ORIGINAL ARTICLE

Comorbidities and their relationship to subtype of cerebral

palsy in a tertiary care hospital in South India
Raghavendraswami Amoghimath, Vykuntaraju K Gowda, Asha Benakappa1
Departments of Pediatric Neurology and 1Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

ABSTRACT
Introduction: Comorbid conditions such as intellectual disability (ID), visual disability, epilepsy, and hearing impairment are associated
with cerebral palsy (CP). For many children with cerebral palsy, it is these cooccurring conditions that may often have the greatest impact
on the child and family from varying perspective.
Aims: The aim of the current study was to provide data on the frequency and type of comorbidities in children with cerebral palsy and
the burden of comorbidities among each motor subtypes of CP. In addition, we evaluated the causative agent of motor subtypes of CP.
Methods: Two hundred consecutive children with cerebral palsy attending the pediatric neurology outpatient department with an age
group from 3 months to 18 years were enrolled in the study. Information on neurologic subtype classified according to the topographic
distribution of the motor impairment on neurologic examination and the presence of comorbidities: ID, visual impairment, hearing
impairment, and coexisting afebrile seizures, was obtained. Demographic factors were also noted.
Results: The mean age of the children was 55 months, with 120 boys and 80 girls. ID was seen in 91% (182/200) of children. Active afebrile
seizure disorder was noted in 40% (80/200), severe auditory impairment was noted in 4% (8/200), and cortical visual impairment was
noted in 19.5% (39/200) of children. Comorbidities were most frequent in children with spastic and dyskinetic cerebral palsy. The most
common type of seizures was focal seizures in 47 individuals (23.5% of all the individuals), followed by generalized seizures in 23 individuals
(11.5% of all the individuals) and myoclonic seizures in 11 individuals (5.5% of all the individuals).
Conclusion: ID and seizures are more frequently associated comorbidities with CP. Bilateral spastic and dyskinetic CP are more likely to
be associated with comorbidities.

Key words: Cerebral palsy, comorbidities, etiology of cerebral palsy, intellectual disability, seizures

INTRODUCTION child grows.[2,3] According to the Surveillance of CP

Cerebral palsy (CP) is accompanied by various
comorbidities and these comorbidities are the
major drivers of outcome and quality of life
which is amenable to intervention, which are
best served by early detection.[1] Comorbidities
reflect brain injury beyond the motor tracts. [2]
CP is not a progressive disorder; however, new
comorbidities may appear or become severe as the
Address for correspondence: Dr. Vykuntaraju K. Gowda,
Department of Pediatric Neurology, Indira Gandhi
Institute of Child Health, Bengaluru, Karnataka, India.
E‑mail: drknvraju08@gmail.com
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in Europe (SCPE), the most common comorbidities
are speech and language impairments, followed by
severe intellectual impairment, epilepsy, and visual
impairment.[4] In addition, hearing impairment
which is a common complication can exacerbate
language difficulties. Social difficulties and autism
spectrum disorders are also commonly associated
comorbidities.[5]
Objectives
The aim of the current study was to provide data on
the frequency and type of comorbidities in children
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DOI: How to cite this article: Amoghimath R, Gowda VK, Benakappa A.

10.4103/2395-4264.204408 Comorbidities and their relationship to subtype of cerebral palsy in a
tertiary care hospital in South India. Indian J Cereb Palsy 2016;2:90-3.

90 © 2017 Indian Journal of Cerebral Palsy | Published by Wolters Kluwer ‑ Medknow

 Amoghimath, et al.: Comorbidities in cerebral palsy

with cerebral palsy and the burden of comorbidities Table 1: Comorbidities in various types of
among each motor subtypes of CP. In addition, we cerebral palsy
evaluated the causative agent of motor subtypes Comorbidity Characteristics Patients
of CP. affected
ID ‑ 91% (182/200) BSCP 138/139
HPCP 27/39
METHODS DPCP 2/7
DKCP 15/15
Our study included 200 consecutive children Epilepsy ‑ 40.5% (81/200) BSCP 58
presenting with clinical features suggestive of cerebral HPCP 22
palsy to a tertiary care center. Detailed history and DPCP 0
clinical examination were noted. CP was clinically DKCP 1
classified both physiologically and topographically. Ocular defects ‑ 19.5% (39/200) Sensory 22
Motor 13
Computerized tomography of the brain was done
Both 4
to find out the cause and severity of brain injury; if
Hearing defects ‑ 4% (8/200) BSCP 6/139
inconclusive, further magnetic resonance imaging DKCP 2/15
was performed. Intelligent quotient was assessed ID: Intellectual disability, BSCP: Bilateral spastic cerebral palsy, HPCP: Hemiplegic
by a clinical psychologist using Vineland Social cerebral palsy, DPCP: Diplegic cerebral palsy, DKCP: Dyskinetic cerebral palsy

Maturity Scale. Visual evaluation was done by a

pediatric ophthalmologist and visual evoked potential
was performed. Hearing assessment was done by
an audiologist with brainstem auditory evoked
potentials. Electroencephalogram was performed in
individuals with epilepsy. Children with neurological
examination consistent with CP and nonprogressive
brain malfunction manifested early in life were
included in the study while children with progressive
neurological disorders were excluded from the study.
RESULTS
The mean age of the children was 55 months (range,
3–180 months) at the time of registration and the sex
ratio male to female was 1.5. Subnormal intelligence
was observed to be the most common comorbidities
in our series (91% of all the individuals). Among
the spastic children, subnormal intelligence was
observed to be more common in bilateral spastic and
spastic hemiplegic (90% combined) as compared to
spastic diplegic (28.5%) children. All the individuals
with dyskinetic cerebral palsy were mentally
retarded [Table 1].
Convulsions were observed in 81 children (40.5%).
The frequency of convulsions was 22 (56.4% of
all individuals with epilepsy) in individuals with
hemiplegic cerebral palsy, and majority had focal
convulsions, whereas 58 (41.7% of all individuals
with epilepsy) individuals of bilateral spastic
cerebral palsy children had epilepsy. One child (6%
of all individuals with epilepsy) with dyskinetic
cerebral palsy and none of children with diplegic
cerebral palsy had convulsion. Overall, the incidence
of focal seizures was observed to be the highest
(47 children, 23.5% of all the individuals), followed
by generalized tonic–clonic seizures (23 individuals,
11.5% of all the individuals) and myoclonic seizures
(11 individuals, 5.5% of all the individuals) [Table 1].
Visual problems were reported in 39 (19.5%)
children with cerebral palsy and hearing deficits
were noted in 8 individuals (4%), 6 of them were
bilateral spastic cerebral palsy (BSCP), and rest 2
were dyskinetic cerebral palsy (DKCP) [Table 1].
History of perinatal asphyxia was found in
138 (69%) individuals making it the single most
common predisposing factor [Table 2]. Of these,
98 (71%) individuals had bilateral spastic type,
30 (21%) children had spastic hemiplegic type,
6 (4%) had diplegic and the rest 4 (2.8%) children
had dyskinetic type of CP. Other etiologies associated
with CP seen in our study include hypoglycemia,
TORCH infection in mother, prematurity, bilirubin
encephalopathy, malformations, perinatal stroke,
and neuro‑infections. Details of each are described
in Table 2.
DISCUSSION
The mean age observed in our study was
55 months (range, 3–180 months) at the time of

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 Amoghimath, et al.: Comorbidities in cerebral palsy

registration. Sex distribution observed in our study
was male to female ratio of 1.5. Our results were
comparable to a multicenter study in Europe (2002),
in which male to female ratio of 1.33.[4] No sex
predisposition was seen in our study.
In the present study, 185 (92.5%) children were
spastic CP and 15 (7.5%) were DKCP. Among spastic
cerebral palsy children, BSCP, 139 (69.5%), was
the most commonly encountered type of spastic
CP, followed by spastic hemiplegic CP (HPCP),
39 (19.5%). Various Indian studies found that the
spastic type of CP was the predominant form in
preterm and term infants. Sharma et  al. reported
77.9% of their individuals with spastic cerebral
palsy and Gowda et  al. mentioned 81% of their
individuals with spastic cerebral palsy.[6,7] According
to a multicenter study done in Europe, 85.7% were
considered to have spasticity [Table 3].[4]
Mental retardation was found in most of the BSCP
as compared to diplegia, thus confirming the general
rule that more the upper limbs are affected, lower
is the intelligence.[8] In our study, developmental
delay was noted in around 90% of children whereas
in Sharma et al., it was 75%, and in Gowda et al.,
it was 55%.[6,7] In SCPE, 69% of individuals had
intellectual delay. A high percent of developmental
delay in our study can be because, we analyzed the
cohort of children who were referred to the tertiary
care center and milder individuals might have been
missed or not referred to the institute.
Epilepsy in children with cerebral palsy was mainly
noted in BSCP and HPCP, whereas convulsions were
less common in diplegia and DKCP individuals. In
a study by Gowda et al., seizures were observed in
46% of individuals. In SCPE, 39% of children had
epilepsy. Lesser prevalence of seizures in spastic
diplegia is probably because of the cortical sparing
of the pathological events resulting in diplegia.
Other comorbidities observed were visual problems in
19.5% (strabismus, nystagmus, cataract, amblyopia,
and cortical blindness) and hearing impairment
in 4% of children (sensorineural hearing loss).
In a study by Gowda et  al., visual problems were
observed in 26% and hearing impairment in 11%
(35.8%), whereas in a study by Sharma et  al.,
35.8% had ocular defects with squint being most
common (12% of the individuals) [Table 4].
Birth asphyxia (hypoxic ischemic encephalopathy)
was most common cause of CP with 69% and
TORCH infections in 8.5% of individuals which were
comparable with a previous study.[6] Prematurity was
observed in 8% of individuals as compared to 25.4%
seen in Sharma et al. and 15% in Gowda et al., which
might be secondary to increased survival of morbid
premature infants in their study [Table 5].

Table 2: Common predisposing factor in cerebral palsy

Etiology Total, n (%) BSCP, n (%) HPCP, n (%) DPCP, n (%) DKCP, n (%)
Birth asphyxia 138 (69) 98 (71) 30 (21) 6 (4) 4 (2)
Hypoglycemia 8 (4) 8 (100) 0 0 0
TORCH 17 (8.5) 16 (94) 1 (6) 0 0
Malformations 2 (1) 2 (100) 0 0 0
Perinatal stroke 3 (1.5) 0 3 (100) 0 0
Prematurity 16 (8) 8 (50) 5 (31) 1 (6) 2 (12)
Bilirubin encephalopathy 7 (3.5) 1 (15) 0 0 6 (85)
Infections 9 (4.5) 9 (100) 0 0 0
BSCP: Bilateral spastic cerebral palsy, HPCP: Hemiplegic cerebral palsy, DPCP: Diplegic cerebral palsy, DKCP: Dyskinetic cerebral palsy

Table 3: Comparison of types of cerebral palsy

Type of cerebral palsy Present study (n=200) Gowda et al. (n=100) Sharma et al. (n=480) SCPE (n=4792)
BSCP 139 58 15 54
HPCP 39 9 8.6 29
DPCP 07 13 54 ‑
DKCP 15 5 5.8 6.5
Hypotonic ‑ 12 8.5 ‑
BSCP: Bilateral spastic cerebral palsy, HPCP: Hemiplegic cerebral palsy, DPCP: Diplegic cerebral palsy, DKCP: Dyskinetic cerebral palsy, SCPE: Surveillance of Cerebral Palsy in Europe

92 Indian Journal of Cerebral Palsy | Volume 2 | Issue 2 | July-December 2016

 Amoghimath, et al.: Comorbidities in cerebral palsy

Table 4: Comparison of associated comorbidities in cerebral palsy

Impairment Present study (n=200) Gowda et al. (n=100) Sharma et al. (n=480) SCPE (n=4792)
Intellectual impairment 182 55 74 23-44
Epilepsy 81 46 26 22-40
Ocular defects 39 26 35 62-71
Hearing abnormality 8 11 ‑ 25
SCPE: Surveillance of Cerebral Palsy in Europe

Financial support and sponsorship

Table 5: Comparison of incidence of risk
factors and etiologies of cerebral palsy Nil.
Etiology Present study Gowda et al. Sharma
(n=200) (n=100) et al. (n=480)
Conflicts of interest
Birth asphyxia 138 (69) 43 48 There are no conflicts of interest.
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TORCH infections 17 (8.5) 4 6.7 REFERENCES
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