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Clinical Spectrum of Cerebral Palsy in North India—An

Analysis of 1000 Cases

by Pratibha D. Singhi,a Munni Ray,a and Gunmala Surib

a Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
b University Business School, Punjab University, Chandigarh, India

Summary
One thousand children with cerebral palsy (CP) were reviewed to study their clinical profile, etio-
logical factors and associated problems. Spastic quadriplegia constituted the predominant group (61
per cent), followed by spastic diplegia (22 per cent). Dyskinetic CP was present in 7.8 per cent of the
cases. Acquired CP, particularly secondary to nervous system infections, constituted a significant
proportion of cases. The clinical spectrum of CP is different in developing countries compared with
developed countries. Associated problems were present in a majority (75 per cent) of cases, of which
mental retardation was the commonest (72.5 per cent). Comprehensive assessment and early
management of these problems are emphasized, which can minimize the extent of disabilities.

Introduction ation. For labeling a child as having birth asphyxia,

Changes in the epidemiology of cerebral palsy (CP)
have been reported from developed countries.1–3
Advances in perinatology have led to increasing
survival of preterms and a change in the distribution
of clinical types of CP.4,5 For the developing coun-
tries no accurate data regarding incidence, preva-
lence or clinical spectrum of CP is available. The
purpose of this study was to evaluate the clinical
profile of CP and to determine the associated risk
factors among North Indian children.
Materials and Methods
The study included 1000 consecutive children with
CP who were seen at The Rehabilitation Centre for
Disabled Children, Chandigarh from 1985 to 1993.
The Centre provides assessment and intervention
services to children with various types of disabilities
brought from all over North India after referral from
hospitals and doctors, or directly from the
community by the parents.
Cerebral palsy was defined as a non-progressive
disorder that manifests as abnormality of motion and
posture and results from a central nervous system
injury sustained in the early period of brain develop-
ment, usually defined as the first 3 or 5 years of life.6
A detailed history was taken from the mother using
a prestructured proforma followed by a complete
physical, developmental and neurological examin-
Correspondence: Dr Pratibha D. Singhi, Department of Pediatrics,
Postgraduate Institute of Medical, Education and Research,
Chandigarh, India. Fax 91–0172–744401. E-mail <medinst@pgi.chd.
nic.in>.
Apgar scores when available were considered. In the
absence of these, the following criteria were used: (i)
history of delayed cry > 5 min after birth; (ii) baby
turning blue and requiring oxygen therapy with baby
having difficulty in respiration, lethargy and/or
seizures within 72 h of birth. Protein energy malnu-
trition (PEM) was graded according to the criteria
proposed by the Nutrition Sub-Committee of Indian
Academy of Pediatrics (1972),7 by expressing the
weight of the child as a percentage of the expected
and classifying as follows: normal, > 80 per cent;
grade I, 71–80 per cent; grade II, 61–70 per cent;
grade III, 50–60 per cent; grade IV, < 50 per cent of
expected weight for age. Sociodemographic and
family structure details were recorded. Assessment
of intelligence/development quotient (IQ/DQ) and
an ENT and ophthalmologic evaluation was
performed in all children.
The cases of CP were classified, using the Swedish
classification, into spastic (tetraplegia, diplegia,
hemiplegia), ataxic and dyskinetic (including atheto-
sis; dystonia) and mixed.8 The etiological classifi-
cation was also used as: (i) congenital (prenatal,
perinatal and mixed pre- and perinatal causes); and
(ii) acquired CP occurring in a child born normally
and due to identifiable factors acquired after birth.
Clinical psychologists conducted psychometric
evaluations and children were categorized into mild
(IQ = 50–70), moderate (IQ = 30–50) and severe (IQ
< 30) mental retardation. All children were screened
for a hearing defect, and in those suspected of having
a hearing loss formal audiometry was done. Children
with active seizures or with a definite history of
recurrent seizures were considered to have epilepsy.
Behavioural problems were considered significant if

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P. D. SINGHI ET AL.

they were severe enough to be perceived as problems TABLE 1

by parents or interfered with therapy or education.
All children were also evaluated by a team of
therapists, provided appropriate rehabilitation, and
were periodically followed-up.
Data were entered in Foxpro and descriptive
statistics were calculated using SPSS software
package.
Results
The age at the time of presentation ranged from 2
months to 16 years (mean age: 36.4 ± 31.9 months). A
male preponderance was noted (67.5 per cent).
About half (50.2 per cent) of the patients were below
2 years of age at the time of their first visit, 34.2 per
cent were between 2 and 5 years, and 15.6 per cent
were above 5 years of age. The presenting problems
were delay in motor milestones (88.8 per cent),
delayed speech (47.6 per cent), seizures (28.1 per
cent), and behavior problems. The majority of the
cases were congenital (77 per cent). Antenatal
problems (Fig. 1) were reported in 25 per cent of the
mothers. In 33.6 per cent of cases the deliveries were
conducted at home; 85 per cent were normal vaginal
deliveries, 9.9 per cent were caesarian section. 1.5 per
cent were breech, 3.7 per cent required instrumenta-
tion; 86.8 per cent were term, and 13.2 per cent were
preterm. Delayed cry was reported in 49.2 per cent
cases. About half (49.6 per cent) of the children were
first borns; 27.6 per cent were second, and 22.8 per
cent were third in birth order. The predisposing
neonatal factors are shown in Table 1. Of the 23 per
cent cases of acquired CP, 63.5 per cent were due to
Neonatal factors predisposing to cerebral palsy
CP cases %
(n = 1000)
Prematurity 132 13.2
Birth asphyxia 453 45.3
Neonatal convulsions 252 25.2
Neonatal septicemia 146 14.6
Neonatal jaundice 215 21.6
Low birthweight 204 20.4
Twins 12 1.2
CNS infections such as meningitis and encephalitis,
and 30.1 per cent were due to bilirubin encephalopa-
thy (secondary to Rh incompatibility or G6PD
deficiency) and 2.7 per cent due to head injury.
The distribution of cases of CP is shown in Table 2;
70 per cent were spastic and 61 per cent had quadri-
plegia. The associated problems as seen in the whole
group are shown in Table 3 and those in relation to
types of CP are shown in Table 4. About half (50.6
per cent) of cases were malnourished; 28.1 per cent
had grades III and IV malnutrition. Children with
mixed CP were most malnourished (68.35 per cent)
followed by those with athetoid (59.50 per cent),
hypotonic/ataxic (51.95 per cent), and spastic (42.86
per cent) CP. Children with spastic hemiplegia were
least malnourished (36.18 per cent). Most children
(88.6 per cent) had a head circumference less than a
2 SD of normal. Mental retardation was seen in 72.5
per cent cases; 42.7 per cent had severe, 26.0 per cent
moderate, and 31.3 per cent had mild mental retar-
dation. All cases of mixed CP and athetoid CP had
mental retardation compared with 62.5 per cent of
cases of spastic and 75.3 per cent of cases of hypo-
tonic CP. Convulsions were seen in 327 children,
most commonly in those with spastic hemiplegia
(42.0 per cent), diplegia (32.5 per cent), quadriplegia
(31.6 per cent), mixed (35.3 per cent), hypotonic
(25.9 per cent), and athetoid (27.4 per cent) CP. The
various types of seizures seen as depicted in Fig. 2.

TABLE 2
Distribution of types of cerebral palsy cases

Type of cerebral palsy n %

Spastic 700 70
Quadriplegia 427 61
Diplegia 154 22
Hemiplegia 119 17
Right 58
FIG. 1. Antenatal complications in mothers of Left 61
children with cerebral palsy. , Antepartum Dyskinetic/athetoid 84 8.4
Hypotonic/ataxic 77 7.7
hemorrhage; , fever; , pre-eclamptic toxemia;
Mixed 139 13.9
, drugs; , other.

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P. D. SINGHI ET AL.

TABLE 3 (43.9 per cent), spastic (38.0 per cent), and hypotonic
Associated problems in children with cerebral palsy (20.9 per cent) CP. Refractory errors were detected
in 48 per cent of cases. Hypermetropia was more
Associated problems n % common than myopia. Strabismus was found in 24.5
per cent cases; 84 per cent had convergent and 16 per
Mental retardation 725 72.5 cent had divergent squint. Optic atrophy (10.87 per
Speech disorder 78 7.8
cent), nystagmus (4 per cent), and cataracts (3.9 per
Visual disorder 410 41.0
Hearing disorder 140 14.0
cent) were also seen. Ptosis, corneal opacity, chori-
Convulsions 327 32.0 oretinitis and cortical blindness were seen in 2–4 per
Behavior problems 72 7.2 cent cases. Speech delay was reported in 82 per cent
Malnutrition 506 50.6 of cases of cerebral palsy. Hearing loss and speech
motor problems were most commonly seen in
dyskinetic CP.

FIG. 2. Types of seizures in children with cerebral
palsy. , Generalized tonic clonic; , focal;
, atonic; , unclassified; , myoclonic.
Ocular defects were found in 41 per cent of children.
These were found more commonly in children with
dyskinetic CP (45.24 per cent) followed by mixed
Discussion
The preponderance of spastic cerebral palsy cases in
our study is similar to that reported by others.10
However, distribution of the clinical types of spastic
cases was very different. Whereas spastic diplegia is
generally the commonest form reported from devel-
oped countries,1 in our series spastic quadriplegia
was most commonly seen, as is also seen in other
developing countries. In developed countries, a
progressive decrease in spastic quadriplegia and a
relative increase in spastic diplegia has been attrib-
uted to the decrease in perinatal mortality rate, with
increasing survival rates of extremely premature
infants.4,5 This situation has not yet been achieved in
our country except in a few tertiary care centres.
Other studies from more developed countries have
found hemiplegia to be the commonest form of
spastic CP.10 In our study this was seen in only17 per
cent cases. While athetoid CP, particularly secondary
to neonatal hyperbilirubinemia, has virtually
disappeared from many parts of the world, it still
constitutes a significant proportion of CP cases in
India, and 41.6 per cent of our cases had a history of
significant neonatal jaundice.
The role of perinatal complications, in particular

TABLE 4
Associated problems in relation to types of cerebral palsy

Types of CP Total Seizures Mental Speech Visual Hearing Microcephaly Malnutrition Behavior
retardation defects defects defects problems

Spastic 427 135 276 31 181 58 399 212 28

quadriplegia (31.6%) (64.6%) (7.3%) (42.4%) (13.6%) (93.3%) (49.7%) (6.55%)
Spastic 119 50 73 8 32 12 106 43 11
hemiplegia (32.5%) (61.3%) (6.7%) (26.9%) (10.1%) (89.1%) (36.1%) (9.2%)
Spastic 154 50 95 10 69 16 119 66 10
diplegia (42.0%) (61.7%) (6.5%) (44.8%) (10.4%) (77.3%) (42.9%) (6.5%)
Mixed 139 49 139 14 61 14 124 95 8
(35.3%) (100%) (10.1%) (43.9%) (10.1%) (89.2%) (68.4%) (5.8%)
Hypotonic/ 77 20 58 6 29 12 72 40 7
ataxic (25.9%) (75.3%) (7.8%) (20.9%) (15.6%) (95.3%) (52.0%) (9.1%)
Athetoid 84 23 84 9 38 28 66 50 8
dyskinetic (27.4%) (100%) (10.7%) (45.2%) (33.3%) (78.6%) (59.5%) (9.5%)

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P. D. SINGHI ET AL.
birth asphyxia, in the causation of CP has been chal-
lenged.11,12 However, we found history indicative of
birth asphyxia in a large number of cases. This is
similar to other studies from Nigeria, Malta, and
other developing countries.13–15 Occurrence of
severe birth asphyxia, which is rarely seen in devel-
oped countries, continues to be a major problem in
many developing countries where obstetric facilities
are virtually non-existent for a vast majority of
women in rural areas.
Several studies have reported a significant associ-
ation between low birthweight and cerebral
palsy.11,12,16,17 Higher survival rate of preterm, low
birthweight infants, usually attributed to more
advanced obstetric care, is associated with a higher
rate of CP in these infants.18 However, unlike
western figures, most children in our study were term
babies.
Acquired cases of CP, particularly secondary to
CNS infections and bilirubin encephalopathy, consti-
tute a significant proportion of CP in our country as
well as other developing countries.19,20
Although a direct causative role of antenatal
problems cannot be commented on with certainty,
they were reported in a third of cases. A significant
association between antepartum hemorrhage and
cerebral palsy has been reported11,16 and refuted.12,18
Toxemia in the mother as a risk factor for cerebral
palsy in the baby has been found by several
authors.11,12 A large proportion of mothers gave
history of fever in the early antenatal period;
however, tests for intrauterine infections in their
babies were negative.
Most of the babies in our study were born by
normal vaginal delivery. Instrument-assisted
delivery18 and caesarian section10,21 have been
associated with cerebral palsy,18 but others have
differed on this.10,22 Multiple pregnancy has been
considered an important prenatal risk factor for
CP.10 However, in our study only four pairs of twins
were identified.
Almost all children with cerebral palsy have at
least one additional disability associated with
damage to CNS.23 Approximately two-thirds of
children with cerebral palsy have mental retarda-
tion.6 Our findings are in accordance with this.
Children with spastic quadriplegia and mixed type
of cerebral palsy have the worst intellectual
outcome.
Epilepsy in children with cerebral palsy occurs
frequently.24 Seizures are reported to be least
common in children with choreoathetoid and ataxic
types of CP,25 as was also found in our study. Most
epileptic patients with cerebral palsy have location-
related epilepsies; focal and generalized seizures
dominate the clinical picture.24 Although general-
ized seizures were commonest, 32 per cent of our
children had myoclonic seizures – this figure is higher
than that described in literature.26 Epilepsy was
Journal of Tropical Pediatrics Vol. 48 June 2002
significantly more common in those children with
cerebral palsy who had mental retardation (85.4 per
cent) compared with those without mental retarda-
tion (14.6 per cent).
The poor nutritional status of children in the study
is explained by feeding problems, gastroesophageal
reflux, inability to independently access food or
communicate hunger and constipation.27,28 Hearing
loss and dysarthria, seen in our children with dyski-
netic or mixed CP, were similar to that reported in
the literature.29 Ocular problems and difficult
behavior were other problems requiring inter-
vention.
In conclusion the spectrum of CP in North India
differs from that seen in the West. The shift to
predominant involvement of preterm survivors is
still not apparent. Severe birth asphyxia is an import-
ant predisposing factor for CP. Acquired CP, particu-
larly secondary to CNS infections and kernicterus,
constitutes a significant proportion of CP cases.
Targeting the preventable causes of CP may help
reduce, to some extent, the enormous problem of
childhood disability in the country.
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