Intended for healthcare professionals

News

NICE publishes guideline on diagnosing and managing cerebral palsy in young people

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j462 (Published 27 January 2017) Cite this as: BMJ 2017;356:j462

Re: Cerebral palsy in India -A brief overview

It is found that 10% of the global population has some form of disability from different causes; in India, it is 3.8% of the population. Nearly 15-20% of physically disabled children are affected by Cerebral Palsy. In India, the estimated incidence is around 3/1000 live births. Cerebral palsy is the most common motor disability in childhood. Because of the developing nature of Indian health care in semi-urban and rural areas and the lack of technology used in these areas, cerebral palsy has been a problem seen during my thirty seven years of caring for such patients.

The topographic classification of CP is monoplegia, hemiplegia, diplegia and quadriplegia; monoplegia and triplegia are relatively uncommon. There is a substantial overlap of the affected areas; diplegia is the commonest form at 30% – 40%), hemiplegia is 20% – 30%, and quadriplegia accounts for 10% – 15%. In an analysis of 1000 cases of CP from India, it was found that spastic quadriplegia constituted 61% of cases followed by diplegia 22%(1). Spastic CP is the commonest and accounts for 70%-75% of all cases, dyskinetic for 10% to 15% and ataxic for less than 5% of cases. (2)

Another classification, GMFCS, describes the functional characteristics in five levels, from I to V, level I being the mildest in the following age groups: up to 2 yrs, 2 – 4 yrs, 4 – 6 years and 6 – 12 years. For each level, separate descriptions are provided. (3).

EARLY DIAGNOSIS
Cerebral palsy is a clinical diagnosis made by a history of risk factors, regular developmental screening of all high risk babies and neurological examination. A systematic approach focusing on maternal, obstetric and perinatal histories, review of developmental milestones, and a thorough neurological examination and observation of the child in various positions such as supine, prone, sitting, standing, walking and running is mandatory.(3) It is not possible to diagnose CP in infants less than 6 months except in very severe cases. The patterns of various forms of CP emerge gradually with the earliest clues being a delay in developmental milestones and abnormal muscle tone. In CP, the history is nonprogressive. Milestones once acquired do not show regression in CP. Tone may be hypertonic or hypotonia. Many cases of early hypotonia change to spasticity or dystonia by 2 – 3 yrs of age. Early signs include presence of hand preference in the first year, prominent fisting, abnormalities of tone–either spasticity or hypotonia of various distribution, persistence of abnormal neonatal reflexes, delay in the emergence of protective and postural reflexes, asymmetrical movements like asymmetrical crawl and hyperreflexia. Primitive reflexes should gradually extinguish by 6 months of age. Among the most clinically useful primitive reflexes are Moro, Tonic labyrinthine and Asymmetric Tonic Neck Reflex (ATNR). In many cases a diagnosis of CP may not be possible till 12 months. Repeated examinations and observation over a period of time may be required in mild cases before a firm diagnosis can be made (4 ,5).

In the further evaluation of a child with CP, an EEG is obtained if there is history of epilepsy. Neuroimaging studies are carried out if they have not been done in the neonatal period that provided the etiology of CP. MRI studies are preferred to CT scans. Genetic and metabolic tests are carried out if there is evidence of deterioration or metabolic compensation, family history of childhood neurological disorder associated with CP. Tests to rule out coagulopathy in children with stroke is necessary.(6)

CP is a chronic condition with considerable morbidity on affected individuals. Overall prevention of CP has not been successful. Early diagnosis and comprehensive management with a multidisciplinary approach with a developmental pediatrician or neurologist, orthopedic surgeon, speech and language therapist, physio and occupational therapist are required for management of a child with CP. Complete evaluation of a child with CP must have an assessment of associated deficits like vision, speech and hearing, sensory profile, oromotor evaluation, epilepsy and cognitive functioning. Orthopedic evaluation is a must as muscle imbalance and spasticity cause subluxation/dislocation of the hips, equinus deformities, contractures, and scoliosis. NICE Guidelines have to be introduced in most of the Indian Cerebral palsy centres.

REFERENCES-
1.Singhi PD, Ray M, Suri G. Clinical Spectrum of Cerebral Palsy in North India-An Analysis of 1000 Cases. J Trop Pediatr 2002; 48: 162-166.
2. Menkes JH, Sarnat HB. Periuatal asphyxia and Trauma. In Menkes JH, Sarnat HB, edn. Child Neurology. Lippincott Williams and Wilkins 2000; 427-436.
3. Palisano RJ, Rosenbaum PL, Walter S et al. Development and reliability of a system to classify gross motor function in child with cerebral palsy. Dev Med Child Neurol 1997; 39: 214-223.
4. Sanger T.D, Delgado M.R, Deborah D, Hallett M, Mink J.W, Task Force on Childhood Motor Disorders Classification and Definition of Disorders Causing Hypertonia in Childhood. Pediatrics 2003; 111(1) : e89-e97.
5. Ellison PH, The Infanib A reliable method for the neuromotor assessment of infants. Therapy skill builders, Texas.
6. Ellison PH, Horn JL, Browning CA. Construction of an Infant Neurological International Battery (Infanib) for the assessment of neurological integrity in infancy. Phys Ther 1985; 65(9) : 1326- 1331.

Competing interests: No competing interests

30 January 2017
Dr EDWIN Dias
PROFESSOR AND HOD
Dr PRAVEEN DORALLI , Dr KISHOR
SIMS AND RC
SIMS AND RC ,MUKKA ,MANGALORE