwecki CM, Roge DL, Schwabe AL. Cerebral palsy. In: David XC, ed. Braddom’s physical medicine and rehabilitation. 5th ed. Philadelphia: Elsevier; 2016:1053-72.
5.
Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Gluppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214-23. [crossref] [PubMed]
6.
Graham HK, Harvey A, Rodda J, Nattrass GR, Pirpiris M. The Functional Mobility Scale (FMS). J Pediatr Orthop. 2004;24:514-20. [crossref] [PubMed]
7.
Novacheck TF, Stout JL, Tervo R. Reliability and validity of the Gillette Functional Assessment Questionnaire as an outcome measure in children with walking disabilities. J Pediatr Orthop. 2000;20:75-81. [crossref] [PubMed]
8.
Keeratisiroj O, Thawinchai N, Siritaratiwat W, Montana B. Prognostic predictors for ambulation in Thai children with cerebral palsy aged 2 to 18 years. J Child Neurol. 2015;30:1812-18. [crossref] [PubMed]
9.
Wu YW, Day SM, Strauss DJ, Shavelle RM. Prognosis for ambulation in cerebral palsy: A population-based study. Paediatrics. 2004;114:1264-70. [crossref] [PubMed]
10.
Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: Incidence, impairments and risk factors. Disabil Rehabil. 2006;28:183-91. [crossref] [PubMed]
11.
Pfeifer L, Rodrigues D, Funayama C, Santos J. Classification of Cerebral Palsy Association between gender, age, motor type, topography and Gross Motor Function. Arq Neuropsiquiatr. 2009;67:1057-60. [crossref] [PubMed]
12.
Andersen GL, Irgens LM, Haagaas I, Skranes JS, Meberg AE, Vik T. Cerebral palsy in Norway: Prevalence, subtypes and severity. Eur J Paediatr Neurol. 2008;12:04-13. [crossref] [PubMed]
13.
O舗Shea. Diagnosis, treatment, and prevention of cerebral palsy. Clin Obstet Gynecol. 2008;51:816-28. [crossref] [PubMed]
14.
Shevell MI, Dagenais L, Hall N. The relationship of cerebral palsy subtype and functional motor impairment: A population-based study. Dev Med Child Neurol. 2009;51:872-77. [crossref] [PubMed]
15.
Beckung E, Hagberg G, Uldall P, Cans C. Probability of walking in children with cerebral palsy in Europe. Pediatrics. 2008;121:187-92. [crossref] [PubMed]
16.
Rumeau-Rouquette C, Mazaubrun C, Mlika A, Dequae L. Motor disability in children in three birth cohorts. Int J Epidemiol. 1992;21:359-66. [crossref] [PubMed]
17.
Laisram N, Saha S. Ambulatory potential in children with cerebral palsy. Indian J Phy Med Rehab. 2017;28:49-52. [crossref]
18.
Iloeje SO, Ogoke CC. Factors associated with the severity of motor impairment in children with cerebral palsy seen in Enugu, Nigeria. S Afr J Child Health. 2017;11:112-16. [crossref]
19.
Montgomery PC. Predicting potential for ambulation in children with cerebral palsy. Pediatr Phys Ther. 1998;10:148-55. [crossref]
20.
Vasconcellos RLM, Moura TL, Campos TF, Lindquist ARR, Guerra RO. Functional performance assessment of children with cerebral palsy according to motor impairment levels. Rev Bras Fisioter. 2009;13:390-97. [crossref]
21.
Nordmark E, Hagglund G, Lagergren J. Cerebral palsy in southern Sweden: Gross motor function and disabilities. Acta Paediatr. 2001;90:1277-82. [crossref] [PubMed]
22.
Rodby-Bousquet E, Hagglund G. Better walking performance in older children with Cerebral Palsy. Clin Orthop Relat Res. 2012;470:1286-93. [crossref] [PubMed]
23.
Kimura-Ohba S, Sawada A, Shiotani Y, Matsuzawa S, Awata T, Ikeda H, et al. Variations in early gross motor milestones and in the age of walking in Japanese children. Pediatr Int. 2011;53:950-55. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/48650.15882

Date of Submission: Feb 02, 2021
Date of Peer Review: Apr 03, 2021
Date of Acceptance: Nov 16, 2021
Date of Publishing: Jan 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 03, 2021
• Manual Googling: Nov 15, 2021
• iThenticate Software: Nov 25, 2021 (15%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com