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Management Patterns of Children With Cerebral Palsy by Physiotherapists Working in Selected Hospitals in Nigeria
*Corresponding author: Dr. Margaret Bukola Fatudimu, Department of Physiotherapy, College of Medicine, University of Ibadan, PMB 5017 GPO Dugbe, Ibadan, Nigeria. bukolafatudimu@yahoo.com
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Received: ,
Accepted: ,
This article has been Retracted, Retraction Notice available at 10.25259/JHS-2024-10-22-(1636)_RT
How to cite this article: Fatudimu MB, Abodunrin GT, Gbonjubola YT. Management Patterns of Children With Cerebral Palsy by Physiotherapists Working in Selected Hospitals in Nigeria. J Health Allied Sci NU. 2026;16:426-32. doi: 10.25259/JHS-2024-10-22-(1636)
Abstract
Objectives
Body composition describes the amount of fat mass (FM) in comparison with the amount of fat-free mass (FFM) in the body. This study was carried out to provide a better understanding of the correlation between gross motor function (GMF) and selected indices of body composition (weight, waist circumference (WC), waist-hip ratio (WHR), body mass index (BMI), skinfold thickness (SFT)) among children with cerebral palsy (CP), as this area has not received significant research attention in Nigeria.
Material and Methods
This was a correlational study involving 48 children with CP who were recruited from the physiotherapy outpatient clinics of Oni Memorials Children Hospital and University College Hospital using a purposive sampling technique. Descriptive and inferential statistics were used to analyse the results at alpha ≤0.05. This study comprised 32 males and 16 females with a mean age of 37.69±27.36 months. Most (41.7%) of the children were on the GMF classification system (GMFCS) level V. The average weight of the children was 10.70±4.21 kg, and their BMI averaged at 12.88±2.83 kg/m2. WC and WHR were measured with an average of 43.13±6.75 cm and 0.98±0.25, respectively. Triceps SFT, SFT over the thighs, and SFT over the abdomen averaged 7.13±3.04 mm, 9.28±4.11 mm, and 6.17±3.10 mm, respectively.
Results
There was a significant and strong linear relationship between GMF and the weight of children with CP. Also, a significantly positive but weak linear relationship between the gross motor function measure (GMFM) and BMI, as well as with the WC of the children. Conversely, a negative relationship was found between the GMFM and WHR of the children with CP. Additionally, a weak but positive relationship was observed between GMFM and triceps SFT of children with CP, and also between their GMFM and abdominal SFT.
Conclusion
The outcome of this study revealed that weight, BMI, WC, triceps SFT, and abdominal SFT showed a positive significant relationship with GMFM, while WHR showed a negative significant relationship with GMFM in children with CP. Therefore, healthcare professionals should consider examining the relationship between body composition and motor skill development as part of rehabilitation programmes for children with CP, rather than prioritising body composition improvement as a central focus.
Keywords
Body mass index
Cerebral palsy
Skinfold thickness
Waist circumference
Waist-hip ratio
Weight
INTRODUCTION
Body composition is the relative proportions of the body fat tissue, bone mass, muscle mass, and total body water in the body.[1] It describes the amount of fat mass (FM) in comparison with the amount of fat-free mass (FFM) in the body.[2] Overweight and obesity are closely associated with poor general health and conditioning, rather than specifically with motor skill development in children with cerebral palsy (CP).[3,4] While the accumulation of fat in the body poses health risks, lean body mass, which comprises the skeletal muscles, has also been found to be of high importance to human function.[5] Lean body mass is an important aspect of human health as it can be an indication of good or poor health,[6] and an excessive loss of lean body mass causes decreased muscular strength, difficulties in performing activities of daily living, impacts on emotions and psychological states and may cause death.[7] This is evident in sarcopenia, a disease that involves the loss of lean body mass, causing remarkable loss in strength, physical activities, and function.[5]
Overweight and obesity are closely associated with poor gross motor development and endurance.[8] An inverse relationship was found between the general motor skills and body mass index (BMI) of typically developing children in the United States,[9] as children who are obese were found to have lesser motor skills when compared to their peers who have normal weight or are overweight.[10] Motor coordination has also been said to be affected by the weight of children, which can persist into adulthood.[11] Normally developing children who are overweight also have difficulties with fundamental movement skills when compared with non-overweight children.[12]
Body composition is an important factor that affects the quality of life, activity, social participation, general health, and functional ability of children with CP and their caregivers.[13] A study carried out in the United States of America revealed that children with hemiparesis and diparetic CP have high BMI when compared to children with quadriparetic CP.[14] However, information on the extent of the correlation between body composition and gross motor function (GMF) among Nigerian children with CP is not readily available. Having established from previous studies that body composition is an important indication of good or poor health,[5] and that it can also impact the physical function of children,[8] studies are needed to reveal the typical relationship that exists between body composition and GMF of children with CP in Nigeria. This information will serve as an important reference for healthcare providers and parents of children with CP to foster healthy body composition in them. These findings may also inform targeted interventions and rehabilitation strategies that optimise motor performance and health outcomes for children with CP.
Although some studies have been conducted to reveal the impact of indices of body composition on the functional ability of children in other parts of the world, no study was found on the relationship between the indices of body composition and the GMF of children with CP in Africa, especially in Nigeria. Also, the lack of data on the correlation between GMF and selected indices of body composition among Nigerian children with CP further necessitated the importance of this research. Therefore, this study was designed to determine the relationship between GMF and selected indices of body composition (weight, BMI, skinfold thickness (SFT), waist circumference (WC), waist-hip ratio (WHR)) among Nigerian children with CP.
MATERIAL AND METHODS
The participants for this correlational study were 48 purposively recruited children with CP between the ages 1-12 years. The study aimed to investigate the relationship between GMF and body composition indices, not the impact of body composition on motor skill development.
Only participants whose parents consented to the study and had been diagnosed with CP by a physician, and aged between 1-12 years were included in the study. However, children with any other neuro-developmental disorder, such as down syndrome, were excluded.
Ethical approval for the study was sought and obtained from the University of Ibadan/University College Hospital Health Research Ethics Committee before the commencement of this study. Since the age range of the proposed participants could not give consent, consents were obtained from their parents. The parents were given consent forms detailing the purpose, process, and time frame of the study. Questions and concerns of the parents were attended to, and they were allowed to decide to participate or not to participate in the study. They were also informed that participation is optional and they could choose to withdraw at any time during the study duration without any consequences.
The socio-demographic data of the participants were documented using a socio-demographic data collection form. The gross motor function measure (GMFM) -88 was used to assess the GMF of the participants. The GMFM is a criterion-referenced measure constructed for the purpose of evaluating change in GMF in children with CP.[15] The GMFM is considered the gold standard for the assessment of GMF in children with CP.[16]
The GMF classification system (GMFCS) was used to classify the children with CP into their functional ability levels. This instrument was initially developed by Palisano et al.,[17] but was later revised to include the age range of 12-18 years, with emphasis on the concepts inherent in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF).[18] The GMFCS is a standardised method for describing the GMF ability of children with CP in one of the five ordered levels.[17]
Height
Height was measured using two different methods; the first method was used for children who could stand upright. The height was measured using the Veena medicare height measuring scale (2.1 m). The height was taken and recorded to the nearest cm (but later converted to m) by placing a straight stick or ruler from the vertex of the head of the participants to meet the height measuring scale. The second method was used for children with CP who could not stand independently by using a Welden Fiberglass tailor’s tape (1.5 m long). With the child lying supine, a straight wooden object or ruler was placed at the vertex (of the head) and made to point upward. The tape was placed in close contact with the body, at 180 degrees from the wood/ruler, parallel to the mid-line of the body, and taken across the body down to the heel of either foot with the legs closely placed together.
Weight
The weight was measured in kg, with the children in underpants or light clothing only. The weight was measured using two different methods for different categories of children. For children who could stand upright independently, their weight was measured to the nearest 0.1 kg using a Rorian analog mechanical weighing scale with a capacity of 120 kg. The researcher took the reading to the nearest 0.1 kg from the weighing scale. For the child with CP who could not stand, the assistant/caregiver’s weight was taken. The assistant/caregiver was then asked to carry the child, and their weight was taken and recorded. The weight of the caregiver was subtracted from the overall weight of the caregiver and child in order to get the weight of the child. The procedure was repeated for all the participants.
BMI
The BMI was calculated for each child by dividing the weight of each child by the square of their individual height. The unit is kg/m2.
WC
The WC of each child was measured using a Welden Fiberglass tailor’s tape (1.5 m long). With each child in supine recumbent position, the tape was placed around the waist at the level of the umbilicus, and the reading in cm on the tape measure was recorded.
WHR
Using an inelastic Welden Fiberglass tailor’s tape (1.5 m long), the hip circumference was measured by placing the tape around the hip and taking the measurement at the highest point of the gluteal region. The hip circumference reading in cm was recorded and compared with the WC to derive the ratio.
SFT
SFT was measured in millimetres using a Fat O’ Meter. The measurement was taken on one side of the body for consistency. The SFT was measured on the right side of the body three times at each site of the triceps, abdomen, and thigh to the nearest 1.0 mm. The mean of the two closest measurements at each site was recorded. Triceps SFT was measured vertically over the triceps muscle midway between the acromion and olecranon process. Thigh SFT was measured vertically at the mid-thigh. The abdominal SFT was measured on the right side and at the level of the umbilicus.
RESULTS
Socio-demographic characteristics of participants
Forty-eight children with CP were recruited into the study. Their mean age was 37.69±27.36 months. The study consisted of a larger proportion of male children (n = 32; 66.7%). The majority of the children fell within the age range of 12-48 months (n = 35; 72.9%). None of the participants recruited was ambulating in a wheelchair, even though the highest percentage of the children had a GMFCS level of 5 (n = 20; 41.7%).
Anthropometric measurements of participants
The average weight of the children was 10.70±4.21 kg, and their BMI averaged at 12.88±2.83 kg/m2. WC and WHR were measured on average as 43.13±6.75 cm and 0.98±0.25, respectively. The SFT measurements were taken at three different sites for each child. Specifically, triceps SFT, SFT over the thighs, and SFT over the abdomen, with average measurements of 7.13±3.04 mm, 9.28±4.11 mm, and 6.17±3.10 mm, respectively.
The GMFM of the children was assessed in various domains such as lying and rolling, sitting, crawling and kneeling, standing, walking, running, and jumping. On average, the children achieved a total GMFM score of 27.06%.
Relationship between GMF and selected indices of body composition of children with CP aged 1-12 years using Pearson correlation estimate
The findings of this study demonstrated a significant and strong linear relationship between the weight of children with CP and their GMFM score (r = 0.569, p = 0.00). A significant positive but weak linear relationship was obtained between the GMFM score and BMI (r = 0.24, p = 0.00). The correlation value revealed a linear relationship between the WC of the children and their GMFM score (r = 0.403, p = 0.004). However, the strength of this relationship is weak (r <0.5), although it can still be considered reliable (p <0.05).
The findings of the study also revealed a negative relationship between the GMFM score and WHR (r = -0.22, p = 0.133). The results also revealed a weak but positive relationship between Triceps SFT and the GMFM score of children with CP (r = 0.302, p = 0.037). However, a very weak correlation was observed between Thigh SFT and the GMFM score in the children (r = 0.08, p = 0.591). Thus, no significant relationship could be established between Thigh SFT and the GMFM score of the children. On the other hand, the results showed a weak but positive relationship between abdomen SFT and GMFM score in the children (r = 0.325, p = 0.024). The relationship between GMF and selected indices of body composition (weight, BMI, WC, WHR, and SFT) of children with CP aged 1-12 years in Nigeria, as determined by Pearson correlation estimate, has been documented in Table 1.
| Variable | GMFM | |
|---|---|---|
| r value | p value (sig.) | |
| Weight | 0.569 | 0.001* |
| Body mass index | 0.247 | 0.090 |
| Waist circumference | 0.403 | 0.004* |
| Waist-hip ratio | 0.220 | 0.133 |
| SFT triceps | 0.302 | 0.037* |
| SFT thigh | 0.080 | 0.591 |
| SFT abdomen | 0.325 | 0.024* |
*Correlation is significant at the 0.05 level (2-tailed), SFT: Skinfold thickness, GMFM: Gross motor function measure.
Relationship between GMF and selected indices of body composition of children with CP aged 1-12 years using the multiple linear regression model.
The relationship between GMF and the selected indices of body composition was further examined using a multiple linear regression model [Table 2]. The model diagnostic shows that the model is good (F = 34.72, p = 0.00), and the combined independent variables (weight, BMI, WC, WHR, SFT thigh, SFT triceps, and SFT abdomen) account for approximately 85.2% of the variance in the predicted/dependent variable GMFM (adjusted r-squared = 0.852). This suggests that the model can be utilised for prediction, and the included predictors are capable of predicting a significant portion of the GMFM score.
| Variable | B | Std. error | Beta (std.) | t | Sig. | f (sig.) | Adjusted (r-squared) |
|---|---|---|---|---|---|---|---|
| (Constant) | 91.572 | 14.456 | 6.334 | 0.001 | 34.72 (0.001) | 0.852 (9.07) | |
| Weight | 2.702 | 0.450 | 0.483 | 6.000 | 0.001 | ||
| Body mass index | -0.388 | 0.527 | -0.047 | -0.735 | 0.466 | ||
| Waist circumference | -0.101 | 0.251 | -0.029 | -0.402 | 0.690 | ||
| Waist-hip ratio | -5.733 | 5.991 | -0.060 | -0.957 | 0.345 | ||
| SFT triceps | 1.676 | 0.625 | 0.216 | 2.681 | 0.011 | ||
| SFT thigh | -1.228 | 0.420 | -0.215 | -2.928 | 0.006 | ||
| SFT abdomen | -1.838 | 0.600 | -0.242 | -3.065 | 0.004 |
Dependent variable: Total GMFM score, SFT = Skinfold thickness, GMFM: Gross motor function measure.
Regarding individual variables, weight (β = 0.483, p = 0.00) and triceps SFT (β = 0.216, p = 0.011) have a significant positive impact on the GMFM score. However, SFT around the thigh (β = -0.215, p = 0.006) and abdomen (β = -0.242, p = 0.004) have a significant negative effect on the GMFM score of children with CP in this study.
DISCUSSION
Socio-demographic characteristics of participants
The study revealed that the majority of the children with CP were males. One possible explanation for the higher prevalence of the male gender with CP could be the greater incidence of preterm birth in males compared to females.[19] Since pre-term birth is a recognised risk factor for CP,[20] it suggests why more male children were found to have had CP in this study. This aligns with other studies, which reported a higher proportion of males compared to females among children with CP.[21,22]
This study also revealed that the average age of children with CP who participated in this study was 37.69±27.36 months, with the majority (72.9%) falling within the 12-48 months age group. A possible reason for this finding could be that parents of older children with CP stopped bringing their children for treatments due to the level of burnout associated with caring for children with CP, hence the scarcity of older children in the clinics.[23]
Anthropometric measurements of participants
Based on the results of this study, it was observed that the average weight of the children was 10.70±4.21 kg. This finding was compared to the result of a study by Adekoje et al.,[24] where the average weight (12.0±4.5 kg) of children with CP (1-12 years) was compared with the average weight (13.7±4.8 kg) of typically developing children (1-12 years). When the mean weight of the participants of this study was compared to the mean weight of typically developing children in the study conducted by Adekoje et al.,[24] it was found that the participants in this study were underweight. One possible reason for the observed underweight among children with CP in this study could be that the majority of them had severe impairment (GMFCS III-V), which could impact motor function and cause associated gastrointestinal co-morbidities like feeding difficulties and constipation, resulting in malnutrition and underweight.
The WC and WHR were measured on average as 43.13±6.75 cm and 0.98±0.25, respectively. The normal WHR cut-off is 0.85-0.96, which means that most of the participants have a low to moderate risk of obesity.[25] The observed result may be attributed to the variation in growth patterns and body compositions exhibited by children with CP in comparison to those without CP. This finding differs from the results of a study conducted by Bansal et al.,[26] which reported that the majority (60%) of children with CP had a mean WHR >1.0, indicating a high risk of obesity. These variances in results can be explained by the inclusion criteria of the studies. Children with severe motor impairment (GMFCS V) were excluded from the study by Bansal et al.[26]
Regarding SFT measurements, the triceps SFT, SFT over thighs, and SFT over the abdomen had average measurements of 7.13±3.04 mm, 9.28±4.11 mm, and 6.17±3.10 mm, respectively. These means are low when compared to the control group of the same age range in a study conducted by Adekoje et al.,[24] This means that the participants of this study have muscle wasting, which may be attributed to undernutrition and reduced physical activities.
The motor function of the children was assessed using the GMFM. On average, the participants achieved a total GMFM score of 27.06%, which is considered to be low, indicating severe disability. The GMFM scores could have been influenced by the children’s age and developmental stage at the time of study, as the majority of the participants (72.9%) fell within the 12-48 months. This finding corresponds to the results of a study conducted by Omole et al.[27] which reported that the majority (61%) of children with CP were classified as severely disabled, and 53.5% had an average GMFM score of <40.9%.
Relationship between GMF and selected indices of body composition of children in Nigeria with CP aged 1-12 years
This study revealed that the highest percentage of the children were on level 5 on the GMFCS, even though none of them were ambulating with the aid of a wheelchair. Caregivers physically carried their children to the clinic despite their age and level of disability. This may be due to the mindset of the caregivers about the possible stigma attached to wheelchair use in an African setting where this study was carried out.
The result of this study shows a significant linear relationship between GMF and the weight of children with CP. This means that as the weight of the children increases, there is a corresponding positive increase in their GMFM score. This finding is consistent with a study by Marmeleira et al.[28] which also reported that weight status had a detrimental impact on gross motor skills and overall motor proficiency in children with CP. However, it is important to note that the study aimed to find the correlation between motor function and body composition, not to establish causality or impact. The effects of abnormal body composition on health and general conditioning, rather than motor skill development due to CNS injury, should be considered for a more comprehensive interpretation of the results.
Furthermore, we found a weakly significant positive linear relationship between GMF and WC in children with CP. This implies that as the WC of children with CP increases, there is a corresponding weak positive increase in their GMFM score. This corresponds to the findings of a study by Tomoum et al.[29] which reported a significant decrease in WC in non-ambulatory children with CP who had reduced motor function.
The result of this study also observed a weak but significantly positive relationship between GMFM and SFT in children with CP. However, no significant relationship was observed between GMF and thigh SFT in these children. Using the percentile references for triceps SFT provided by WHO in 2006 (underweight = <9.7 mm, Normal = 9.8-11.5 mm, overweight = 11.6-13.4 mm, obese = >13.5 mm), it was observed that the majority of the participants in this study were slightly underweight, which can be explained by likely feeding difficulties as a result of the severity of motor impairment in the majority of the participants.
Effect of spasticity on the outcome of this study
Spasticity, a hallmark of CP, may have influenced the study outcomes by affecting both motor function and body composition. Increased muscle tone from spasticity can impair movement and postural control, which may alter anthropometric measures. The positive correlation between weight and GMFM scores (r = 0.569, p = 0.00) might be confounded by spasticity, as it can reduce mobility and lead to abnormal fat distribution.[30] Similarly, the weak correlation between BMI, WC, and GMFM (r = 0.24, p = 0.00; r = 0.403, p = 0.004) could reflect disproportionate muscle and fat distribution in children with spasticity.[31] In addition, SFT measurements may be altered due to spasticity, affecting fat distribution.[32,33] The negative relationship between GMFM and WHR (r = -0.22, p = 0.133) might also reflect posture distortions caused by spasticity.[34] Given these factors, future studies should assess spasticity and muscle tone to better understand their impact on body composition and motor function in children with CP, using more precise measurement techniques like DXA.
Limitations
The study, while providing valuable insights into the relationship between GMF and body composition in children with CP, has several limitations:
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1.
Sample size and demographics: The sample size of 48 children, consisting of 32 males and 16 females, may limit the generalisability of the findings. Additionally, the majority of children were at GMFCS level V, which could skew results and may not fully represent the broader population of children with CP across all functional levels.
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2.
Measurement limitations: Body composition was assessed using indices like BMI, WC, and SFT, which, although valid, may not provide a comprehensive understanding of muscle mass vs. FM, which is critical in understanding GMF in CP.
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3.
Age range and variability: With an average age of 37.69 ± 27.36 months and a wide range of ages, the findings may be influenced by developmental stage, as motor function and body composition can vary significantly with age.
These limitations suggest that further research with a larger, more diverse sample, more precise body composition measures, and longitudinal designs would be beneficial to confirm and expand upon these findings.
CONCLUSION
This study found that selected body composition indices, particularly weight and triceps skinfold thickness, are significantly associated with GMF in children with CP, while waist-hip ratio shows a negative relationship. However, these associations are mostly weak to moderate, indicating that body composition alone does not determine motor function.
The findings highlight the need for a holistic rehabilitation approach that integrates body composition assessment with functional and clinical factors such as severity of impairment and spasticity. Routine evaluation of nutritional and physical status should therefore complement physiotherapy interventions.
Further studies with larger samples and more precise measurement methods are recommended to better understand these relationships and inform clinical practice.
Ethical approval
The research/study was approved by the Institutional Review Board at University of Ibadan/ University College Hospital Health Research Ethics Committee, number UI/EC23/0187, dated 21st March 2023.
Declaration of patient consent
The authors certify that they have obtained all appropriate consent forms from the participants’ parents/guardians. In the form, they have given their consent for the participants’ clinical information to be reported in the journal. They understand that the names and initials will not be published and due efforts will be made to conceal the participants’ identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
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