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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 105-125


Date of Web Publication12-Apr-2017

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How to cite this article:
. Abstracts. Indian J Cereb Palsy 2016;2:105-25

How to cite this URL:
. Abstracts. Indian J Cereb Palsy [serial online] 2016 [cited 2018 Dec 15];2:105-25. Available from: http://www.ijcpjournal.org/text.asp?2016/2/2/105/204411

  Clinicoradiological comparison of seizure and nonseizure groups in children with cerebral palsy in a tertiary care center Top

Ayesha Mariam, Maria Lewin

Department of Pediatrics, St. John's Medical College and Hospital, Bengaluru, Karnataka, India.

E-mail: ayesha.mariam@yahoo.com

Background/Objectives: Cerebral palsy (CP) has many known associated comorbidities, out of which epilepsy is the most frequent single complication.[1] However, it is difficult to predict which child may have associated seizures. Our objective was to identify differences in clinical profile in terms of risk factors, phenotype, and radiological findings and to determine specific differences in neuroimaging patterns between the two groups.

Study Design: This was a retrospective cohort study.

Study Participants and Settings: A cohort of 99 children diagnosed with cerebral palsy for the management on an inpatient or outpatient basis in a tertiary care setting between January 2014 and June 2016.

Materials and Methods: Data were obtained by chart review from the existing medical records. Details collected include risk factors, phenotype of CP,[2] details of seizures, and radiological findings. Neuroimaging was reviewed in 41 children into five main groups – congenital malformations; gray matter damage; white matter damage; ventriculomegaly, atrophy, or cerebrospinal fluid space abnormalities; miscellaneous abnormalities not included above.[3] Data were entered into Microsoft Excel and analyzed using SPSS for statistical significance.

Results: Ninety-nine children diagnosed with cerebral palsy were included; the mean age was 5.07 ± 4.38 years, with 58% being males. Spastic CP (84%) was the most common type, with quadriplegia (59.5%) being the predominant motor involvement. Sixty-one (61.4%) of the children had seizures, generalized tonic–clonic seizures (41.4%) being the most common. In the seizure group, the predominant type was spastic CP (82%) with quadriplegia (80.3%). Birth asphyxia contributed as a risk factor in 45.9% of children. Eighteen percent had status epilepticus. Among the nonseizure group, the predominant type was spastic CP (86.8%) with diplegia (36.8%). Isolated neonatal seizures were seen in 3 (7.9%) children. The neuroimaging review showed isolated white matter damage (30%) predominated among nonseizure group while cerebral atrophy (22%) and combined gray and white matter involvement (18.5%) predominated in the seizure group. Five children (18.5%) among the seizure group had a normal magnetic resonance imaging (MRI). The first choice of antiepileptic drug was sodium valproate (45.9%), followed by phenytoin (31.1%). Twenty-four children (39.3%) required more than one antiepileptic drug for seizure control. Seizures remained well controlled in 50% of children and poorly controlled in 18 (29.5%) children. Among the poorly controlled group, the predominant neuroimaging finding was combined involvement of gray and white matter.

Conclusion/Significance: (1) Spastic CP (84%) was the most common type of CP, overall with quadriplegia (59.5%) being the predominant motor involvement. (2) Those with spastic quadriplegia were more likely to have seizure (P = 0.000). (3) Isolated white matter damage (30%) predominated among nonseizure group while cerebral atrophy (22%) and combined gray and white matter involvement (18.5%) predominated in the seizure group. (4) 18.5% among the seizure group had a normal MRI. (5) 29.5% of the children had poorly controlled seizures, with combined involvement of gray and white matter being the predominant radiological finding.


  1. Ford FR. Diseases of the Nervous System in Infancy, Childhood and Adolescence. 2nd ed. Springfield, Illinois, USA, 1944.
  2. Chitra Sankar et al. Cerebral palsy – Definition, classification, etiology and early diagnosis. Indian J Pediatr 2005; 72 (10): 865-868.
  3. Steven J et al. A systematic review of neuroimaging for cerebral palsy. J Child Neurol 2008 23:216.

  Effect of behavior therapy in drooling: A case report Top

Babita Gupta

Medico Pastoral Association, Bengaluru, Karnataka, India. E-mail: babitaa.gupta@gmail.com

Background: Hypersecretion of saliva or impairment of swallowing leads drooling among children, which carries physical and medical complications and social stigma to the family and affects child's mental health in a negative way. Physiotherapy, behavior therapy, pharmacotherapy, and surgery were reported for the treatment of drooling in literature. Several behavior medication techniques such as cueing, positive reinforcement, biofeedback, and punishment and oral motor exercise were used; however, use of aversion therapy was not reported. In this paper, aversion therapy in combination of visual cueing and praising has been examined.

Objective: To see the effect of behavior therapeutic intervention program which includes aversion therapy, visual cueing, and praising techniques on drooling in a child with developmental disorder.

Design: Single case design was used and pre- and post-intervention assessment approach was performed.

Study Sample and Setting: The child belongs to a North Indian nuclear family living southern part of India. Parents were working and belong to upper-middle-class background. The child was 4 years, 6 months old diagnosed with mild developmental disorder based on the Diagnostic and Statistical Manual of Mental Disorders – 4th edition criteria. The child was attending preschool education in a formal school. The study was done in clinical setting.

Methods: Drooling measures rating scale and semi-structured interview with teacher and parents (self-prepared) were used and results of all tests were served as the baseline for the present study. Therapeutic intervention program was structured mainly using aversion therapy (pinching/pain) and visual cueing for creating awareness of drooling and praising child for successfully achieving the task. The therapeutic intervention sessions were held with twice in a week for 40 min duration for 4 months. The sessions were conducted in a playful manner and on the floor of the activity room at Child and Adolescents Health Center, Bengaluru. Subsequently, fortnightly, follow-up sessions were conducted for 6 months. Qualitative analysis was done.

Results: Preassessment results revealed profuse severity level (clothing, hands, and objects become very wet) and frequent drooling (every day but not all the day) in all the setting such as school, at home and playground, while playing with toys and talking with others. The child also showed lack of awareness of saliva control. Postintervention results revealed occasional drooling. It was not every day and there was significant reduction in frequency and quantity of saliva. The child showed mild drooling on severity scale (only lips were wet). Based on the feedback from parents and teacher, it was found that child showed occasional saliva control and child became more socialized with the peer group. The child started wiping affected parts without reminder. They rated drooling in child reduced by 70%–80%.

Conclusion: Behavior therapeutic intervention program which includes aversion therapy, visual cueing, and praising techniques on drooling was found very effective in reducing drooling in developmental disorder. Use of aversion therapy (pinching/inflicting pain) may pose ethical limitations on its widespread use. To make the therapeutic program generalized approach for treatment, the study required to be conducted on larger sample size.

  Dietary intake and undernutrition in preschool children with cerebral palsy: Comparison between high- and low-resource countries Top

KA Benfer1, KA Weir1, 2, 3, KL Bell1, 2, 4, PSW Davies2,4, RS Ware2,5, RN Boyd1

1Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, 2Queensland Children's Medical Research Institute, 3Department Speech Pathology, Royal Children's Hospital, 4Children's Nutrition Research Centre, Queensland Children's Medical Research Institute, The University of Queensland, 5School of Population Health, The University of Queensland, Brisbane, Queensland, Australia.

Background: Undernutrition is common in children with cerebral palsy and is associated with decreased dietary intake based largely on studies in high-resource countries. There has been no direct analysis of how patterns of dietary intake and body composition differ between high- and low-resource countries.

Objective: To determine the energy intake and prevalence of undernutrition in preschool children with cerebral palsy in Bangladesh (BD) compared to Australian children.

Study Design: This was a cross-sectional, comparison study of two cohorts.

Participants and Setting: One hundred and eighty children with cerebral palsy aged between 18 and 36 months, 81 children born in BD (mean = 27.6, 50 males, Gross Motor Function Classification System [GMFCS] I–II = 23.5%, III = 30.9%, IV–V = 45.7%), and 99 children born in Queensland, Australia (AU) (mean = 27.1 months, 65 males, GMFCS I–II = 56.2%, III = 17.7%, IV–V = 26.2%).

Materials and Methods: Parents reported on their child's dietary intake using a 1-day (BD) and 3-day (AU) weighed record. Records were analyzed for energy intake using FoodWorks dietary analysis software. Gross motor skills were classified using the GMFCS.

Statistical Analysis: GMFCS levels were collapsed for analysis (GMFCS I–II, III, IV–V). (i) Mean energy intake between AU and BD samples was compared by GMFCS with t-tests. Linear regression was used to determine differences in energy intake for the two samples based on body weight. (ii) Z-scores for children's weight for age, height for age, weight for height, and body mass index (BMI) for age were calculated using the World Health Organization (WHO) reference data. The proportion of each sample with undernutrition (<−2 standard deviation [SD]) and severe undernutrition (<−3SD) was analyzed by GMFCS. (iii) The association between energy intake and the proportion with undernutrition was analyzed using multinomial logistic regression (STATA v10.0).

Results: (i) Mean energy intake was greater for AU = 4051.0 kJ (standard error [SE] = 108.2) compared to BD = 2219.6 kJ (SE = 111.7) (P < 0.01), even when stratified for GMFCS level: GMFCS I–II-AU = 4288.1, BD = 2292.0 (P < 0.01); GMFCS III-AU = 3941.7, BD = 2382.1, (P<0.01); GMFCS IV–V-AU = 3571.8, BD = 2072.7 (P < 0.01).

Energy intake was consistently higher for the AU sample when adjusted for body weight (P < 0.01); however, the increase in energy intake for every increase in kilogram of body weight was equivalent (P = 0.39) [Figure 1]. (ii) There was a significantly higher proportion of underweight children (AU, n = 6 [6.0%], BD, n = 55 [67.9%]) in the BD sample (P < 0.01). (iii) Energy intake (odds ratio [OR] = 0.9, P < 0.01) and GMFCS level (OR = 1.8, P = 0.01) were significantly associated with underweight status.

Conclusion: Bangladeshi children have on average much lower energy intakes compared to Australian children even when adjusted for body size. Given the significantly higher proportion of children in this sample with undernutrition, we can postulate that these intakes are insufficient to meet basic nutritional needs for healthy growth. Further analysis is needed to understand the impact of various social and economic factors on these patterns and interventions to promote improved nutritional status in low-resource settings.

Level of Evidence: This was a level II study.

Regression: Include mother's BMI to adjust for ethnic differences?

The WHO Global Database on Child Growth and Malnutrition: Z-score cutoff point of <−2SD low weight-for-age, low height-for-age, and low weight-for-height as moderate and severe undernutrition and <−3SD to define severe undernutrition. http://www.who.int/nutgrowthdb/about/introduction/en/index5.html.

  Motor severity in children with cerebral palsy studied in a high-resource and low-resource country Top

Katherine A Benfer1,2, Rachel Jordan1, Robert S Ware4,5, Roslyn N Boyd1

1Queensland Cerebral Palsy and Rehabilitation Research Centre, The School of Medicine, The University of Queensland, 3Queensland Paediatric Rehabilitation Service, Royal Children's Hospital, 4School of Population Health, The University of Queensland, 5Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Queensland, Australia, 2Centre for the Rehabilitation of the Paralysed, Dhaka, Bangladesh.

Objective: To compare the patterns of motor type and gross motor functional severity in preschool-aged children with cerebral palsy (CP) in Bangladesh and Australia.

Methods: Comparison of two prospective studies was performed. Three hundred children with cerebral palsy aged 18–36 months were included, of which 219 Australian children (mean = 26.6 months, 141 males) recruited through tertiary and community services and 81 clinic-attendees born in Bangladesh (mean = 27.5 months, 50 males). All children had diagnosis confirmed by an Australian physician, and birth and developmental history were collected from a physician checklist. All children were classified by the same raters between countries using the Gross Motor Function Classification System (GMFCS) and motor type and distribution.

Results: There were more children from GMFCS I–II in the Australian sample (GMFCS I P < 0.01, III P < 0.01, V P = 0.03). The patterns of motor type also differed significantly with more spasticity and less dyskinetic types in the Australian sample (spasticity P < 0.01, dystonia P < 0.01, athetosis P < 0.01). Birth risk factors were more common in the Bangladesh sample, with risk factors of low Apgar scores (Australia P < 0.01), lethargy/seizures (Australia P = 0.01), and term birth (Bangladesh P = 0.03) associated with poorer gross motor function. Cognitive impairments were significantly more common in the Bangladesh children (P < 0.01), and visual impairments were more common in Australia (P < 0.01).

Conclusions: Patterns of functional severity, motor type, comorbidities, etiology, and environmental risk factors differed markedly between settings. Our results contribute to understanding the patterns of CP in low-resource settings and may assist in optimizing service delivery and prioritizing appropriate early interventions for children with cerebral palsy in these settings.

Level of Evidence: This was a level II study.

  Oropharyngeal dysphagia in preschool children with cerebral palsy: Comparison between high- and low-resource countries Top

KA Benfer1, KA Weir1, 2, 3, KL Bell1, 2, 4, PSW Davies2,4, RS Ware2,5, RN Boyd1

1Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, 2Queensland Children's Medical Research Institute, 3Department Speech Pathology, Royal Children's Hospital, 4Children's Nutrition Research Centre, Queensland Children's Medical Research Institute, The University of Queensland, 5School of Population Health, The University of Queensland, Brisbane, Queensland, Australia.

Background: Feeding difficulties (oropharyngeal dysphagia [OPD]) are common in young children with cerebral palsy (CP) based on studies in high-resource countries. There has been no analysis of how patterns of OPD differ between high- and low-resource countries.

Objective: To determine the prevalence and severity of OPD in preschool children with cerebral palsy in Bangladesh (BD) and how this compares to Australian children.

Study Design: This was a cross-sectional, comparison study of two cohorts.

Participants and Setting: Two hundred and eleven children with cerebral palsy aged between 18 and 36 months, 81 children born in BD (mean age = 27.6 months, 61.7% males), and 130 children born in Queensland, Australia (AU) (mean age = 27.4 months, 62.3% males), were included in the study.

Materials and Methods: OPD prevalence and severity were analyzed using part 2 of the dysphagia disorders survey (DDS) (scored out of 22) rated from video by a speech pathologist. Gross motor skills were classified using the Gross Motor Function Classification System (GMFCS), motor type, and distribution.

Statistical Analysis: Samples were stratified according to ambulatory status for analysis (GMFCS I–II, III, IV–V). Data were analyzed using (i) descriptive statistics (GMFCS, motor type, distribution; prevalence of OPD [adjusted based on validation data]; mean DDS score, SD); (ii) difference in OPD prevalence between BD and AU samples by GMFCS strata using Chi-square test and binomial logistic regression; (iii) difference in OPD severity between BD and AU samples by GMFCS strata using independent t-tests and linear regression (STATA v10.0).

Results: (i) BD sample (%): GMFCS I–II = 23.5, III = 30.9, IV–V = 45.7, motor type: spasticity = 61.3, dyskinetic = 27.5, ataxia/hypotonia = 11.3; OPD prevalence = 66.6; OPD severity = 10.4 (standard error [SE] = 0.9). AU sample (%): GMFCS I–II = 56.2, III = 17.7, IV–V = 26.2, motor type: spasticity = 86.8, dyskinetic = 4.7, ataxia/hypotonia = 7.8; OPD prevalence = 33.3; OPD severity = 7.0 (SE = 0.7). (ii) There was no difference in OPD prevalence between samples: GMFCS I–II-AU = 31.5, BD = 31.6 (P = 0.99); GMFCS III–AU = 69.6, BD = 56.0 (P = 0.33); GMFCS IV–V-AU = 91.2, BD = 91.9 (P = 0.91); OPD prevalence was associated with GMFCS (odds ratio = 4.6, P < 0.01).

(iii) There was no difference in OPD severity (DDS score) between samples: GMFCS I–II-AU = 2.96, BD = 2.88 (P = 0.94); GMFCS III-AU = 6.3, BD = 5.7 (P = 0.73); GMFCS IV–V-AU = 16.4, BD = 16.0 (P = 0.71); OPD severity associated with GMFCS (F = 86.8, P < 0.01).

Conclusion: Despite qualitative differences in the patterns of OPD between the BD and Australian samples, the prevalence (when adjusted for the functional gross motor severity of the samples) was equivalent. Furthermore, the severity (based on the sum of the number of impaired ingestion functions) was also comparable between samples (when adjusted for GMFCS). This study provides support for the robust association between functional motor severity and OPD prevalence/severity in young children with cerebral palsy, regardless of ethnicity and health resourcing.

Level of Evidence: This was a level II study.

Motor Type When Stratified for GMFCS:

OPD Prevalence Overall:

GMFCS I–II between samples: AU = 72.9, BD = 57.9: χ2 = 1.58, P = 0.21.

GMFCS III between samples: AU = 100, BD = 80: χ2 = 5.13, P = 0.02.

GMFCS IV–V between samples: 100% of both samples.

OPD Severity (Based on DDS):

GMFCS I–II between samples: AU = 2.96, BD = 2.88: t = 0.07, P = 0.94.

GMFCS III between samples: AU = 6.32, BD = 5.74: t = 0.35, P = 0.73.

GMFCS IV–V between samples: AU = 16.42, BD = 15.97: t = 0.37, P = 0.71.

Regression for Prevalence: Age, gender, GMFCS, motor type: LR χ2 = 22.27, P < 0.01, only significant for GMFCS (<0.01) and age (<0.01).

Regression for Severity: Age, gender, GMFCS, motor type: F = 86.8, P<0.001, only significant for GMFCS (<0.01) and age (<0.01).

GMFCS I–II: Australian sample on average 1 month older (P = 0.46)

GMFCS III: Australian sample on average 5 months younger (P = 0.002)

GMFCS IV–V: Australian sample on average 2.7 months older (P = 0.55)

Box Plots for DDS Scores by GMFCS: With modified scoring based on my TDC validation results (18–24 months ≥5; 30–36 months ≥3): 33.3% of Australian sample have OPD, 66.6% of BD sample have OPD.

OMD Overall:

GMFCS I–II between samples: AU = 31.5, BD = 31.6: χ2 = 0.000, P = 0.995.

GMFCS III between samples: AU = 69.6, BD = 56.0: χ2 = 0.951, P = 0.332.

GMFCS IV–V between samples: AU = 91.2, BD = 91.9: χ2 = 0.012, P = 0.914.

Pharyngeal Phase (Swob): AU: 62.9, BD: 60.4.

By Texture:

  • Puree – AU: 46% impaired, BD: 70.6% impaired (24:28; 52:55; 93:100)
  • Chewable – AU: 72.6%, BD: 67.1% (58:29; 87:56; 96:94)
  • Fluid – 67.5, 73.75 (58:34; 70:64; 89:100).

  Evaluation of balance in children with cerebral palsy using the balance master: A cross-sectional study Top

Deepa Metgud, Lecrissa H Fernandes

KLEU Institute of Physiotherapy, Belagavi, Karnataka, India. E-mail: lecrissa@gmail.com

Objective: The purpose of this study was to evaluate the balance in children with cerebral palsy using the balance master and pediatric balance scale (PBS).

Design: This study was an observational study. Twenty-two children with cerebral palsy with Gross Motor Function Classification System (GMFCS) Level I and Level II were recruited. The age ranged from 5 to 18 years. They were evaluated for balance using the balance master and PBS, a standard tool.

Results: The children with a higher GMFCS level and less PBS score had poor balance compared to the children with lower GMFCS level and high PBS score. The children with GMFCS Level II performed similar to the children in GMFCS Level I in some components of PBS.

Conclusion: The children with cerebral palsy have balance problems but not necessarily affecting the functional activities of the children.

Key words: Balance, balance master, cerebral palsy, pediatric balance scale

  Does Q-angle change in spastic diplegic children? Top

TU Jimshad, Sanam Mainali, KS Swethankh1, Anil T John

Dayananda Sagar College of Physiotherapy, Bengaluru, 1Specialist Rehabilitation Centre, Manasagangotri, Mysore, Karnataka, India. E-mail: smainali1110@gmail.com

Background: Quadriceps angle provides useful information about the alignment of the knee joint. Any variation in Q-angle, either less or more, can lead to gait abnormality as well as increased susceptibility to injuries. Although numerous studies have been conducted on Q-angle worldwide, relatively few of those studies aimed on Q-angle in pediatric population. In case of children with spastic diplegia, because of abnormal femoral torsion and tibial torsion, there occurs a deviation of Q-angle from its normal range which can be used as a major tool for prognosis during rehabilitation.

Objectives: To find out Q-angle value in male children with spastic diplegia aged between 7 and 12 years and to compare Q-angle changes between children with internal and external tibial torsion.

Study Design: This was an observational, cross-sectional study.

Study Participants and Setting: A total of thirty male children with spastic diplegia and age between 7 and 12 were included in the study. The study was conducted in pediatric rehabilitation centers in Bengaluru and Mysore.

Methods: A total of thirty male children (sixty legs) with spastic diplegia and age between 7 and 12 were included in the study. Sample was collected on the basis of convenience sampling after giving due consideration to inclusion and exclusion criteria. Children were divided into two groups, Group A: 15 children with internal tibial torsion and Group B: 15 children with external tibial torsion. Tibial torsion was measured by assessing thigh-foot angle. Data were collected by measuring Q-angle with the use of standard goniometer. In both groups, Q-angle was assessed with children lying in supine position to maintain homogeneity of the data as some diplegic children were not able to stand without support.

Results: Mean age of Group A was 8.73 and Group B was 8.66 years; mean body mass index of Group A was 17.13 and Group B was 16.8. Remarkable variation in Q-angle was found between Groups A and B. However, no significant difference was noticed between right and left leg of individual children. Spastic diplegic children with internal tibial torsion had decreased Q-angle with a mean of 6.4 on the left side and 6.46 on the right side whereas those with external tibial torsion had increased Q-angle mean of 22.6 on the left side and 22.4 on the right side.

Conclusion: After analyzing results from the current study and support from the past literature, this study concludes that Q-angle is a good outcome variable for assessing musculoskeletal problem related to lower limb in spastic diplegic children. This study also proves that spastic diplegic children with internal tibial torsion have decreased Q-angle and children with external tibial torsion have increased Q-angle.

Key words: Q angle, spastic diplegia, tibial torsion


  1. Bhalara A, Talsaniya D, Nikita, Gandhi N. Q angle in children population aged between 7 to 12 years. Int J Health Sci Res 2013;3:57-64.
  2. Fabry G. Normal and abnormal torsional development of the lower extremities. Acta Orthop Belg 1997;63:229-32.
  3. Nguyen AD, Boling MC, Levine B, Shultz SJ. Relationships between lower extremity alignment and the quadriceps angle. Clin J Sport Med 2009;19:201-6.
  4. Sass P, Hassan G. Lower extremity abnormalities in children. Am Fam Physician 2003;68:461-8.

  Caregivers thinking and opinion about treatment strategy among cerebral palsy children: A descriptive study Top

T Karthikeyan, Moorthy1

NIMHANS University, Bengaluru, Karnataka, India.

E-mail: karthik_77in@yahoo.co.in

Introduction: Cerebral palsy is considered a neurological disorder caused by a nonprogressive brain injury or malformation that occurs while the child's brain is under development. In India, it is 3.8% of the population. Nearly 15%–20% of the total physically disabled children who have cerebral palsy. For India, the estimated report incidence is around 3/1000 live births; however, being a developing country, the expected actual figure may be much higher.

Objectives: The following survey-based study was designed to obtain parental perspectives on key issues related to the perceived quality of educational services and communication with school personnel.

Methods: The 32-item open-ended questionnaire which included combination of Likert scale and narrative responses, which identify the probe parents' perceptions of the various therapeutic interventions and treatment strategy that the student would need to successfully complete his or her school experience, was used.

Participants: The number of participants included in the descriptive study was 11 female and 5 male caregivers of the parents. The participated children ranged in the age from 5 to 21 years. Fifteen (94%) children were South Indians and one child (6%) was North Indian.

Results: Overall, general satisfaction rates with school-based services were quite high. Fifty percent of caregivers reported that they were very satisfied with the provisions of their child's school program. Thirty-one percent of caregivers reported that they were satisfied and 12% reported that they were dissatisfied with the provisions of their child's school program. School nurse services were rated most favorable outcome. Among the participants, 69% of students receiving regular school nurse treatment services, and 91% of caregivers reported that they were satisfied with those acquired treatment services.

Conclusion: The overall estimated survey report stated that the respondents expressed less satisfaction with each of above-mentioned channels of communication than they did with overall treatment services. Caregivers expressed even less confidence in the communication between school and outside healthcare providers and communication among school personnel. In the former area, only one subdiscipline of neurorehabilitation, especially functional rehabilitation (physiotherapy) treatment approach, clinically marked mean ratings in the good accomplishment service provider.

Key words: Ataxic, athetoid, cerebral palsy, rigid and mixed, spastic

  The conceptual underpinnings of dynamical systems approach: Implications for understanding the moderating effects of early intervention Top

Madhavilatha Maganti

Department of Psychology, Ashoka University, Rajiv Gandhi Education Society, Sonepat, Haryana, India.

E-mail: madhavi.maganti@ashoka.edu.in

There are no single effective pushes to the developing system, but rather a combination of influences leads to observable change (Nelson 1996, p. 85). This theoretical review paper will explore how the concepts from dynamical systems approach (DSA) can provide a basis for understanding the mechanisms through which early interventions can operate to generate its effects. The goal is to apply the key concepts of self-organization, multicausality, and nested timescales from DSA. For promoting the emerging social and cognitive competence in at-risk infants and toddlers, it is important to study how subsystems self-organize creating an emerging pattern. Taking intrauterine growth restriction (IUGR) infants as a prototype, some of the neurobehavioral measures such as habituation, infant temperament, attachment, and the parent–child transactions will be reviewed for understanding the interrelationships and reciprocal influences that can have moderating effects on the child's unique characteristics. Developing organisms are embedded within the environmental subsystems interacting at multiple levels. According to Guralnick,[1] the DSA involves integration at three levels: The first is at the level of child development, the second is at the level of child and environmental interactions, and the third is at the level of support available from the environment for optimal family patterns of interaction. Here, we apply these three levels from DSA on a population of IUGR infants to demonstrate the moderating effects of early intervention. Specifically, it is essential to understand how the reciprocal patterns of influence that operate across the three levels of the DSA for normative development constitute causal relationships.[2],[3] IUGR infants are born at term but are born with low birth weight (birth weight <2.2 kg) and are at-risk for developmental delays. Children with potential biological and environmental risk factors show variability in social and cognitive competencies. Resiliency effects in these infants are dependent on an array of developmental resources. The study conducted at the National Institute for the Mentally Handicapped, Secunderabad, involved longitudinal follow-up of IUGR infants from birth to 18 months of age to study the reciprocal influences and causal mechanisms. For purposes of the study, about 150 IUGR infants and their families who gave their consent participated. The infants were recruited from Government Maternity Hospital at Hyderabad and Secunderabad and whose birth weight was between 1.2 and 2.2 kg. These infants were assessed on NNNS, infant temperament, mother–infant interactions, attachment, and Bayley's Scale of Infant Development to assess child characteristics. Other assessments measures such as maternal self-esteem, parental stress, family support, home environment measured the environmental characteristics. The study emphasized the importance of psychosocial intervention for facilitating and promoting the child's development. Intervention was designed to correct the identified deficits after periodical assessment of the child, mother, and family. Major findings of the study revealed the importance of early intervention for enhancing the child's mental development. In conclusion, the study listed the potential risk and protective factors that impede or promote the child's development. The home environment emerged as a significant factor for facilitating the child's development. Despite uncertainties, the study helped to delineate causal relationships between child-, maternal-, and family-related characteristics with considerable confidence. The conceptual foundations from the DSA have longstanding implications in enlarging the scope of understanding atypical patterns of developmental change.


  1. Guralnick MJ. Why early intervention works: A systems perspective. Infants Young Child 2011;24:6-28.
  2. Collins WA, Maccoby EE, Steinberg L, Hetherington EM, Bornstein MH. Contemporary research on parenting. The case for nature and nurture. Am Psychol 2000;55:218-32.
  3. O'Connor TG. Annotation: The 'effects' of parenting reconsidered: findings, challenges, and applications. J Child Psychol Psychiatry 2002;43:555-72.

  Early intervention for improving developmental outcomes in at-risk infants and toddlers Top

Madhavilatha Maganti

Department of Psychology, Ashoka University, Rajiv Gandhi Education Society, Sonepat, Haryana, India.

E-mail: madhavi.maganti@ashoka.edu.in

Empirical evidence from studies assessing the efficacy of early interventions have shown effect sizes averaging 0.50–0.75 standard deviations, indicating the wide range of responsiveness among individual children.[1] In this pre- and post-intervention study, we apply the key concepts from dynamic systems approach to formulate early interventions that can facilitate cognitive processes in at-risk infants and toddlers from 3 to 36 months of age. Further, we wanted to study how children with heterogeneous developmental delays can benefit from early intervention. For this study, the mothers of all babies and toddlers aged between 4 and 33 months who were receiving early intervention services at the National Institute for the Mentally Handicapped in Secunderabad, India, were contacted, provided that the mothers resided within the limits of the twin cities of Secunderabad/Hyderabad and had been educated to at least higher secondary level. These mothers were then asked to sign a form consenting to their inclusion in the study, resulting in the recruitment of 75 participants. Forty-five participants were then randomly allocated to the experimental (enhanced support) group, while thirty participants were allocated to the control (normal support) condition. The “enhanced interaction” and “control” groups matched in terms of both their ages at testing and their etiology, received individualized interventions from their mothers for 4–5 months. Mothers were trained to use the problem-solving intervention model devised for the study. The mental development index (MDI) scores for both “enhanced interaction” (EI) and “control” (C) babies before and after intervention, the changes measured and the rates of change derived from Bayley's Scale of Infant Development showed a steadily improving MDI (54.8 at pretest and 59.9 at posttest) for the EI group, while the C babies showed a small but steady decline (42.1 at pretest and 41.2 at posttest). However, the data also show that the C babies began with MDI scores that were significantly lower than those of the EI group, and it is possible that these initial differences could account for the differences in developmental outcome between the two groups. To investigate this possibility, further, we re-examined the initial MDI scores that were obtained from the EI and C group babies and identified twenty pairs of babies (one EI, one C) who only differed by <1 MDI point at the time of their first test and repeated our analysis on this subsample of “matched pairs.” The outcome measures for the “matched pairs” subsample show striking difference in rate of MDI change over time. To further investigate the relationship between group (EI or C) and other characteristics of the infants (their age, etiology, and birth weight), we carried out an analysis of variance in which rate of MDI change was entered as the dependent variable, and age, etiology, and birth weight were entered as independent variables. The highly significant main effect of group was confirmed once again (F = 13.3; df = 1; P = 0.001). Furthermore, a significant interaction between group and age was found (F = 3.3; df = 2; P < 0.05), indicating that the benefits of early intervention are greatest for the youngest infants.


  1. Guralnick MJ. Why early intervention works: A systems perspective. Infants Young Child 2011;24:6-28.

  Efficacy of dynamic prolonged stretch orthosis in reducing knee flexion contracture in children with cerebral palsy Top

Rajesh Kumar Mohanty, Janmejaya Prasad Nayak, Subhasmita Sahoo, SN Rout

Department of Prosthetics and Orthotics (Training), Swami Vivekanand National Institute of Rehabilitation Training and Research, Cuttack, Odisha, India.

E-mail: rajeshmpo48@gmail.com

Background: Range of motion deficits due to contractures of the lower extremity occur in about the half of the children with spastic cerebral palsy (CP) which can cause joint deformities, deviations in gait pattern and limitations in mobility. Static positioning orthosis recommended for knee flexion contracture is often untolerated and often rejected. Comparative study between static and dynamic orthosis to light their efficacy has not been extensively studied.

Objective: To examine and compare the efficacy and tolerance of dynamic prolong stretch orthosis for knee flexion contracture management in children with spastic cerebral palsy.

Study Design: This was a case study.

Study Participants and Setting: Six cerebral palsy children (mean age 7.2 years, 3 boys) with bilateral or unilateral knee flexion contracture ≥20° participated in this study. Static KAFO without knee joint and dynamic articulated KAFO with dial lock knee were fabricated in standard workshop setting at Swami Vivekanand National Institute of Rehabilitation Training and Research.

Methods: The clinical trial was randomized for ten legs (five static, five dynamic) and comparison was made between two orthotic variants. Children continued to wear the orthosis throughout the night according to the protocols described. Children were accessed for goniometric measurement of knee extension, popliteal angle, hamstring spasticity level, and orthosis tolerance in successive follow-up appointments. For consistency of results, same researcher took the measurement.

Results: Dynamic orthosis was found to be more effective in reducing knee flexion contracture at 3 months (12.3 vs. 3.5) and at 6 months (15.6 vs. 4.3). There were improvements in passive range of motion (ROM) for all ten hamstring muscles. Significant improvement in hamstring spasticity and tolerance (75% good or very good with dynamic vs. 25% with static) was observed. Moreover, by reducing flexion contracture, standing balance and weight bearing were possible with walker or other mobility devices.

Conclusion: In children with cerebral palsy, 6 months of treatment with dynamic prolong stretch orthoses can improve passive ROM, hamstring spasticity, and tolerance while reducing knee flexion contracture. Dynamic orthosis is superior to static and should be used as a frontline of conservative management for knee flexion contracture in children with cerebral palsy.

Key words: Cerebral palsy, contracture, dynamic, knee, orthosis, static


  1. Farmer SE, James M. Contractures in orthopaedic and neurological conditions: a review of causes and treatment. Disabil Rehabil 2001;23:549-58.
  2. Anderson JP, Snow B, Dorey FJ, Kabo JM. Efficacy of soft splints in reducing severe knee-flexion contractures. Dev Med Child Neurol 1988;30:502-8.
  3. Steffen TM, Mollinger LA. Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents. Phys Ther 1995;75:886-95.
  4. Charlton P, Ferguson D, Peacock C, Stallard J. Preliminary clinical experience of a contracture correction device. Prosthet Orthot Int 1999;23:163-8.
  5. Light KE, Nuzik S, Personius W, Barstrom A. Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures. Phys Ther 1984;64:330-3.
  6. Flowers KR, LaStayo P. Effect of total end range time on improving passive range of motion. J Hand Ther 1994;7:150-7.

  Effect of random and blocked practice schedules on motor learning in children Top

Parab Shrutika, Bose Meruna

Department of Physiotherapy, MGM Institute's University,

Navi Mumbai, Maharashtra, India.

Background/Objective: Variability of practice schedules and its effect on motor learning has been an area of research interest for long. However, findings of studies on random and blocked practice effectiveness are few and results are inconsistent in children. This creates a challenge for practitioners who want to create an optimal learning environment for the child. In our study, we selected traditional game of single leg hopping as multi-joint task with three patterns of increasing complexity with an objective to study effect of random and blocked practice schedules on motor learning in children by determining if there is a change in response time and number of errors post 24 h and 7 days delay in both practice schedules.

Design: This was a randomized crossover study.

Participants and Settings: One hundred and twenty school children between 6 and 12 years of age were selected by random sampling from schools of varied administrative settings after acquiring ethical approval and consent from authoritative bodies. They were allocated to random practice and blocked practice group equally through lottery method. All participants were pre-tested to ensure that they are novice considering more than three errors on test pattern as inclusion criteria.

Materials and Methods: Single leg hopping in a pattern was used as a task. The task involved hopping in seven squares of 15 inch × 15 inch drawn on the floor in a fixed pattern. Each participant completed total 72 trials (set of 12 trials) in each of three practice patterns (Block A, Block B, Block C) of increasing complexity. Errors were counted on losing balance, landing outside margins of the square, hopping in the same square twice. Time and number of errors were documented at baseline, post 1 h, post 24 h, and post 7 days as acquisition and retention trials respectively. Each child underwent transfer test on the 7th day after acquisition to assess adaptability to task trained. Transfer test was administered as the same task with complex pattern having 14 square boxes of 12 inch × 12 inch. Number of errors was measured and response time was noted. For transfer test, three trials were administered to each child.

Results: Analysis was done using repeated measures ANOVA with Greenhouse–Geisser correction resulting in blocked practice group outperforming the random practice group in all three blocks of increasing complexity (P < 0.01). Transfer test demonstrates better performance of blocked practice group (P < 0.05) in errors as measure of outcome, time variable shows better performance of blocked group, but difference is not significant (P >0.05).

Conclusion: This study concludes that children in age group of 6–12 years benefited and motor task learning was enhanced by blocked practice schedule in a complex, multi-joint motor task when applied to a field setting like one legged hopping selected in this study as they were able to plan and apply strategies better than random practice group.

Level of Evidence: This was level II study.

  Free Paper Presentation In IACPCON 2016: Comorbidities and their relationship to subtype of cerebral palsy in a tertiary care hospital in South India Top

Raghavendraswami Amoghimath, KN Vykuntaraju, Asha Benakappa

Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India.

E-mail: drknvraju08@gmail.com

Introduction: Early-onset objective signs of motor impairment that is both cerebral in origin and the product of a nonprogressive lesion to the developing central nervous system are essential in defining cerebral palsy (CP).[1] Comorbid conditions such as intellectual disability, visual disability, and epilepsy are associated with CP.[2] For many children with cerebral palsy, it is these co-occurring conditions that may often have the greatest impact on the child and family from varying perspective.[3]

Aim: The present study aims to provide data on the frequency and type of comorbidities in children with cerebral palsy.

Study Design: This was a retrospective, observational study.

Methods: Two hundred consecutive children with cerebral palsy attending neurology outpatient department with age group from 3 months to 18 years were enrolled. Information on neurologic subtype classified according to the topographic distribution of the motor impairment on neurologic examination and the presence of comorbidities – cortical visual impairment, hearing impairment, feeding problems, and coexisting afebrile seizures – was obtained. Demographic factor, type of comorbidities, and type of cerebral palsy were noted.

Results: The mean age of children was 55 months (range, 3–180 months), with 120 boys and 80 girls. Intellectual disability was seen in 91% (182/200), and spastic diplegic cerebral palsy children had less chance of having intellectual disability (2/7). Active afebrile seizure disorder in 40% (80/200), severe auditory impairment in 3.5% (7/200), and cortical visual impairment in 19.5% (39/200) were noted. Comorbidities were most frequent in children with spastic and dyskinetic cerebral palsy. The most common type of seizures was focal seizures in 68%, followed by GTCS in 18%, and the remaining 14% had West syndrome.

Conclusion: Intellectual disability and seizures are more frequently associated comorbidities with cerebral palsy. Bilateral spastic and dyskinetic CP are more likely to be associated with comorbidities, whereas unilateral CP is less commonly associated with comorbid illness.


  1. Kuban KC, Leviton A. Cerebral palsy. N Engl J Med 1994;330:188-95.
  2. Pruitt DW, Tsai T. Common medical comorbidities associated with cerebral palsy. Phys Med Rehabil Clin N Am 2009;20:453-67.
  3. Shevell MI, Dagenais L, Hall N; REPACQ Consortium. Comorbidities in cerebral palsy and their relationship to neurologic subtype and GMFCS level. Neurology 2009;72:2090-6.

  Impact of physical functioning on participation and health-related quality of life of adolescents and adults with cerebral palsy Top

Saumen Gupta, Kavitha Raja1, Asha Kamath2

Sikkim Manipal College of Physiotherapy, Sikkim Manipal University, Gangtok, Sikkim, 1JSS College of Physiotherapy, Mysore, Department of Community Medicine, Kasturba Medical College, Manipal, Karnataka, India.

Background/Objectives: With the increase in life expectancy and individuals with cerebral palsy (CP) progressing toward adolescence and adulthood (Aysha Association for Woman and Child Protection [AAWCP]), the focus of management has shifted toward improvement in participation and health-related quality of life (HRQOL) which largely reflects independent living.[1] Physical functioning (PF) which is vastly dictated by underlying international classification of functioning (ICF) constructs of body structure, body function, and activity have been reported to affect participation and HRQOL.[2],[3] PF profiling along with contextual factors gives a broader view of modifiable and nonmodifiable factors influencing participation and HRQOL. Hence, country-specific data are required for planning interventions where literature is notable in their absence. Therefore, the objective of this study is to explore the influence of domains of PF on participation and HRQOL and the direction of contribution.

Study Design: This was a cross-sectional study.

Study Participants and Settings: Two hundred and twenty-six participants with cerebral palsy who were above 13 years of age, able to comprehend and respond verbally, or by pointing were recruited through convenience sampling from nongovernment organization (NGO), health association, and private clinics. Sampling was conducted from 14 states of the country. AAWCP was examined at the NGO and or in their homes.

Materials and Methods: Following the consent, participants were examined using robust outcome measures representing different domains of ICF using validated protocols. Scales were administered to the participants through interview method. Least exertive tests such as passive measurements were interspersed with active testing including energy consumption while walking indoors and outdoors. Gait was recorded using Edinburgh Visual Gait Score for those participants who were able to walk. Socioeconomic status, level of education and parents QOL were recorded. Structural equation modeling (SEM) was conducted to determine the contribution of PF to participation and HRQOL.

Results: The mean age for males was 19.41 years (standard deviation [SD] = 4.32 years) and for females was 20.41 (SD = 7.07 years). Majority of the participants with cerebral palsy belonged to Gross Motor Function Classification System III group. In this SEM model, Chi-square for Model I (total population) was 26.2 (21), P = 0.20 and Model II (ambulatory CP) was 43.881 (38), P = 0.236, which states that the data fit well. Participation was influenced by body alignment, strength, hamstring spasticity, fatigue, and gross motor functioning directly. HRQOL was influenced by participation, hamstring spasticity, gross motor functioning, and pain and directly and indirectly influence HRQOL through mediated effects of strength, alignment, and fatigue.

Conclusions/Significance: SEM has highlighted strength and activity capacity as factors which shape participation and HRQOL. Participation in AAWCP in both the models strongly depended on fatigue and activity capacity, while, in ambulatory CP, additional indicators of PF, i.e., energy efficiency and strength emerged as important factors determining the difficulty experienced in participation. Strengthening was a factor which we believe would improve participation. Several modifiable factors such as spasticity, mobility, and strength have shown to have impact on HRQOL, whereas nonmodifiable factors such as financial constraints, physical accessibility, education, and family support may also play an important part in the participation and HRQOL of AAWCP.

Level of Evidence: This was a level III study.


  1. Bottos M, Feliciangeli A, Sciuto L, Gericke C, Vianello A. Functional status of adults with cerebral palsy and implications for treatment of children. Dev Med Child Neurol 2001;43:516-28.
  2. McConachie H, Colver AF, Forsyth RJ, Jarvis SN, Parkinson KN. Participation of disabled children: how should it be characterised and measured? Disabil Rehabil 2006;28:1157-64.
  3. Painter P. Physical functioning in end-stage renal disease patients: update 2005. Hemodial Int 2005;9:218-35.

  Relationship between lower extremity muscle strength and balance performance in children aged 6–10 years Top

Snehal Dharmayat, Kashmira Gupte, Amogh Kulkarni, Melissa Luis

KLEU Institute of Physiotherapy, Belagavi, Karnataka, India.

Background: Children seem to be at greater risk of sustaining falls and sports-related injuries than healthy young adults because their neuromuscular system is not fully developed and many motor skills are still emerging. In fact, lower performance levels in balance and muscular strength have been observed in children compared to young healthy adults. Knowledge about balance and muscular strength status may be important for identification of children with an increased fall and injury risk and development of fall and injury preventive measures.

Objective: The purpose of the study was to determine the relationship between lower limb muscle strength and balance in typically developing children in the age group of 6–10 years. Furthermore, we intended to study the influence of age, gender, and body mass index on lower limb muscle strength and balance.

Methodology: One hundred and fifty children (75 males and 75 females) were randomly included in the study. Demographic data (name, age, gender) of the children were taken. Balance was assessed using Pediatric Berg Balance Scale (PBBS) and Community Balance and Mobility Scale (CB and MS), followed by Muscle strength assessment by a hand-held dynamometer. Best score out of three trials score was noted.

Results: There was a significant relationship between lower limb muscle strength and balance scores on PBBS scores - hip flexors (0.0026), extensors (0.0066), abductors (0.0021), adductors (0.0047), and knee extensors (0.0397). There was also significant relation between muscle strength of hip extensors (0.0236), external rotators (0.0255), abductors (0.0032), adductors (0.0092), knee flexors (0.0303), extensors (0.0338), ankle dorsi flexors (0.0216), invertors (0.0500), and evertors (0.0041) with CB and MS scores.

Conclusion: Muscle strength is related to balance as children having less strength performed poor on PBBS and CB and MS. Balance is also influenced by gender where females performed better.

Key words: Balance, Community Balance and Mobility Scale, hand-held dynamometer, Lower limb muscle strength, Pediatric Berg Balance Scale, typically developing children

  Assessment of autonomic functions in individuals with cerebral palsy Top

Sowmya Panju, BL Preethi, G Jaisri

Department of Physiology, MS Ramaiah Medical College, Bengaluru, Karnataka, India.

Background and Objective: Cerebral palsy (CP) is a group of nonprogressive, but often changing, motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages of its development.[1] It is frequently a combination of both motor and sensory involvement.[2] There are many studies to prove this, but very few studies have been done to assess the autonomic nervous system in CP, especially in children. Hence, the objective of our study is to assess and compare the functions of autonomic nervous system between the children with cerebral palsy and normal children using heart rate variability (HRV).

Materials and Methods: Fourteen age- and sex-matched children with cerebral palsy and normal children were recruited for the study. The nutritional status of both the group was assessed using various anthropometric measurements. Autonomic function was assessed using HRV.[3],[4] HRV in supine position was recorded in Lead II, under quiet, calm conditions. Time-domain parameters such as SDNN, RMSSD, pNN50, and NN50 and frequency-domain parameters such as absolute low frequency (LF), absolute high frequency (HF), LF normalized unit, HF normalized unit, LF/HF ratio, and total power were analyzed. Mann–Whitney U-test was used to compare the difference in HRV values in children with cerebral palsy and normal children. Independent sample t-test was used to determine the quantitative variables. The level of significance was fixed at P < 0.05.

Results: Independent sample t-test was employed for all the quantitative variables, expressed in mean ± standard deviation. The anthropometric values of children with cerebral palsy and normal children were comparable with no statistical difference. There was no statistically significant difference in any of the HRV parameters. However, a trend toward reduction was seen in normalized LF and LF/high risk ratio in children though not statistically significant.

Conclusion: There was no significant difference in HRV parameters between children with cerebral palsy and normal children, indicating a normal sympathovagal balance. In addition, there was no significant difference in the anthropometric measurements among children with cerebral palsy and normal children, indicating a normal nutritional status in cerebral palsy children. The calm, relaxed conditions during our recording and similar nutritional status could have contributed to the significantly same HRV findings of among the children with cerebral palsy and normal children.


  1. Mutch L, Alberman E, Hagberg B, Kodama K, Perat MV. Cerebral palsy epidemiology: where are we now and where are we going? Dev Med Child Neurol 1992;34:547-51.
  2. Bass N. Cerebral palsy and neurodegenerative disease. Curr Opin Pediatr 1999;11:504-7.
  3. Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J 1996;17:354-81.
  4. Park ES, Park CI, Cho SR, Lee JW, Kim EJ. Assessment of autonomic nervous system with analysis of heart rate variability in children with spastic cerebral palsy. Yonsei Med J 2002;43:65-72.

  Free Paper Presentation In IACPCON 2016: Pattern of seizures in children with cerebral palsy in a tertiary care hospital in South India Top

Sushma Veeranna Sajjan, KN Vykuntaraju, Asha Benakappa

Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India.

E-mail: drknvraju08@gmail.com

Introduction: Cerebral palsy (CP) is frequently encountered in neurology practice and is the most common cause of physical disability in childhood. Seizures are frequently associated in children with cerebral palsy, and almost all types of seizures can be seen in children with cerebral palsy. Diagnosis of seizures in children with cerebral palsy presents with difficulties. In addition, seizures are more severe and often require polytherapy.

Aim: The present study aims to provide data on the frequency and type of seizures in children with cerebral palsy.

Methods: This is a retrospective study of children attending neurology outpatient department with the age group from 3 months to 18 years. Two hundred consecutive children with cerebral palsy were enrolled in the study and the occurrence, type of seizures, and type of CP were noted. Furthermore, demographic factors such as age and sex were analyzed.

Results: A total of 200 children were analyzed, of which 132 (66%) children were boys and 68 (34%) were girls. Out of 200 children, 155 (77.5%) had bilateral spastic CP, 23 (11.5%) had hemiplegic CP, 16 (8%) had dyskinetic CP, and 6 (3%) had mixed CP. Seizures were present in 96 (48%) children with cerebral palsy, of which 58 (60.4%) were male and 38 (39.6%) were female. Seizures were present in 46.5 % of children with bilateral spastic cerebral palsy, 65.2% of children with hemiplegic cerebral palsy, 31.25% of children with dyskinetic cerebral palsy, and 66.4% of children with mixed cerebral palsy. The most common type of seizures was focal seizures 38.5% (37/96), followed by mixed seizure type 33.3% (32/96) and generalized seizures 28% (27/96). About one-fourth of the kids with seizures had infantile spasms and most of children with infantile spasms presented around 5–7 months of age.

Conclusion: Seizures are frequently seen in children with cerebral palsy. In our study, 48% (96/200) of children with cerebral palsy had seizures. Seizures are frequently seen in children with mixed cerebral palsy, followed by hemiplegic CP. The most common seizures associated are focal seizures and infantile spasms.

  Gross motor function in preschool children with cerebral palsy: Comparison between a high- and low-resource country – Is a GMFCS Level IIIa III? Top

Katherine A Benfer, Rachel Jordan, Sasaka Bandaranayake, Christine Finn, Robert S Ware, Roslyn N Boyd

Background/Objectives: Gross Motor Function Classification System (GMFCS) levels are the international language to guide surveillance and clinical management of children with cerebral palsy (CP). The aim of this study was to compare the Gross Motor Function Measure (GMFM-66) in preschool age children in high- and low-resource countries Bangladesh and Australia with cerebral palsy according to GMFCS.

Study Design: Comparison of two cross-sectional studies is the design of the study.

Study Participants and Setting: Two hundred and seventy-eight children with cerebral palsy aged 30–48 months were assessed at tertiary or rehabilitation centers: 237 children born in Queensland or Victoria, Australia (mean age = 33 months, 150 males [63%], GMFCS I = 114 [48%], II = 27 [11%], III = 35 [15%], IV = 31 [13%], V = 32 [13%], unilateral spasticity = 75, bilateral spasticity = 129, dyskinesia = 11, hypotonia/ataxia = 22), and 41 clinic-attendees born in Bangladesh (mean age = 40 months, n = 26 males [63%], GMFCS I = 4 [9%], II = 6 [15%], III = 9 [22%], IV = 8 [20%], V = 14 [34%], unilateral spasticity = 2, bilateral spasticity = 21, dyskinesia = 11, hypotonia/ataxia = 7).

Materials and Methods: Diagnosis of CP and motor type was confirmed by a physician across both cohorts. Children's motor ability was measured using the GMFM-66 and classified for GMFCS and motor type by the same two independent raters through video analysis across both cohorts. Children's GMFM-66 scores were converted to age- and GMFCS-normed percentile scores and compared using linear regression (adjusted for age, GMFCS, and motor type). Domain scores from GMFM-88 were analyzed using age- and gender-matched children from Australia to the Bangladesh sample.

Results: Mean total GMFM-66 scores for each sample were lower in Bangladesh (38.4, standard deviation [SD] = 15.7) compared to Australia (50.5, SD = 15.5). Children's scores in Bangladesh remained significantly lower when converted to percentiles and compared accounting for GMFCS motor type and age (11 percentile units, P = 0.025). The differences were significantly lower for children classified GMFCS Level III (26.9 percentile units lower, P = 0.005) and GMFCS IV–V (14.2 percentile units lower, P = 0.024). GMFCS I and II were not significantly different. The Australian sample was reflective of the normative data from the original Ontario motor study.

Conclusions/Significance: Children from Bangladesh have lower gross motor capacity when compared to Australian children of equivalent age and motor performance. Further studies are required to establish possible differences in motor growth curves in populations of children with cerebral palsy in low-resource settings. Use of GMFCS is helpful in optimizing service delivery and prioritizing appropriate early interventions for children with cerebral palsy in these settings; however, motor performance varies.

Level of Evidence: This was a level II study.

  Effects of inhibition of retained symmetric tonic neck response: A case study in a patient with cerebral palsy spastic diplegia Top

Objective: To assess quantitatively the effects of reflex inhibiting positions for retained symmetric tonic neck response (STNR) in a child with spastic diplegia due to cerebral palsy.

Methods: The patient underwent 30 min of reflex inhibiting positions along with 30 min of regular physical therapy such as stretching, strengthening, and gait training. Gross Motor Functional Measure and Barthel Index were collected before (pre) and after 6 months of treatment (post).

Results: After the intervention, the child shows improvement in overall gross motor function such as sitting, crawling, kneeling, and walking with support of orthosis. Improvements appeared in spasticity grading, at the ranges of motion in shoulder, elbow, hip, and knee joints.

Conclusion: Reflex inhibiting positions for retained STNR helps his/her on facilitating Gross and Fine Motor Function. Further investigations are certainly needed to assess effectively the effects of the intervention in larger sample.

  iGest –Physiotherapy Top

Kalvina Rajendran1, Pradeep T1, Anil Prabhakar1,2

1Enability Foundation for Rehabilitation, 2Department of Electrical Engineering, Indian Institute of Technology Madras, Chennai, Tamil Nadu, India.

Introduction to Therapy:

  • Therapy helps persons with cerebral palsy, autism, MD, and MR
  • Consistency improves outcomes
  • Inconsistency leads to complicated muscle textures
  • Besides all, the therapists also face communicational and motivational issues in training the children.


  • Develop a device that monitors compliance
  • Create exercises with iGest that motivates children
  • Develop assessment tools to aid therapists
  • Solve issues encountered during therapy sessions.

Targeted Results:

  • Exercises are recorded by iGest on a tablet/mobile
  • Assessment is done by the therapists
  • Evaluated as perfect/improvements needed
  • Diagnosis is done only by the therapists
  • iGest aids the therapists in diagnosing and monitoring.


  • Wearable motion sensor device that recognizes gestures
  • Inertial measurement unit-9 axis sensors
  • Accelerometers, gyroscopes, magnetometers; three each
  • iGest connects to mobile app through Bluetooth
  • Wristband can be redesigned (size and position independent).


  • Positioning
  • Strengthening
  • Gait analysis.


We would like to acknowledge Mr. Jayavel, AT Lab, IITM; MSME; Students from Vidya Sagar; Incubation cell, IITM Research Park; and Therapists from Vidya Sagar and SPASTN.

  Effect of therapist designed pediatric Dry Needling, IASTM, RehabSuit Therapy, Taping protocol on gross motor function of spastic children with cerebral palsy Top

Objectives: Cerebral palsy is a condition where nonprogressive disorders of posture caused by abnormal development of, or damage to, motor control centers of the brain resulting in abnormal movements. Improving gross motor function in children with cerebral palsy has been a major aim of physical therapist. The purpose of this study is to find out the effect of therapist designed pediatric Dry Needling, Pediatric Instrument Assisted Soft Tissue Mobilization (IASTM), RehabSuit Therapy and Taping (DIRT) Protocol on Gross Motor Function of spastic children with cerebral palsy.

Materials and Methods: A comparative study was conducted to find out the Effect of Therapist Designed Pediatric DIRT Protocol on Gross Motor Function Compared to Traditional Physical Therapy on Gross Motor Function in spastic children with cerebral palsy. Ten spastic children with cerebral palsy were selected for this intervention. Age group between 4 and 8 years With Gross Motor Function Classification System Level III–IV were selected for this study. These children were equally distributed in each group.

Intervention: Therapy lasted for 8 weeks (5 days a week and 2 h/day). Group A – five children were subjected to Therapist Designed Pediatric DIRT Protocol. Group B – five children were subjected to traditional physical therapy. Gross Motor Function Measure was used to assess gross motor abilities of the children before and after intervention.

Results: The result showed significant improvement Therapist Designed Pediatric DIRT Protocol than traditional physical therapy on Gross Motor Function Measure.

Conclusions: Therapist Designed Pediatric DIRT Protocol is more effective and beneficial therapy than traditional physical therapy in improving Gross Motor Function in spastic children with cerebral palsy.

  Motor skills in children with profound hearing impairment aged 6–10 years Top

Komal Agrawal, Divya Mohan, S Karthik Babu

Background: Children with hearing impairment have balance and motor deficits primarily due to concomitant damage to the vestibular structure.

Aim: The aim of the study was to examine the motor skills in children with hearing impairment.

Methods: Fifteen children with hearing impairment aged 6–10 years (mean age = 7.3 years and male:female = 2:3) were assessed for their motor skills by Test of Gross Motor Development-2 (TGMD-2) and were compared with 15 typically developing children in the same age group (mean age = 8 years and male:female = 1:1). Comparison of raw scores of the two groups on the locomotor and object control subsets of TGMD-2 will be done by independent t-test.

Results: According to descriptive ratings of TGMD-2 scale, only 6.67% children with hearing impairment showed above average performance on locomotor and object control subsets of TGMD-2, which was demonstrated by 40% typically developing children. It is an ongoing trial where more number of children will be recruited in typically developing group in a period of 1 month, following which statistical analysis to compare the two groups shall be done.

  A semi-structured interview with caregivers of children with cerebral palsy: Implications for understanding the International Classification of Functioning, Disability, and Health-Children and Youth components Top

Madhavilatha Maganti, Anjan Bhattacharya1

Department of Psychology, Ashoka University, Rajiv Gandhi Education Society, Sonepat, Haryana, 1Child Development Center, Apollo Gleneagles Hosptial, Kolkata, West Bengal, India.

The International Classification of Functioning, Disability, and Health - Children and Youth (ICF-CY) with its components of body structure and body functions, activity and participation, and contextual factors has the potential to broadly describe the health status of children with cerebral palsy and meaningful aspects of the child's functioning. To this end, ICF core sets are useful standards for research, clinical practice and teaching. The comprehensiveness of the five components of the ICF-CY to capture aspects of growth and development of children at different stages of life and with different health conditions promises to advance the health, development and well-being of children and youth through practices, policy, and research. Of these five components, the component of participation is identified as the overall outcome of greatest importance to children and their families. However, there has been paucity of appropriate measures of this dimension due to lack of conceptual clarity. The ICF defines participation as “a person's involvement in a life situation.”[1] According to Coster and Khetani,[2] the definition does not specify if the measures of participation should focus on objective indicators, subjective experience or both? Therefore, it is essential to clarify the role of the child, the family, and the environmental factors to conceptualize the components of participation. To refine our understanding of these factors, we wanted to analyze caregivers' perspective to better understand the proximal and distal components of participation. Thus, we prepared questions for conducting a semi-structured interview with parents of children with cerebral palsy that were not included in the ICF-CY core sets. For the purpose of the study, we prepared a set of 56 open-ended questions in English, categorized as eleven broad areas namely, general questions, interacting with objects/people, music and hobbies, likes and dislikes, attention span, language, temperament and attachment, sensory functions, attitudes and perceptions, socialization and technology in daily life. We hypothesized that exploring the interactive relationship between the child and the contextual factors from caregivers' narratives can bring unique perspectives in understanding the component of participation. The children comprised three caregivers and their children with cerebral palsy aged 4, 6, and 13 years. The children were recruited from the National Institute for the Mentally Handicapped, New Delhi. The three semi-structured interviews were audio-taped and then transcribed for qualitative analysis. From the three transcribed interviews, caregivers clearly pointed to the child's functional abilities and barriers restricting the child's participation and engagement in family activities. Further, the opportunities and constraints available to the family are important determinants for understanding the dimension of participation. For instance, the family's resources, parental stress, perceptions of parents about their child's abilities, or limitations determined the environmental opportunities were made available to the child. The resiliency to function at optimal levels of functioning can be determined from the risk and protective factors in the child. The caregivers' narratives are integral to highlight the importance of exploring the multidimensional aspects involved in conceptualizing participation. The classifications of the ICF-CY aim to provide building blocks for researchers who wish to create theories of disability.[1],[3] Many different applications of using ICF have found their way in disability rehabilitation.


  1. World Health Organization. International Classification of Functioning, Disability and Health. Geneva, Switzerland: WHO; 2001.
  2. Coster W, Khetani MA. Measuring participation of children with disabilities: issues and challenges. Disabil Rehabil 2008;30:639-48.
  3. World Health Organization. International Classification of Functioning, Disability, and Health: Children & Youth Version: ICF-CY. World Health Organization; 2007.

  ”Identification of Developmental Disabilities and Early Action:” A training module Top

G Shashikala, Meenakshi Girish

Introduction: In the absence of a structured curriculum dedicated to developmental disabilities (DD) at undergraduate and postgraduate levels in our country, expertise for diagnosis and intervention in DD is different at different levels of health care delivery. Everybody cannot be a DD specialist and every child cannot reach a DD specialist. A typical scenario is a child taken to a generalist by the parents with concerns about development. The generalist does not have any clue how to clinically approach such a case, ends up either referring the child to another doctor or communicates to parents that the disease is incurable. The child is either left neglected at home or continues visiting doctors while affecting with consequences of delayed intervention. Early intervention at the age of 3 months is the most exciting development in the global scenario. Use of GMs and HINE are revolutionizing the outcome of children with DD, but the sad truth is that in large part of our country, Neonatal Intensive Care Unit graduates do not come back for follow-up and even if they do, the family has neither the time nor money to afford a team of specialists. Identification of Developmental Disabilities and Early Action (IDDEA) targets generalists and general pediatricians who are usually the first doctors approached by parents. It shifts focus from cause to impact and has been designed with the basic premise that “diagnosis alone does not predict service needs or functional outcome.” It also lays emphasis on the dictum that precise communication should be empowering not despairing.

Study Design: This was a teaching and training module.

Pilot Workshop Results: Only short-term impact of the training module was measured in the form of feedback analysis and pretest-posttest knowledge gap analysis; the results are presented below.

Participants: Thirty-nine MBBS doctors working in public health centers in rural India.

Feedback Analysis: Practical utility of content: 33/39 (84.61%). (i) Hands on training quality: Excellent 23/39 (58.97%). (ii) Felt need for similar training: 39/39 (100%).

Conclusion: The IDDEA was well received by the participants, for whom it was designed. It serves to empower the middle level of health care providers (general pediatricians and generalists) in a three-tier model of health-care delivery with DD specialists at the top and the health care workers at the bottom. It thus helps to cast the net wider so as to train all the stakeholders in the system of health care delivery, thus maintaining a continuum of care for children with DD.

  Barriers for childhood disability care-pilot survey Top

G Shashikala, Premalatha1, Gayathri1, R Senthil Amudhan2, Maria Levin3, Minakshi Girish4

IACP, 1Bangalore Medical College and Research Institute, 2National Institute of Mental Health and Neurosciences,

3St. John's Medical College, Bengaluru, Karnataka, 4NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India.

Background and Objective(s): Early diagnosis with a multidisciplinary approach is the key for effective management of childhood developmental disorders. However, most of the available guidelines for early diagnosis are from the developed countries which are either difficult to implement/inappropriate to the resource-limited middle-income countries such as India. A multicenter pilot survey was undertaken to understand the physician barriers for early childhood disability care to provide evidence for developing early diagnosis guidelines for childhood developmental disability in India.

Study Design: This was a descriptive study.

Study Participants and Setting: Participants were pediatricians, general practitioners, and medical officers providing child health services. This pilot survey was carried out on a representative sample from public and private sector at three sites in India (Nagpur, Bengaluru and Kolar).

Level of Evidence: This was a Level IV study.

Materials and Methods: Participants were given a self-administered questionnaire - Barriers for Childhood Disability Care Provider version, developed and validated by our interdisciplinary research team. The questionnaire was administered through direct contact, mail and email. The questionnaire had six parts – clinic social details, screening barriers, management barriers, referral barriers, early intervention practice knowledge and needs, and support issues. Descriptive statistics and qualitative analysis were performed. For qualitative analysis, the authors get familiarized with the content and themes (derived from objectives of the study) by reading the qualitative data repeatedly. An attempt was made to present the data semi-quantitatively.

Results: There were 81 respondents with 48 having postgraduation in pediatrics. Nearly one-third had 5–10 years of experience, and another one-third had >10 years of experience in clinical practice. Majority of the respondents were from private practice (49/81) and from urban area (77/81) (reflective of real situation in India). None of them had any special training in childhood disabilities and most of them encounter (44/81) at least one case of developmental disorder per week. Cerebral palsy was the most common developmental disorder encountered by them (80/81). Nearly one-third of them lacked confidence in identifying developmental disabilities. Nonavailability of simple standardized screening tool was perceived as the major barrier for early diagnosis of childhood disabilities in routine practice. Even most of the pediatricians were not confident in communicating with the caregivers after diagnosis, and one of the major barriers in management of a child with developmental disability was denial of child's condition by the caregivers. Major barriers identified in early referral were accessibility to other professionals for team management and affordability by parents. To improve early diagnosis and intervention, most of them preferred workshops and regular continuing medical education's for training in childhood disability and all of them had a positive response to adopt a low-cost, culturally appropriate clinic-based model in their setting.

Conclusions/Significance: The pilot survey highlights the major barriers and needs of early childhood disability care. Addressing issues emerged from this study will enable us to develop a comprehensive, evidence-driven, care-oriented, and need-based clinical practice guidelines for early diagnosis and intervention.


  1. Sand N, Silverstein M, Glascoe FP, Gupta VB, Tonniges TP, O'Connor KG. Pediatricians' reported practices regarding developmental screening: do guidelines work? Do they help? Pediatrics 2005;116:174-9.
  2. Palfrey JS, Singer JD, Walker DK, Butler JA. Early identification of children's special needs: a study in five metropolitan communities. J Pediatr 1987;111:651-9.
  3. Varghese J, Grills N, Mathias K. Barriers in health care access faced by children with intellectual disabilities living in rural Uttar Pradesh. J Soc Incl 2015;6.
  4. Ertem IO, Pekcici EB, Gok CG, Ozbas S, Ozcebe H, Beyazova U. Addressing early childhood development in primary health care: experience from a middle-income country. J Dev Behav Pediatr 2009;30:319-26.
  5. Campbell FA, Ramey CT, Pungello E, Sparling J, Miller-Johnson S. Early childhood education: Young adult outcomes from the Abecedarian Project. Appl Dev Sci 2002;6:42-57.
  6. Desai PP, Mohite P. An exploratory study of early intervention in Gujarat state, India: pediatricians' perspectives. J Dev Behav Pediatr 2011;32:69-74.
  7. Rydz D, Srour M, Oskoui M, Marget N, Shiller M, Birnbaum R, et al. Screening for developmental delay in the setting of a community pediatric clinic: a prospective assessment of parent-report questionnaires. Pediatrics 2006;118:e1178-86.
  8. Thorburn MJ, Paul TJ, Malcolm LM. Recent developments in low-cost screening and assessment of childhood disabilities in Jamaica. Part 2: Assessment. West Indian Med J 1993;42:46-52.
  9. Pinto-Martin JA, Dunkle M, Earls M, Fliedner D, Landes C. Developmental stages of developmental screening: steps to implementation of a successful program. Am J Public Health 2005;95:1928-32.
  10. Mackrides PS, Ryherd SJ. Screening for developmental delay. Am Fam Physician 2011;84:544-9.

  Influence of aquatic therapy for 1 week on structure, activity, and participation in cerebral palsy: A case report Top

Rajashree J Fadnavis, CG Prashanth1

Shree Hospital, Pune, Maharashtra, 1SDM College of Physiotherapy, Dharwad, Karnataka, India.

E-mail: rajashreefadnavis@gmail.com

Background/Objectives: Aquatic therapy benefits children with cerebral palsy due to properties of water such as viscosity, hydrostatic pressure, buoyancy, and continuous feedback with the presence all around thus giving somatosensory input. This aids in muscular activity, facilitating neuromuscular control, building endurance, and strengthening. Studies have shown improvement in functions with long-term aquatic interventions.[1]Will short-term aquatic intervention of 1 week show results on structure, activity, and participation?

Aim: To study effect of aquatic therapy on structure-tone, activity-Gross Motor Function Measure (GMFM), and participation-walking speed.

Study Design: This was a descriptive, case study.

Study Participants and Settings: (i) Sampling method – convenient sampling. (ii) Setting – outdoor club pool.

Materials and Methods: After consent from parents and the hospital authorities, the study was conducted. An 8-year-old spastic diplegic child, Gross Motor Function Classification System Level II, Manual Ability Classification System Level I, participated in the study, where outcome measures were taken at the beginning and post seven sessions of aquatic. Outcome measures used were tone as per modified Ashworth scale, GMFM and 10 m walk test for self-paced and fast walking speed. After initial assessment, aquatic therapy was given at outdoor club pool. This therapy included two sessions of adjustment and three sessions of water specific therapy (WST). Along with this, the child also received regular therapy based on the lines of neurodevelopmental therapy and sensory integration. Each session of WST was for 30 min.

As seen above, changes were evident in GMFM and 10-m walk test. Aquatic therapy has an influence on dynamic movement as it is based on action system approach.

Conclusions/Significance: Thus, we conclude that 1 week of aquatic therapy influenced activity and participation of walking. However, due to its short-term therapy, the effects on structures were insignificant.


  1. Getz M, Hutzler Y, Vermeer A, Yarom Y. The effects of aquatic intervention on energy expenditure and gross motor function in children with cerebral palsy. Eur J Spec Needs Educ 2007;22:217-28.
  2. Getz M, Hutzler Y, Vermeer A. The relationship between aquatic independence and gross motor function in children with neuro-motor impairments. Adapt Phys Activ Q 2006;23:339-55.

  Factors influencing participation in children with cerebral palsy: A literature review Top

BK Ranjana Murthy, Divya Mohan,

S Karthik Babu

Background: Cerebral palsy is one of the most common physical disabilities in childhood with an incidence of 2–2.5/100 live births. The motor impairments are associated with varying degrees of cognitive, communicative, and behavioral impairments which have an impact on the child's ability to participate in daily activities, thereby reducing their quality of life.

Objective: The objective of this review was to provide insight into the different factors that influence participation in children with cerebral palsy.

Methods: A comprehensive search on factors influencing participation in children with cerebral palsy from 2006 to 2013. Database searched were PubMed, EMBASE, CINHAL, and ScienceDirect. Articles were included only if they were in English, studies targeting determinants of participation, facilitators, and barriers to participation in various setting in children with cerebral palsy. Studies were excluded if they focused on the frequency and degree of participation, repeated studies and those focusing on the tools of participation and on physical activity.

Results: Search yielded 88 articles, of which 20 articles met the inclusion criteria which included 2 systematic reviews, 10 cross-sectional studies, 3 prospective, 3 longitudinal studies, and 2 pilot studies.

Conclusion: The review suggested that participation of children with cerebral palsy was influenced by various factors such as physical, social, and attitudinal environment and also the personal factors such as age, gender, personality, and impairments. More studies have been identified on the role of environment and on leisure activities and recreation. Less studies focused on the factors influencing social functioning, community, and school participation and targeting the adolescents.

Key words: Cerebral palsy/participation – home, community/factors, school

  Integrated kyphoscoliosis postural control brace and wheelchair seating assembly for cerebral palsy: A case report Top

Rajesh Kumar Mohanty, Biswaranjan Mohapatra, Susmita Barik, SN Rout

Department of Prosthetics and Orthotics (Training),

Swami Vivekanand National Institute of Rehabilitation Training and Research, Cuttack, Odisha, India.

E-mail: rajeshmpo48@gmail.com

Background: More than 50% of children with cerebral palsy (CP) develop spinal curvature due to muscle imbalance and deformation inviting positioning, which is an area to be focused extensively. Therefore, an appropriate use of spinal orthosis or seating devices is an important adjunct in the rehabilitation of spinal and sitting postural problems in CP. Much of the literature regarding seating systems and their components has been conflicting or appeared to be a matter of clinical opinion as opposed to evidence based. Controversy exists about the most appropriate seating position for children with cerebral palsy to promote energy conservation and maximize upper-extremity function.

Objective: The primary aim of this study was to design, develop the clinical trial of an integrated orthosis – wheelchair system to maintain functional positioning of the spine and improve sitting balance; second, the objective was to derive the biomechanical factors affecting sitting in CP.

Study Design: This study was a single subject design.

Study Participants and Setting: A 5-year-old child with cerebral palsy associated with kyphoscoliosis and poor sitting balance, apex at T8 level (Cobb's angle = 25°) and apex of kyphotic curvature was at midthoracic level. The fabrication, fitting, clinical trial was performed in the Department of Prosthetics and Orthotics Training, Swami Vivekanand National Institute of Rehabilitation Training and Research under standard conditions.

Methods: A bivalved molded thoracolumbar sacral orthosis with height adjustable chin support was integrated to a modified CP chair designed and fabricated according to ergonomic principles and taking children measurements, characteristics of children, alignment, and symmetry of trunk, pelvis into consideration. Pre- and post-assessments were performed to check the efficacy of the integrated system in terms of sitting balance, posture, use of upper limbs, and other abilities.

Results: It has resulted in a significant improvement in the quality of life. The integrated system straightens the spine to improve posture and alleviate the need for the child to use their hands and arms to support their upper body. The increased sitting balance and release of the upper extremities from their role of “trunk crutches” have allowed the patient to develop bimanual activities, including independent wheelchair propulsion. The majority of evidence supports the positive effects of a neutral to slightly forward orientation on upper extremity function.

Conclusion: This positioning can improve upper extremity function, postural alignment and prevent the development of deformity in children and young people who lack postural control and are unable to maintain appropriate postures. With the pelvis positioned for stability and mobility, and with the body properly aligned, this integrated system can produce positive effects for physiological structure and function, as well as activity and participation outcomes for early intervention and school-age children with cerebral palsy.

Key words: Brace, cerebral palsy, integrated, kyphoscoliosis, posture, sitting and wheelchair


  1. Burgman I. The trunk/spine complex and wheelchair seating for children: A literature review. Aust Occup Ther J 1994;41:123-32.
  2. Clark J, Michael S, Morrow M. Wheelchair postural support for young people with progressive neuromuscular disorders. Int J Ther Rehabil 2004;11:365-73.
  3. Thorpe S. What is the evidence for the effectiveness of postural management? Int J Ther Rehabil 2003;10:449-55.
  4. Green EM, Nelham RL. Development of sitting ability, assessment of children with a motor handicap and prescription of appropriate seating systems. Prosthet Orthot Int 1991;15:203-16.
  5. Healy A, Ramsey C, Sexsmith E. Postural support systems: their fabrication and functional use. Dev Med Child Neurol 1997;39:706-10.
  6. Kotwicki T, Durmala J, Czaprowski D, Glowacki M, Kolban M, Snela S, et al. Conservative management of idiopathic scoliosis – Guidelines based on SOSORT 2006 Consensus. Ortop Traumatol Rehabil 2009;11:379-95.
  7. Haefeli M, Elfering A, Kilian R, Min K, Boos N. Nonoperative treatment for adolescent idiopathic scoliosis: a 10- to 60-year follow-up with special reference to health-related quality of life. Spine (Phila Pa 1976) 2006;31:355-66.
  8. Aulisa L, Di Benedetto A, Vinciguerra A. Biomechanical analysis of the spinal brace system in idiopathic scoliosis. Arch Putti Chir Organi Mov 1981;31:185-94.
  9. Negrini S, Marchini G, Tessadri F. Brace technology thematic series – The Sforzesco and Sibilla braces, and the SPoRT (symmetric, patient oriented, rigid, three-dimensional, active) concept. Scoliosis 2011;6:8.

  Low-cost toy models for home-based play therapy to teach shape concept Top

KS Shilpa, Maria Lewin

The Unit of Hope, St. John's Centre for Children with Special Needs, St. John's Medical College Hospital, 1Department of Paediatrics, St. John's Medical College Hospital,

Bengaluru, Karnataka, India.

E-mail: dr.shilpa.paedrehab@gmail.com

Background: Early intervention for children with developmental delay is most effective from birth to 5 years of age.[1] During this period, repeated exposure to multisensory stimuli using a variety of games that are ability appropriate and interesting help children to achieve developmental goals. However, the cost and availability of toys or activity materials are the problems for parents living in remote rural areas. Consequently, this results in low accessibility of early intervention programs either due to high cost or inadequate parental knowledge on how to adapt local resources for stimulation and play therapy especially in children with developmental impairments.[2],[3] Innovative methods of creating toys or activity materials using locally available resources help to overcome this constraint. The UNESCO manual[4] and National Association for Education of Young Children[5] give good examples of converting local materials into toys for early childhood education. A set of appropriately designed low-cost toy models using locally available materials modified to provide sensory stimulation can have multipurpose benefit for developmental stimulation across domains during the critical period of neuroplasticity. Such models are useful for early intervention in children with sensory and perceptual difficulties as well as typically developing children.

Aim: This pilot project aims to develop low-cost toy models to teach shape concept to children with early developmental impairment and to create awareness among caregivers regarding adaptation of local resources for developing these toy models. The concept of shapes is introduced around 2 years of age.[6]

Study Design: Teaching model used for teaching shape concept to children with developmental delay – A pilot model.

Study Participants: Children with developmental delay irrespective of diagnosis and their caregivers from rural or low socioeconomic backgrounds attending the Unit of Hope Centre for Children with Special Needs at the hospital or outreach clinic of St. John's Medical College Hospital, Bengaluru.

Materials Required: (Home-available) Newspapers, metal bangles, empty boxes (big and small size), scissors, blade, empty cardboard cartons (procured from local provision stores), paint, glue, and cellophane tape.

Conclusion: Low-cost toy models can be used to teach shape concept and can be combined with sensory stimulation through home-based play method. Low-cost toy models are easily reproducible, replaceable, and environment-friendly. Caregivers, irrespective of their educational and socioeconomic status, can be encouraged to develop such models. Measured benefits in developmental progress and with respect to cost need to be scientifically assessed using these low cost toy models.


  1. David M. Organization of Early Intervention Services. Secunderabad: National Institute for the Mentally Handicapped; 2008.
  2. Baker-Henningham H, Boo FL. Early Childhood Stimulation Interventions in Developing Countries: A Comprehensive Literature Review. Washington, DC: Inter-American Development Bank; 2010. Available from: https://www.publications.iadb.org/bitstream/handle/11319/2660/earlychildhoodstimulationinterventionsin developingcountries: acomprehensiveliteraturereview.pdf?sequence=1.
  3. Nwokah E, Hsu HC, Gulker H. The use of play materials in early intervention: The dilemma of poverty. Am J Play 2013;5:187-213.
  4. Dhungana AS, Pradhananga D, Vergese S. Using locally resourced low cost materials to extend young children's learning. Nepal: UNESCO; 2008.
  5. Guyton G. Using toys to support infant-toddler learning and development. Young Child 2011; p. 50-6.
  6. Bluma S, Shearer M, Frohman A, Hilliard J. Portage Guide to Early Education. Portage, Wisconsin: Co-operative Educational Service Agency No. 12; 1976.

  Profile of selective voluntary motor control deficits in children with cerebral palsy with crouch gait pattern Top

Sneha Ravi, Divya Mohan, S Karthik Babu

Background: Among the range of motor deficits contributing to crouch gait, lack of selective voluntary motor control (SVMC) in cerebral palsy (CP) is also a probable cause, which is defined as performance of specific isolated joint movements upon request. Reduced SVMC has been implicated for poor function especially gait in CP, but there is limited understanding. Therefore, the aim of this study was to evaluate the degree and distribution of the SVMC impairment across the lower extremity joints in relation to crouch gait.

Methods: A cross-sectional study design with purposive sampling to recruit children with crouch gait was done. An observational two-dimensional video gait analysis was done using a standard protocol to confirm the gait pattern, and SVMC scores of the hip, knee, ankle, subtalar, and toes of 17 children with spastic diplegic crouch gait were evaluated using the tool selective control assessment of lower extremity.

Results: Out of the 17 children evaluated (males 12, females 5; age group between 10 and 18 years; mean age 12.2 years; Gross Motor Function Classification System Levels I–III), it was observed that during examination of hip SVMC, 70% of the children had impaired voluntary control; at the knee, it revealed that 20% of the children had normal SVMC scores; the remaining had severe impairment or no voluntary control at all. Ankle examination revealed 40% had impaired SVMC with others being unable to perform selective movements. Subtalar and toes examination revealed that 80% of the children were unable to selectively move the joints with the remaining 20% having impaired control.

Conclusion: Selective movements at the knee and ankle are required for adequate push off during the propulsive phase of gait. It was observed that in these children SVMC was poor at knee, ankle, subtalar, and toes. Therefore, this could be one of the important contributors to the crouch pattern of gait.

Note: This is an ongoing trial. Hence, more children will be recruited for the study in a period of another 1 month.

  Poster Presentation In IACPCON 2016: A study of clinical profile and predisposing factors in cerebral palsy Top

KN Vykuntaraju, S Varun, Naveen Benakappa, Asha Benakappa

Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India. E-mail: drknvraju08@gmail.com

Introduction: Cerebral palsy (CP) is the most common physical disorder of children. Causes such as jaundice and birth injury though are decreasing; complications resulting from the survival of low birth weight babies are replacing some of the older etiologies. Hence this study was planned.

Objectives: The objective was to study the clinical patterns and predisposing factors in children with cerebral palsy.

Materials and Methods: The present study is a hospital-based retrospective chart review of consecutive cases from June 2015 to May 2016 in children presenting to a pediatric neurology clinic at a tertiary care teaching hospital in India. Six hundred children with clinical features suggestive of CP were included in the study. Children were evaluated by history, clinical examination, and necessary investigations.

Results: Out of 600 children, 82% of spastic, 8% of hypotonic, 8% of dystonic, and 2% of mixed cerebral palsy children. The mean age of presentation was 1 year, 9 months, with male to female ratio being 1.2:1. The most common predisposing factors observed were pregnancy induced hypertension (7%), birth asphyxia (40%), neonatal hyperbilirubinemia (9%), and neonatal meningitis (5%). Associated comorbidities were mental retardation (60%), followed by seizure disorder (42%), failure to thrive (49%), visual problems (22%), hearing problems (15%), and orthopedic problems such as dysplasia/developmental dislocation of the hip (2%).

Conclusion: The proportion of preventable intranatal causes and antenatal causes observed in the study were significant warranting the need for measures to be taken to reduce the burden of CP. Comorbidities observed in the study were also significant implying the need for a multispecialty approach to manage a child with cerebral palsy.

Key words: Cerebral palsy, clinical profile, comorbidities, predisposing factors


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