|Year : 2015 | Volume
| Issue : 1 | Page : 9-20
Physical profile of children with cerebral palsy in Jalandhar district of Punjab India
Raju Sharma1, AGK Sinha2
1 Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar, Punjab, India
2 Department of Physiotherapy, Punjabi University, Patiala, Punjab, India
|Date of Web Publication||21-Apr-2015|
Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar, Punjab
Source of Support: None, Conflict of Interest: None
Introduction: Cerebral palsy (CP) has emerged as one of the major causes of childhood disability in India. Physical and functional status of children with CP and their relation with various sociodemographic variables in the Indian context are not widely reported.
Objective: This report describes the physical and functional status of children with CP in Jalandhar district of Punjab and examines its association with biological and social factors.
Methodology: A survey using physical examination of child and schedule interview of parents has been conducted on 248 children with CP of age group 3-13 years. Descriptive analysis has been conducted with probability level set at 0.05.
Results: Spastic CP (83.46%) has been observed the most prevalent type of motor impairment. In spastic type diplegia has been major presentation (43.5%), followed by quadriplegia (34.3%), majority of children fall in level V (57.7%,) of Gross Motor Function Classification System (GMFCS). Mental retardation (MR) is (42.3%) the most frequent associated disability and epilepsy are the most prevalent co-morbidity. About 69% subjects have been found nonambulatory and dependent in their -self-care domains. More than 70% of children have been observed with deformities of more than four joints. GMFCS levels were significantly associated with topography, MR, age of diagnosis, time constraint of parent, difficulty in arranging physiotherapy, ignorance of parents about condition and rehab services required, poor belief in rehabilitation methods.
Conclusion: Lack of comprehensive rehabilitation facilities for children with CP was reflected in the poor physical and functional status of the children. Beside the primary impairments, social factors have played an important role in determining the functional status of these children.
Keywords: Cerebral palsy, functional status, rehabilitation, topography
|How to cite this article:|
Sharma R, Sinha A. Physical profile of children with cerebral palsy in Jalandhar district of Punjab India. Indian J Cereb Palsy 2015;1:9-20
|How to cite this URL:|
Sharma R, Sinha A. Physical profile of children with cerebral palsy in Jalandhar district of Punjab India. Indian J Cereb Palsy [serial online] 2015 [cited 2017 Apr 23];1:9-20. Available from: http://www.ijcpjournal.org/text.asp?2015/1/1/9/153557
| Introduction|| |
After eradication of polio, cerebral palsy (CP) has emerged as one of the major causes of childhood disability in India. The term CP describes a group of disorders of development of movement and posture, causing activity limitation that is attributable to nonprogressive disturbances occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, perceptions, cognition, communication, and behavior; by epilepsy, and by secondary musculoskeletal problems.  The world-wise incidence of CP is 2-2.5/1000 live birth  CP is a life lasting disability and is one of the most expansive health condition.  Attributable lifetime medical cost of CP has been estimated to be 1.8 times the basic lifetime medical cost of the general population. 
The task of reducing the burden of disability due to CP would involve two steps. First reduce the occurrence of CP and second maximize the functional potential of the children with CP by providing necessary support and rehabilitation services to the child. Implementation of the first task requires information on predisposing and precipitating factors related to the birth of children with CP. For example, the incidence of CP child is related with several peri-natal conditions and addressing these issues may bring about a decrease in the prevalence of CP children. The second task of organizing rehabilitation services for maximizing the functional potential of children with CP would essentially require information on the physical status of cerebral children living in the community and various contributing factors. Such information would contribute to delineating the magnitude of the problem, identify the need and services required and hence that these can be addressed in an organized way through a multidisciplinary rehabilitation programs. The studies regarding the status of CP children have not received much attention in the literature. Population-based data of the long-term consequences of CP are limited.  The information on the physical status of children with CP, and factors responsible for the physical status of the child are not widely available. Limited studies in this field have emerged from developed countries.  Indian studies on CP ,, have dealt with the incidence and risk factors associated with the occurrence of CP. There is a scarcity of literature on the physical and functional status of children with CP and their relation with various sociodemographic variables in the Indian context. The status and need of these children and concern of their families have been remaining unidentified. Keeping this in mind, the present study has been planned to explore these aspects of disability in CP in Jalandhar, a major district of Punjab, India.
| Methodology|| |
The study has been approved by BPSAR of Punjabi University Patiala. The study has been designed to collect information about all the identified children with CP in all the 10 blocks of Jalandhar district belonging to the age group of 3-13 years (mean age 7.95 ± 3.33). The study has been conducted in two distinct phases. In the first phase, a database of all the children of CP was prepared. In the second phase each child was clinically examined using standardized clinical tools and interview of the parents of the children using a schedule of semi-structured questions.
Preparation of database
In the absence of any organized system of registering CP children in the state, investigator devised its own strategy to locate the subjects. Initially, the records of children's hospitals, physiotherapy centers and camp for children with CP organized at the investigator's institute were used as a base to locate the name and address of the children with CP. Later subjects were located through various camps organized in different blocks by sarv shiksha abhiyan unit of Jalandhar district. Investigator contacted the parents of the children over the phone and explained them the purpose of the study and sought their consent and cooperation in bringing the child to the investigators institute for detailed examination and interview of parents. He personally went to the home of children whose phone numbers were not mentioned in the list. The following criteria were applied to retain a child in database: (a) Diagnosed cases of CP and or (b) presence of motor delay and motor disorder, abnormal muscle tone, abnormal posture or asymmetry and persistence of primitive reflexes  and (c) have completed the age of 3-13 years on March 2008. During 2008-2011 a database of 248 children with CP of age group 3-13 years was prepared that has constituted the cohort of this study.
In the second phase of the study, the physical examination of child and interview of parents was undertaken by a physiotherapist having 11 years of experience in working with children with CP. Parents were requested to bring the child to a physiotherapy teaching institute located in Jalandhar city for examination. No financial assistance was offered to the parents though the physiotherapy consultation and advice were given free of cost. Many parents have expressed their inability to bring the child to center. These children were examined at their home. Verbal informed consent of parents was obtained prior to physical examination and interview.
Every child has been physically examined for muscle tone using Tone Assessment Scale,  Gross Motor Function using Gross Motor Function Measure (GMFM-88),  Fine motor function using QUEST,  and passive range of motion using goniometry.  The co-morbidity has been evaluated using WHO, s "Ten Question Screening Instrument" commonly used in the identification of disability in the community.  Level of independence in self-care activities eating, drinking, toileting, washing one self, and dressing was assessed by interview of parents using a set of questions developed on Likert scale as per chapter 5 of ICF.  The motor severity among children with CP has been was described by Gross Motor Function Classification System-Expanded and Revised (GMFCS-E&R).  For the deformity assessment, the passive range of motion of all the joints of upper limb and lower limb was assessed using the standard procedure.  Presence of hypomobility and hypermobility in a joint was the criteria for considering the joint as deformed.  Based on the total number of deformed joints, each child has been classified into one of the four categories: Nil (all the joints having full passive range of motion), mildly deformed (15%, up to 3 out of 21 joints) joints have limitation in full passive range of motion), moderately deformed (45%, 4-9 joints have limitation in full passive range of motion) severely deformed (75%, 10-15 joints have limitation in full passive range of motion) and profoundly deformed (>75%, more than 15 joints).
The schedule of interview of family consisted of semi-structured questions focusing on demographic information (name, age, gender, address, occupation, education level and monthly income of parent, house condition) birth history, treatment history, associated problems, perceived constraints of resources, concerns, expectations, believes, awareness and impact of child condition on family. Initial draft of questionnaire prepared after a review of literature and in-depth interview of some family members of children was validated for content by a panel of experts consisting of a physiotherapist, a pediatrician and a social worker. The schedule was pretested on 25 parents before using for final data collection. When available, information related to medical and treatment history was retrieved from the medical records.
The clinical characteristics of a child have been recorded as primary impairment (type of motor disorder, associated co-morbidity and limbs distribution) and secondary impairments (deformity level), functional ability (gross motor abilities, hand function ability, self-care ability) and the social consequence (schooling). The barrier and facilitator were identified and reported as social consequence.
Data reduction and statistical analysis
Data have been analyzed using SPSS version 16.0 (USA) for windows. Descriptive analysis of each variable has been carried out in the present study on the basis of type, topography, age group, and GMFCS level. Cross tabulation with Chi-square test is a tool of statistical analysis for categorical variables, whereas for continuous variables one-way ANVOA with post-hoc Tuckey test has been used to examine the difference between the groups. Spearman rank order correlation co-efficient test has been used to examine the relation of GMFCS with GMFM score, quest score. Results have been presented in absolute numbers and percentage.
| Results|| |
[Table 1] displays the demographic and birth characteristics of CP children of Jalandhar district of Punjab. The distribution of types of CP in various age groups is displayed in [Table 2]. Spastic type of CP (83.46%) was most common in all the age groups, followed by dyskinetic (16.93%), mixed (2.82%) and ataxic (2.01%) type. In spastic type, diplegia was major presentation (43.5%), followed by quadriplegia (34.3%), hemiplegia (13%) and triplegia (9.2%). In subjects afflicted with dyskinetic, ataxic and mixed type, quadriplegia was only presentation. No case of monoplegia was observed.
|Table 1: Demographic characteristic of children with CP in Jalandhar district|
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|Table 2: Distribution of types of main motor impairments according to age group|
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[Figure 1] and [Figure 2] present the distribution of levels of GMFCS according to predominant motor impairment type and topography respectively. Majority of children fall at level V (57.7%, 143 out of 248) of GMFCS. The percentage of children in Level I, II, III and IV were 10.5%, 8.1%, 12.1% and 11.7% respectively. GMFCS level was not significantly associated with type (χ2 = 18.32, P = 0.10) and age group (P = 0.14), but association between GMFCS levels and topography was highly significant (χ2 = 66.05, Carmer v = 0.24, Kandall tau b = 0.30, P = 0.001). Majority of subjects in level I (42.3%), level II (35.0%) and level III (63.3%) had spastic diplegia, whereas majority in level V (39.4%) had spastic quadriplegia. Maximum percentage of hemiplegics children were at level I (33.3%).
|Figure 1: Distribution of gross motor function classification system levels according to type of main motor impairment|
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|Figure 2: Distribution of gross motor function classification system levels according to topography|
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Mental retardation (42.3%) was the most common associated disability distributed in all the types of CP [Table 3], followed by other impairments (39.9%), epilepsy (28.6%), communication impairments (18.5%) and visual impairment (4.5%) respectively. Proportion of all types of co-morbidities was highest in quadriplegia [Table 3]. Communication impairment was associated with types and topography of CP. 62.8% and 80% of children with dyskinetic and ataxic type respectively had this impairment, whereas in topography this impairment was more in quadriplegia (51.3%). Out of 6 cases of visual impairment 5 (93.34%) had spastic quadriplegia, whereas 1 (6.66%) child belonged to dyskinetic group. MR was significantly associated with GMFCS (χ2 = 29.88, P<0.001) with 61.5% of level V children with MR in comparison with 26.9% of level I children.
[Table 4] presents the distribution of different topography according to deformation level. 26.2% children were severely deformed, whereas 14.8% children had no deformity. Majority of children were moderately deformed (39.9%, 99 out of 248), followed by mildly deformed (29%). The level of deformation was not significantly associated with age group (χ2 = 13.61, P = 0.13), but it was significantly associated with topography (χ2 = 97.91, P = 0.001) type (χ2 = 18.45, P = 0.30) and GMFCS level (χ2 = 49.47, P = 0.001). Percentage of severely deformed children was highest in level V (41.3%) whereas at level I and II this percentage was nil. The spastic quadriplegia group had a maximum number of severely deformed children (60.6%) as against 0% of hemiplegia. No case of severely deformed child was observed in ataxia and mixed group. [Figure 3] and [Figure 4] present the distribution of deformation level according to GMFCS levels and type respectively.
|Figure 3: Distribution of deformation level according to gross motor function classification system level|
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|Figure 4: Distribution of deformation level according to type of main motor impairment|
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In upper limb deformities of the forearm were most common (42.3%) followed by wrist (39.3%). Ankle (59.8%) was most commonly affected joint of lower limb followed by knee (55%), 4.8% children had spinal deformities [Table 5]. Involvements of joints were significantly associated with age group and type. The frequencies of hip, shoulder, elbow and hand deformities were relatively higher in the age group of 9-11 and 12-14 years. In all the topographic presentations, ankle deformity was most common followed by knee.
[Table 6] and [Table 7] present the mean scores of different domains of GMFM and QUEST between different levels of GMFCS, respectively. Significantly differences were observed between QUEST and GMFM scores of various levels of GMFCS (F = 68.72). Post-hoc analysis with Tucky test revealed that means scores of level I was significantly different from that of level III, IV and V, but significant differences were not observed between the level I and level II and between level II and level III. However, scores of level V was different from level IV. In QUEST scores, level V was significantly different from all the other levels. However, significant differences between the levels up to level IV were not observed. [Figure 5] displays the mean scores of GMFM and QUEST among various levels of GMFCS.
|Figure 5: Mean gross motor function measure-88 scores (a) and QUEST scores (b) of various levels of gross motor function classification System|
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[Table 8] presents the status of functional status of various levels of GMFCS in the 5 domains of self-care. Most children were dependent in self-care domains. Toileting, dressing, and washing were the area where maximum dependence was observed. Percentage of children having independence in eating was more followed by drinking, washing, toileting and dressing. Highly Significant association (P < 0.001) of GMFCS level with the level of independence was observed in the all the 5 domains. The level of independence was not associated with type, but it was highly significantly associated with topography. Most children of dependent categories in all the domains belonged to quadriplegia. [Figure 6] presents the dictomous distribution of self-care abilities by clubbing independence level I, II and III as CAN DO and IV and V as CAN NOT DO.
|Figure 6: Distribution of ability of self-care in different gross motor function classification system levels|
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In an attempt to see which measure best describes the status of CP children for epidemiological purpose the correlation analysis of the scores of GMFCS, GMFM, QUEST, deformity level, scores of all 5 domains of self-care and deformity level have been carried out. Highly significant negative correlation (P < 0.001) were observed between GMFCS levels and GMFM scores (−0.72) and QUEST scores (−0.61) [Figure 7]. Significantly positive correlation (P, 0.000) was also observed between GMFCS level and scores of self-care domains of eating (Kendall tau b = 0.52), drinking (Kendall tau b = 0.55), toileting (Kendall tau b = 0.59), washing (Kendall tau b = 0.5) and dressing (Kendall tau b = 0.5) and deformity level (Kendall tau b = 0.33). The socioeconomic status (χ2 = 8.26, P = 0.40), locality (χ2 = 7.19, P = 0.12) and educational level of parents (χ2 = 11.84, P = 0.45), type of delivery (χ2 = 4.91, P = 0.29) were nonsignificantly associated with level of GMFCS.
|Figure 7: Correlation between mean scores of gross motor function measure and QUEST among gross motor function classification system levels|
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[Table 9] presents the distribution of health and rehabilitation service utilization according to GMFCS level. Highly Significant association was observed between the GMFCS level and advice for rehabilitation (χ2 = 73.04, Kendal tau b = −0.47 P < 0.001), utilization of physiotherapy (χ2 = 35.13, Kendall tau b = −0.33), neurological procedures (χ2 = 12.80, Kendall tau b = 0.17) and use of orthoses (χ2 = 73.54, Kendall tau b = −0.06) but not with other services. 57.7% children of level I were advised for rehabilitation whereas in level V this percentage was 17.3%.
|Table 9: Distribution of health and rehabilitation service utilization according to GMFCS level|
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GMFCS was significantly associated with age of diagnosis (Kendall tau b = 0.65), personal and time constraint (Kendall tau b = 0.18) difficulty in arranging physiotherapy (Kendall tau b = 0.33), ignorance of parents about condition and rehab services required (Kendall tau b = 0.41), and poor beliefs in rehabilitation methods (Kendall tau b = 0.33).
| Discussion|| |
This cross-sectional study is a census of children with CP of age group 3-13 years of a major district of Punjab that provides baseline data for planning of services required for children with CP in the region. Male: Female ratio of 1.7:1 observed in this study is in agreement with previous studies ,,, which CP is more common among boys than among girls. The distribution of types of motor impairment and topographical classification observed in this study are quite similar to previous reports emerged from India ,, and other parts of the world.  Our observation that spastic type of CP (83.46%) was most prevalent in all the age groups followed by dyskinetic (16.93%), mixed (2.82%) and ataxic (2.01%) type is in agreement with previous studies emerged from India and from different part of the world. ,, In spastic type, diplegia was a major presentation (43.5%), followed by quadriplegia (34.3%) and hemiplegia (13%) and triplegia (9.2%). This observation is in variance with previous studies  that reported quadriplegia as the major presentation in spastic CP. However it is in agreement with a recent Indian study of 182 children with CP that reported diplegia as the most common topographical pattern in spastic type, followed by quadriplegia, hemiplegia triplegia and monoplegia  and supports the observation of Singhi et al. (2011) that the spectrum of CP is evolving in the developing countries with an increase in diplegics and a decrease in quadriplegic CP. The distribution of associated disabilities and co-morbidity across limb distribution and main motor impairment type are also in agreement with the previous reports. Our findings that MR was the most prevalent associated impairment of with CP are in agreement with Pakula et al.  and others. , The prevalence of all co-morbidity was highest in quadriplegia that supports the observation that maximum damage to the brain lead to more disability.
A highly significant (P < 0.001) but modest association (Cramer v = 0.24, Kandall tau b = 0.30) between GMFCS and topographical classification observed in this study is in agreement with the observation of Muzaffar et al.  and Gorter et al.  who also observed a highly significant but modest to week association between these two classification system. However unlike Gorter et al.  we did not observe statistically significant association of GMFCS level with the predominant type of motor impairment (χ2 = 18.32, P = 0.10).
The comparison of the distribution of levels of GMFCS by motor impairment type and topography presents quite a different picture. In Canadian study of Gorter et al.  3.3% children with hemiplegia and 46.0% children with quadriplegia were classified at level V of GMFCS. However In the present study, these percentages were quite high. 29.6% and 75% of hemiplegia and quadriplegia respectively were represented at level V. In Sweden study  94% children with hemiplegia were characterized by limitation at level I and II of GMFCS, whereas the corresponding figure in this study was only 44.4%. Our observation that the majority of children with hemiplegia were classified as level I is in agreement with the observation of Muzaffar et al.  and Gorter et al.  However unlike Gorter et al., 2004 who found 87.8% children with hemiplegia at level I We observed 33.3% children with hemiplegia at level I which is similar to 34% of Muzaffar et al.  Kulak et al.  reported in their study, most of spastic diplegics were observed to be in level II and III whereas spastic tetraplegics in level IV and V  while in a Turkish study,  spastic diplegics were in level III and IV and spastic tetraplegics in level IV and V. Except for hemiplegia, children with level V constituted the majority in all categories of topographical and motor impairment classification.
This disparity can be explained by the observation that sample of previous two studies were recruited from the rehabilitation centers implying that they all must have been receiving some kind of rehabilitation services. However in the present study only a minor percentage of children were provided with rehab services and for the majority the data represents the natural course of CP without any organized multidisciplinary intervention. This indicates that apart from biological factors geographical location and facilities of rehab in the society also influence the functional outcome in CP.
Jalandhar is one of the most prosperous districts of Punjab. The area of Jalandhar district is 3,401 km 2 with total population 19,53,508 persons (10, 26, 535 males and 9, 26, 973 Females) with 47.2% rural and 52.93% urbane. Male and female literacy were 86.15 and 78.48 respectively. Children under 0-6 formed 10.32% population (census India, 2011).  Jalandhar city has probably the highest density of hospitals and nursing homes.
However, the rehabilitation service utilization among children with CP in Jalandhar can at best be described as abysmal. Parents of only 17.3% children were given advice for rehabilitation. Physiotherapy and orthotics were the only rehab services available to most of these children. Only 55.6% children had received physiotherapy that too quite irregularly. Not a single child had received occupational therapy. Speech therapy was offered to just 4% (n = 10) children though 18.5% (n = 46) were afflicted with communication impairments. MR was the most common co-morbidity observed in 47.17% (n = 117) children but special education was available to only 4.8% (n = 12) children. Absence of literature on service utilization of CP children in India makes it difficult to compare the findings. However, the scenario is alarming and in gross variance with those reported from the western countries. In Ireland Services used among families of CP children was very high with 59% receiving physiotherapy at least twice a week for 30 min.  In an another study, over half of children (53.2%) and adolescents with CP (57.5%) were in regular schools, and The remainder was in special schools. The majority of children (84.6%) were receiving at least one rehabilitation service. PT and OT were most common, and services were provided predominantly in the school setting.  In Hongkong, approximately 38% of children with CP attended a mainstream school and 134 (61%) received out-patient therapy support.  In Sweden almost all children with CP and with normal cognitive development are integrated in mainstream school education, whereas children with learning disability are referred to special schools and have some degree of educational activity on a daily basis in a form of communication or music therapy.  In contrast, only 4.1% CP children in Jalandhar district have been regular to any school.
It is clear that comprehensive rehabilitation facility for children with CP do not exist in Jalandhar district and the result of which reflected in the physical and functional status of the children. Majority of children were nonambulatory and were dependent in self-care domains. More than 70% of children have been observed to have the deformities of more than four joints. Highly Significant but modest association between deformation level and the GMFCS level (Kendall tau b = 0.33) suggests that in the course of time the contribution of these secondary impairments in limiting the functional potential of CP child far exceeds the primary impairments.
Highly significant association of GMFCS levels with social factors such as personal and time constraint, lack of advice for rehabilitation, difficulty in arranging physiotherapy, ignorance of parents about condition and rehab services requirement and poor believe in rehabilitation methods highlights that social factors play as important a role in determining the functional status of these children as the primary impairments.
The WHO model of health and disease provides an important framework to guide modern thinking about treatment for children with CP. Disability is not an attribute of an individual, but rather a complex collection of conditions, many of which are created by the social environment. An individuals' disability in a specific domain represents an interaction between health condition and the contextual factors such as environmental factors and personal factors hence the management of problem require social action and it is the collective responsibility of society at large to make the environmental modification necessary for full participation of people with disabilities in all areas of social life.  Rehabilitation is a continuous process that involves identifying the problems and needs of individuals, relating the problems to relevant factors of the person and the environment, defining therapy goal, planning and implementing the intervention and assessing the effects of the intervention using measurements of relevant variables. 
As CP cannot be cured the goal of management should be to use the appropriate combination of interventions to promote function, to prevent secondary impairments and to increase the developmental capabilities of the child.  Management of a child with CP requires multidisciplinary inputs from the discipline of medicine, surgery, physiotherapy, occupation therapy, speech therapy, orthotics, inclusive and special education.  Functional abilities of locomotion and ADL are the outcome of practice and training and early and multidisciplinary intervention play major role in maximizing the functional capability of children with CP along with physiotherapy, occupational therapy is oriented towards Activity of daily living such as eating, clothing, washing, writing in an attempt to provide personal autonomy to person with CP.  The lack of occupational therapy and obsession with walking may be accounted for poor functional independence of CP children observed in the present study. Comparison of data of this study with the reports emerged from developed nations indicate that the rehab services markedly influence the functional status of children with CP. The International data of CP surveillance suggest that most children with hemiplegia can attain the level I and II.  When a child with hemiplegia stays at level V it may not be exclusively due to his primary impairment but due to the lack of rehabilitation.
Besides the availability of services in the vicinity, the Health care service utilization by children with CP greatly depends on the awareness, belief and willingness of the parents. We have observed that close to 80% parents are grossly ignorant about the condition of CP. Neither they have knowledge about the rehabilitation services required for management of such children nor did they believe that rehabilitation methods such as exercises and training would bring about any changes in the physical and functional status. Majority of parents believed that CP was a disease that could be cured by administration of drugs or surgery. In childhood disability like CP, the aim of the intervention is not complete cure but habilitation. This truth is often emotionally not acceptable to parents, and they tend to be lured toward other treatment methods existing in the community.  Consumption of homeopathic medicine by 77.0%, ayurvedic medicine by 86.3% and magical remedies (24.6%) observed in this study, supports this notion. In this situation, it becomes imperative that parents of the child are provided with accurate information about the condition and the services required for physical empowerment of the child. Being the first contact professional allopathic medical doctors are the best person to advice the parents about the need of comprehensive rehabilitation services.
However, it was appalling to note that only 17.3% of the families had received information and advice for rehabilitation. Majority (91.1%) of children were just prescribed an assortment of tonics and vitamins. Such practices only serve to strengthen the wrong perception that CP is a disease not a lifelong condition. It is essential that the sensitization and advocacy programs on rehabilitation of CP should be initiated for the medical professionals as without the cooperation of medical professionals the rehabilitative efforts would not gain acceptance in the community. The need for such program has also been emphasized by Padmamohan et al.  whose study on preschool disabled children in rural Kerala identified poor perceptions about the disease and disability and poor acceptability of services as factors responsible for lower utilization of rehabilitation services.
Awareness and sensitization programs for parents about the condition and rehab requirements of the children with CP should become the priority of the service providers. This can be effectively carried out at the time of initial diagnosis. Establishment of CP registry and a district resource center for multidisciplinary rehabilitation would help in providing targeted need-based early intervention which in long term would contribute to improving the physical and functional status of these children.
This study supports the observation of Wood and Rosenbaum  that in comparison to the classification by limb distribution (topography) or type of motor impairment, GMFCS provides meaningful distinction in the gross motor development between the five sub-functional group and enable the clinician in prognostic and interventional planning. This system correlates well with GMFM, QUEST and functional abilities in self-care domains. Use of this system in longitudinal epidemiological studies would serve to ascertain the real effect of a policy intervention such as creation of CP registry, establishment of comprehensive rehab unit in the district and awareness sensitization and advocacy program for both medical community and the parents.
The sociodemographic and epidemiological transition in developing countries has brought noncommunicable disease to the forefront of the health care delivery system. Within this group neurological disorders constitute a significant proportion. The management of these conditions essentially requires long-term multidisciplinary rehabilitation services. The urgent need for reorganization of services with optimal use of existing specialized manpower has been expressed. However, the rehabilitation services are expanding in India at a slow pace and in the unorganized manner. Epidemiological studies provide scientific backdrop for public health efforts including quantifying the magnitude of health problem, identifying the contributing factors and providing quantitative guidance for allocation of public health resources. 
The study was delimited to children of age group 3-13 years. Similar studies including adolescent and adults with CP would bring out true impact of CP on the individual and the family. In conclusion, it can be said that while the findings of this study related to biological factors are similar to the previous national and international reports, the findings on the functioning, disability, participation and service utilization presents quite a different picture. This has important policy implications with regards to identification and management of these children. The study highlights that the physical and functional status of CP children of Jalandhar district is below the international standards. The influence of secondary impairments on the functional status far exceeds the primary impairment and the role of social factors in determining the physical and functional status of these children be significant. Awareness sensitization and advocacy programs for rehabilitation of these children among medical professionals and parents would hopefully bring about favorable changes. At the same time effort to establish a CP registry and comprehensive rehabilitation unit for rehabilitation of children with CP should be intensified.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]