IJCRR - Vol 04 Issue 05, March, 2012
Date of Publication: 30-Nov--0001
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MOTOR ABILITIES AND ASSOCIATED IMPAIRMENTS IN CHILDREN WITH CEREBRAL PALSY
Author: Vijesh P. V., P. S. Sukumaran
Abstract:Objectives:- In children with cerebral palsy, the gross motor and fine motor abilities are
impaired at different levels due to the lesions in the developing brain. Even though the damage primarily affects the loco-motor system, the presence of associated impairments are common in these children. For the successful rehabilitation of children with cerebral palsy, the assessment of gross motor and fine motor abilities are very important specifically in planning the short term and long term goals. The objective of the study is to find out the gross motor and fine motor abilities of these children and how these are correlated with each other and also with the associate impairments. Methods:-100 children with cerebral palsy aged between 6-14 years who attended special schools were assessed using gross motor classification system (GMFCS) and fine motor ability classification system (MACS). The presence of associated impairments were collected from the school records of these children. Results:- Within the framework of traditional classification of cerebral palsy, these children had different levels of gross motor and fine motor abilities as measured by GMFCS and MACS. The study also revealed that there is a significant positive correlation between the gross motor and fine motor abilities of these children (rho=0.56, p< 0.01). Also, it was evident that as the gross motor and fine motor abilities reduced they had more associated impairments. Conclusions:-The gross motor and fine motor abilities and the presence of associated impairments are the key areas that have to be assessed while evaluating the child with cerebral palsy. These two abilities are correlated with each other and also the associated impairments are more in those children who had limited gross motor and fine motor abilities.
Keywords: Gross motor ability, fine motor ability, cerebral palsy
The term cerebral palsy (CP) covers a group of non progressive, but often changing, motor impairment syndrome secondary to lesions or anomalies of the brain arising in the early stages of development1 .It is one of the most common causes of severe physical disabilities in children and results in considerable suffering to both affected individuals and their families. Studies on prevalence in industrialized nations have shown a range averaging between 1.5 and 2.5 per 1000 live births2,3,4 . In India, with a population of 1 billion, is having roughly 25 lakh people with cerebral palsy and roughly 150 children are born everyday which later develop this disorder5 . Even though the definition for cerebral palsy concentrates on the developmental delay and motor impairment, the practical picture is more complicated. The associated impairments can be observed in different levels- sensory (vision, hearing, touch), neurological (epilepsy), intellectual, speech and language6 . The increased life expectancy of cerebral palsy children over last decades have brought about an additional demand for health, educational and social services7 . The traditional classification of children with cerebral palsy includes the labeling of the child as spastic, ataxic, athetoid or as diplegic, hemiplegic etc8 . But nowadays the motor abilities and clinical manifestations of cerebral palsy are well addressed by the International Classification of Functioning, Disability and Health (ICF) which incorporates biological and social perspective of disablement to an individual?s life9 . Motor ability is one of the keen area that has to be assessed in detail. Knowledge about the gross motor and fine motor ability of the child with cerebral palsy enables the therapist in planning short term and long term goals for the rehabilitation. With the availability of numerous assessment tools for the measurement of motor ability, Gross Motor Function Classification System (GMFCS)10 and Manual Ability Classification System (MACS)11 are found to be reliable in these children with cerebral palsy. Presence of associated impairments too make the rehabilitation of the child with cerebral palsy a challenging task to the professionals in this field. This study is an attempt to assess the children with cerebral palsy based on their motor abilities and how it is associated with other impairments. The main objectives of the study were 1. To identify the extent of gross motor and fine motor abilities of children with cerebral palsy. 2. To find out the relation between gross motor and fine motor abilities of children with cerebral palsy 3. To find out the associated impairments of children with cerebral palsy. 4. To analyze the relationship between motor ability and associated impairments in children with cerebral palsy.
MATERIALS AND METHODS
Cross sectional survey method was used to collect the data. The study was done among 100 children with cerebral palsy aged between 6 to 14 years who were attending special schools in Kerala state. After obtaining the ethical clearance from f Mahatma Gandhi University, the investigators approached the special school authorities and the need and significance of the study were explained to them and also to the parents of the children with cerebral palsy. The consent form was obtained from them prior to data collection. From a pool of 112 children with cerebral palsy, 100 children were taken for the study using lottery random method. The tools used for the study included Case Record Sheet, Gross Motor Function Classification System (GMFCS), Manual Ability Classification System (MACS). Case record sheet was prepared to collect general information about the child with cerebral palsy and his/her family from the case profile of the child which is kept in the special school. Information needed to categorization of the subjects into respective sub samples on the basis of variables such as child?s age, gender, motor type of cerebral palsy, topographical distribution, presence or absence of mental retardation, hearing, speech, visual impairments etc are included in this sheet. GMFCS is an internationally accepted tool for assessing the children with cerebral palsy based on the functional abilities and limitations. It is a five level ordinal scale grading system with different age bands.
Children in level I have the ability to walk indoors and outdoors and climb stairs without limitation, while children in level II have to use rails for walking and climbing stairs. Children in level III will use assistive devices for mobility, while wheelchair mobility is needed for level IV. In level V, independent mobility is totally restricted. For collecting data for the present study, the investigators used the GMFCS with age band 6-12 years. MACS provide a systematic method to classify how children with cerebral palsy use their hands when handling objects in daily activities. This is also an ordinal scale with five levels of description. In level I, child handles objects easily and successfully, while in level II the child handles the objects with reduced quality and speed. In level III, the child handles the objects with difficulty and in level IV child handles the objects in a limited manner in adapted situations. Children in level V need total assistance in handling the objects. After developing a proper rapport with the child and the parent, the investigators started the process of data collection initially with the case record sheet. The data obtained from the school record were cross checked physically and verbally with the child and the parent. Grouping of children with cerebral palsy into different levels using GMFCS and MACS were also done. The entire procedure took around 60-90 minutes per child. Statistical Methods The results were analyzed using SPSS version 17 for windows using Spearman?s correlation coefficient.
Age and gender The mean age of the children with cerebral palsy participated in the study was 9.85 (SD=1.69) years with 61 children belonging to male category and 39 in female category. Motor type and topographical distribution The demographic profile of the children with cerebral palsy were shown in table 1 from which it can be seen that out of 100 children, 81 were spastic in nature ,16 were choreoathetoid, 2 were ataxic and one was in floppy type.Also,52 were diplegic while 37 were quadriplegic and 11 were hemiplegic in limb distribution. Associated impairments Out of 100 children, 94 were having different levels of mental retardation such as 78 were in mild category,48 were moderately retarded while 4 were severely affected. Also, 24 children were having visual impairments, while 15 were showed hearing impairments, 48 were having different types of speech impairments, 37 were having behavioural problems and 35 were having epileptic attacks. Thus most of the children were multiply handicapped. (position for Table No 1 ) Gross motor and fine motor abilities The distribution of 100 children with cerebral palsy according to their motor ability are shown in figure 1 and table 2 and 3. Thirty five percentage children were independent in their gross motor functions while 47% were independent in their fine motor functions. Table 4 and figure 2 explains the cross tabulation of gross motor function (GMFCS) and fine motor function (MACS) of these children from which it is clear that 23 children were independent in their gross motor function (GMFCS- I) and fine motor function (MACS- I) while 6 children were severely limited in their self mobility (GMFCS-V) and object handling capacity(MACS-V) (position for Table 2 , 3 and 4 , Figure 1 and 2) The correlation between gross motor and fine motor functions in children with cerebral palsy as measured by GMFCS and MACS are found to be significantly positive (Spearman?s rho 0.56,p<0.01) The distribution of 100 children with cerebral palsy according to their motor type and topographical distribution into different levels of motor ability are shown in table 5,6,7, and 8 with graphical representation in figure3,4,5 and 6. On close examination of the values from table 5, it can be seen that among the 35 children in GMFCS level I, 30 (85%) were in spastic type and only 5 (15%) were in choreo-athetoid type. While among the 24 children in GMFCS level II, 19 (79.2%) were spastic type and 5 (20.8%) were in choreo athetoid type. And among the 15 children who belonged to GMFCS level III, 11 (73.4%) were in spastic type, 2 (13.3%) were each in choreo athetoid and ataxic types. Among the 14 children in GMFCS level IV, 11 (78.6%) were in spastic type and 3 (21.4%) were in choreo athetoid type. Finally, among the 12 children in GMFCS level V, 10 (83.4%) were in spastic type and 1 (8.3%) was each in choreo athetoid and floppy type.From the table 5, it can be also summarized that among the 81 children in spastic type, 30 (37%) were in GMFCS level I, 19 (23.5%) were in level II, 11 ( 13.6%) were each in level III and IV, and 10 (12.3%) were in level V of GMFCS. Among the 16 children who belonged to the choreo athetoid type, 5 (31.2%) were each in GMFCS level I and II, 2 (12.5%) were in GMFCS level III, 3 (18.8%) were in GMFCS level IV and only 1 (6.3%) was in GMFCS level V. The two children with ataxic cerebral palsy belonged to the GMFCS level III and the only one floppy child with cerebral palsy belonged to GMFCS level V. (position for Table 5, and 6, Figure 3 and 4) On close examination of data from table 6, it can be seen that among 35 children in GMFCS level I, 20 (57.2%) were diplegic, 4 (11.4%) were hemiplegic and 11 (31.4%) were quadriplegic type. Among the 24 children in GMFCS level II, 15 (62.5%) were diplegic, 8 (33.3%) were quadriplegic and only one child (4.2%) was in hemiplegic type. While among the 15 children in GMFCS level III, 7 (46.7%) were in diplegic type, 5 (33.3%) were in quadriplegic type and 3(20%) were in hemiplegic type. A total of 14 children who belonged to the GMFCS level IV, in which, 8 (57.2%) were in diplegic type and 3 (21.4%) were each in hemiplegic and quadriplegic types. Among the 12 children in GMFCS level V,10 (83.3%) were in quadriplegic type and 2 (16.7%) were in diplegic type. From the table 6, it is also evident that, among the 52 diplegic children,20 (38.5%) were in GMFCS level I,15 (28.8%) were in level II,7 (13.5%) were in level III, 8 (15.4%) were in level IV and 2 (3.8%) were in GMFCS level V. Similarly,among the 11 hemiplegic children,4 (36.4%) were in GMFCS level I, 1 (9.1%) was in level II and 3 (27.3%) were each in level III and IV . There was no hemiplegic child in GMFCS level V. Also, among the 37 quadriplegic children with cerebral palsy,11 (29.7%) were in GMFCS level I, 8 (21.6%) were in level II, 5 (13.5%) were in level III, 3 (8.1%) were in level IV and 10 (27%) were in level V. (Position for Table 7 and 8, Figure 5 and 6) From the table 7, it is clear that among the 47 children in MACS level I, 45 (95.7%) were in spastic type and 2 (4.3%) were in choreo athetoid type.While among the 25 children in MACS level II,18 (72% ) were in spastic type, 6 (24%) were in choreo athetoid type and 1 (4%) was in ataxic type. Twelve children belonged to MACS level III, in which 7 (58.3%) were spastic type, 4 (33.3%) were in choreo athetoid type and 1 (8.4%) was in ataxic type. Among the 7 children in MACS level IV, 6 (85.7%) were in spastic type and 1 (14.3%) was in choreo athetoid type. Finally, among the 9 children in MACS level V, 5 (55.6%) were spastic, 3 (33.3%) were choreo athetoid and 1 (11.1%) was in floppy type. From the table 7 it is also evident that, among 81 spastic children, 45 (55.6%) were in MACS level I, 18 (22.2%) were in level II, 7 (98.6%) were in level III, 6 (7.4%) were in level IV and 5 (6.2%) were in MACS level V. A total of 16 children were in choreo athetoid type, in which, 2 (12.5%) were in MACS level I, 6 (37.5%) were in level II, 4 (25%) were in level III, 1 (6.3%) was in level IV and 3 (18.8%) were in MACS level V. Among the 2 ataxic children, 1 (50%) was each in MACS level II and III. The only one floppy child belonged to the MACS level V. On close examination of data from table 8, it can be seen that among 47 children in MACS level I, 32 (68.1%) were diplegic, 5 (10.6%) were hemiplegic and 10 (21.3%) were quadriplegic type. Among the 25 children in MACS level II, 13 (52%) were diplegic in nature, 4 (16%) were hemiplegic type and 8 (32%) were in quadriplegic type. While among the 12 children in MACS level III, 4 (33.3%) were in diplegic type and 8 (66.6%) were in quadriplegic type. A total of 7 children who belonged to the MACS level IV, in which, 3 (42.9%) were each in hemiplegic and quadriplegic types and 1 (14.3%) was in hemiplegic type. Finally among the 9 children in MACS level V, 8 (88.9%) were in quadriplegic type and only one (11.8%) was in hemiplegic type.From the table 8, it is also evident that, among the 52 diplegic children, 32 (61.5%) were in MACS level I, 13 (25%) were in level II, 4 (7.7%) were in level III, 3 (5.8%) were in level IV and there was no diplegic child in MACS level V. Similarly, among the 11 hemiplegic children, 5 (45.5%) were in MACS level I, 4 (36.4%) were in level II and 1 (9.1%) was each in level IV and V. There was no hemiplegic child in MACS level III. Also, among the 37 quadriplegic children with cerebral palsy,10 (27%) were in MACS level I, 8 (21.6%) were each in level II, III and V. Three ( 8.2%) quadriplegic children were in MACS level IV. Presence of associate impairments in children with cerebral palsy according to their motor ability are shown in table 9 and 10 with a graphical representation in figure 7 and 8. From these tables, it is clear that those children in IV and V levels of GMFCS and MACS have more associated impairments than that children in levels I, II and III. (Position for Table 9 and 10 , Figure 7 and 8)
DISCUSSION This is, to our knowledge, it is the first study in the state of Kerala ,where the gross motor and fine motor abilities of children with cerebral palsy are assessed along with the traditional method of classification. The assessment of motor ability of a child with cerebral palsy along with the traditional classification gives the clear picture of the child with cerebral palsy. For example, labeling a child as spastic diplegic CP with GMFCS level II and MACS level III is more informative than saying as just spastic diplegic CP. Hence the authors strongly suggest the usage of GMFCS and MACS while assessing children with cerebral palsy. The association between the gross motor and fine motor abilities of the children with cerebral palsy under study assessed using GMFCS and MACS are found to be strong as evaluated by Spearman?s correlation coeffient. These findings are consistent with those of Gunel et al. (2008) in which a high correlation was reported between GMFCS and MACS in 185 children with cerebral palsy12 . But it is important to note that this degree of correlation can vary according to the topographical distribution of children with cerebral palsy. A high correlation can be expected in quadriplegic children while low correlation can be seen in hemiparetic children. This is due to the fact that in quadriplegic children the trunk, upper and lower limbs are affected so that a child who has a good gross motor function can have a good fine motor function too and also if the gross motor function is less, naturally his or her fine motor function will be also poor. But in a hemiparetic child, with the alternate hand he can function normally and thus can have a good fine motor function even in the presence of limited gross motor function. It is also noteworthy that as their lower limbs are more affected than upper limbs in diplegic children, their MACS levels will be better than GMFCS levels. That means,they can have good fine motor abilities than gross motor functions. Several recent studies12,13 have supported this viewpoints. Based on the motor type of the cerebral palsy also this correlation can vary. In a choreo-athetoid type of cerebral palsy, the gross motor function may be better, but the fine motor function of hands may be limited due to the chorea type of movements. The associated impairments that are seen these children varied from child to child. One important factor noted in this study is relation between fine motor and gross motor abilities with respect to associated impairments. It is evident that those children with cerebral palsy who belonged to IV and V levels of GMFCS and MACS are having most of associated impairments in them. Thus from this study it can be stated as motor ability of child with cerebral palsy reduces there is a chance of occurrence of more associated impairments.
This study, clearly demonstrates how the gross motor and fine motor abilities of children with cerebral palsy are varied as per their subtypes. Assessment of motor ability of children with cerebral palsy along with traditional classification will be more useful in clinical setup while setting up the treatment goals. Also, as the motor ability of the child reduces, he or she has the chance to more associated impairments which makes the rehabilitation a challenging task.
The authors are grateful to parents, their children with cerebral palsy and staff of Jyothis and Adarsh special schools in the state of Kerala. Also to Dr S Sharma, Professor in statistics, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram Kerala. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
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