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Relationship Between Gross Motor Function and Selected Indices of Body Composition in Children With Cerebral Palsy
* Corresponding author: Dr. Margaret Bukola Fatudimu, Department of Physiotherapy, College of Medicine, University of Ibadan, Ibadan, Oyo, Nigeria. bukolafatudimu@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Fatudimu MB, Odimayo D, Gbonjubola YT. Relationship Between Gross Motor Function and Selected Indices of Body Composition in Children With Cerebral Palsy. J Health Allied Sci NU. doi: 10.25259/JHS-2024-5-7-(1380)
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 aimed to provide a better understanding of the relationship between gross motor function and selected indices of body composition, including weight, waist circumference, waist-hip ratio, BMI, and skinfold thickness, 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 Memorial Children’s Hospital and University College Hospital using a purposive sampling technique. Descriptive and inferential statistics were used to analyse the results at an alpha level of ≤ 0.05. The 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 GMFCS level V. The average weight of the children was 10.70±4.21 kg, and their BMI averaged 12.88±2.83 kg/m2. Waist circumference and waist-hip ratio were measured with an average of 43.13±6.75 cm and 0.98±0.25, respectively. Triceps skinfold thickness, skinfold thickness over the thighs, and skinfold thickness 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 gross motor function and weight of children with CP. Additionally, a significantly positive but weak linear relationship was found between the GMFM (gross motor function measure) and BMI (body mass index), as well as with the waist circumference of the children. Conversely, a negative relationship was found between the GMFM and waist-hip ratio of the children with CP. Additionally, a weak but positive relationship was observed between the GMFM and triceps skinfold thickness (SFT) of children with cerebral palsy, as well as between their GMFM and abdominal SFT.
Conclusion
The outcome of this study revealed that weight, BMI, waist circumference, triceps skinfold thickness, and abdominal skinfold thickness showed a significant positive relationship with GMFM, while the waist-hip ratio showed a significant negative relationship with GMFM in children with CP. Therefore, healthcare professionals should consider prioritising the improvement of body composition as part of rehabilitation programmes for children with CP.
Keywords
Body mass index
Cerebral palsy
Skinfold thickness
Waist circumference
Waist-hip ratio
INTRODUCTION
Body composition refers to the relative proportions of fat tissue, bone mass, muscle mass, and total body water in an individual.[1] It specifically indicates the balance between fat mass (FM) and fat-free mass (FFM).[2] Over time, body fat has garnered the most attention due to its association with a higher risk of various diseases, systemic dysfunctions, and premature death.[3,4] While excess body fat poses significant health risks, lean body mass, which includes skeletal muscle, has also been recognised as crucial for overall human function.[5] Lean body mass is a key health indicator, reflecting both physical health and wellness.[6] A significant reduction in lean body mass can lead to reduced muscle strength, difficulty performing daily activities, negative emotional and psychological effects, and even mortality.[7] This is particularly evident in sarcopenia, a condition characterised by the loss of lean body mass, leading to substantial declines in strength, physical activity, and overall functionality.[5]
Overweight and obesity are strongly linked to poor gross motor development and endurance.[8] Studies have shown a negative relationship between motor skills and body mass index (BMI) in typically developing children in the United States,[9] with obese children demonstrating poorer motor skills compared to their peers with normal or overweight status.[10] The weight of children has also been found to influence motor coordination, with effects persisting into adulthood.[11] Overweight children who are developing normally tend to have greater difficulty mastering fundamental movement skills compared to their non-overweight counterparts[12]
Body composition plays a critical role in influencing the quality of life, activity levels, social participation, general health, and functional capabilities of children with cerebral palsy (CP) and their caregivers.[13] Research conducted in the United States found that children with hemiparetic and diparetic CP had higher BMI compared to those with quadriparetic CP.[14] However, there is limited data on the relationship between body composition and gross motor function in Nigerian children with CP. Previous studies have emphasised that body composition serves as an important health indicator[5] and significantly impacts physical function in children.[8] Hence, further research is needed to investigate the specific relationship between body composition and gross motor function in Nigerian children with cerebral palsy (CP). This research will provide valuable insights for healthcare professionals and parents, helping to promote healthy body composition in children with CP. The findings may also inform targeted interventions and rehabilitation strategies designed to enhance motor performance and improve health outcomes for children with cerebral palsy.
While studies in other parts of the world have examined the impact of body composition indices on children’s functional abilities, no research has been conducted on the relationship between body composition indices and gross motor function in children with CP in Africa, particularly in Nigeria. Additionally, the lack of data on the correlation between gross motor function and body composition indices in Nigerian children with CP underscores the need for this study. Therefore, this research aims to investigate the relationship between gross motor function and selected body composition indices, including weight, BMI, skinfold thickness, waist circumference, and waist-hip ratio, in Nigerian children with cerebral palsy.
MATERIAL AND METHODS
The participants in this correlational study were 48 purposively recruited children with cerebral palsy (CP) between the ages of 1 and 12 years, who were brought to the physiotherapy clinics of the University College Hospital and Oni & Sons Memorial Children’s Hospital, located on Ring Road, Ibadan, Nigeria, for management by their caregivers. The two centres where the participants were recruited are the two major referral centres for CP in the southwestern part of the country. Only participants whose parents had consented to the study and who had been diagnosed with CP by a physician, and who were aged between 1 and 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 obtained from the University of Ibadan/University College Hospital Health Research Ethics Committee prior to the commencement of this study. Since the proposed participants’ age range did not allow them to give consent, it was obtained from their parents. The parents were given consent forms that detailed the purpose, process, and timeframe of the study. The parents’ questions and concerns were addressed, and they were given the option to participate in the study or decline. They could choose to withdraw at any time during the study duration without any consequences.
The socio-demographic data of the participants was documented using a socio-demographic data collection form. The gross motor function measure (GMFM) -88 was used to assess the gross motor function of the participants. The GMFM is a criterion-referenced measure designed to evaluate changes in gross motor function in children with cerebral palsy.[15] The GMFM is considered the gold standard for the assessment of gross motor function in children with CP.[16]
The Gross Motor Function Classification System (GMFCS) was used to categorise children with cerebral palsy (CP) according to their functional ability levels. This instrument was initially developed by Palisano et al. [17] but later revised to include an age range of 12 to 18 years, with an 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 gross motor functional 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 recorded to the nearest centimetre (later converted to metres) by placing a straight stick or ruler from the vertex of the participants’ heads to 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 a 180-degree angle from the wood/ruler, parallel to the midline of the body, and taken across the body down to the heel of either foot with the legs closely together.
Weight
The weight was measured in kilograms (kg), with the children wearing only underpants or light clothing. 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 analogue mechanical weighing scale with a capacity of 120 kg. The researcher rounded the reading to the nearest 0.1 kg on 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 to calculate the weight of the child. The procedure was repeated for all the participants.
Body mass index
The body mass index (BMI) was calculated for each child by dividing the child’s weight by the square of their height. The unit was kg per meter square (kg/m2).
Waist circumference
The waist circumference of each child was measured using a Welden Fiberglass tailor’s tape (1.5 m long). With each child in a supine recumbent position, the tape was placed around the waist at the level of the umbilicus, and the reading in centimetres on the tape measure was recorded.
Waist-hip ratio
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 centimetres was recorded and compared with the waist circumference to derive the ratio.
Skinfold thickness
Skinfold thickness was measured in millimetres using a Fat O’ Meter. The measurement was taken on one side of the body for consistency. The skinfold thickness 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 skinfold thickness was measured vertically over the triceps muscle midway between the acromion and olecranon process. Thigh skinfold thickness was measured vertically at the mid-thigh. The abdominal skinfold thickness was measured on the right side at the level of the umbilical.
RESULTS
Socio-demographic characteristics of participants
Forty-eight children with cerebral palsy (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 were ambulating in a wheelchair, despite the highest percentage of children having a Gross Motor Function Classification System (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 body mass index (BMI) averaged 12.88±2.83 kg/m2. Waist circumference and waist-hip ratio were measured at an average of 43.13±6.75 cm and 0.98±0.25 cm, respectively. The skinfold thickness measurements were taken at three different sites for each child. Specifically, triceps skinfold thickness, skinfold thickness over the thighs, and skinfold thickness 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, including “lying and rolling”, “sitting”, “crawling and kneeling,” and “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 cerebral palsy and their GMFM score (r =0.569, p<0.001). A significantly positive but weak linear relationship was observed between the GMFM score and BMI (r=0.24, p< 0.01). The correlation value revealed a linear relationship between the children’s waist circumferences and their GMFM scores (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 study’s findings also revealed a negative correlation between the GMFM score and waist-hip ratio (WHR) (r= -0.22, p=0.133). The results also revealed a weak but statistically significant positive correlation between SFT and GMFM scores in children with CP (r=0.302, p=0.037). However, a very weak correlation was observed between the 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 correlation between abdominal SFT and GMFM scores in the children (r = 0.325, p = 0.024). The relationship between gross motor function and selected indices of body composition (weight, BMI, waist circumference, waist-hip ratio, and skinfold thickness) in children with cerebral palsy (CP) aged 1-12 years in Nigeria, as determined by Pearson correlation estimates, is documented in Table 1.
| Variable | GMFM | |
|---|---|---|
| r-value | P-value | |
| Weight | 0.569 | 0.000* |
| BMI | 0.247 | 0.090 |
| Waist circumference | 0.403 | 0.004* |
| Waist-hip ratio | 0.220 | 0.133 |
| ST triceps | 0.302 | 0.037* |
| ST over thigh | 0.080 | 0.591 |
| ST over abdomen | 0.325 | 0.024* |
GMFM: Gross motor function measure, BMI: Body mass index, ST: Skinfold thickness.
P-value indicates the probability that the relationship occurred by chance (p < 0.05 is typically considered statistically significant).
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 gross motor function 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 utilized for prediction, and the included predictors can account for a significant portion of the GMFM score.
| B | Standard. error | Beta (Standard deviation) | t | Significance | F (Significance) | Adjusted (R-squared) | |
|---|---|---|---|---|---|---|---|
| (Constant) | 91.572 | 14.456 | 6.334 | 0.00 | 34.72 (0.00) | 0.852 (9.07) | |
| Weight | 2.702 | 0.45 | 0.483 | 6 | 0.00 | ||
| BMI | -0.388 | 0.527 | -0.047 | -0.735 | 0.466 | ||
| Waist Circumference | -0.101 | 0.251 | -0.029 | -0.402 | 0.69 | ||
| Waist-hip ratio | -5.733 | 5.991 | -0.06 | -0.957 | 0.345 | ||
| ST Triceps | 1.676 | 0.625 | 0.216 | 2.681 | 0.011 | ||
| ST Over Thigh | -1.228 | 0.42 | -0.215 | -2.928 | 0.006 | ||
| ST Over Abdomen | -1.838 | 0.6 | -0.242 | -3.065 | 0.004 |
Dependent Variable: Total GMFM (Gross motor function measure) score, BMI: Body mass index, ST: Skinfold thickness.
B: Unstandardized coefficient — the actual change in the dependent variable (GMFM score) for a one-unit change in the predictor variable; Standard Error: the standard deviation of the coefficient estimate, showing the variability; F (Significance): F-statistic and its significance — used to test the overall significance of the regression model; Adjusted (R-Squared): the proportion of variance in the dependent variable explained by the independent variables, adjusted for the number of predictors.
Regarding individual variables, weight (β=0.483, p=0.00) and triceps skinfold thickness (β=0.216, p=0.011) have a significant positive impact on the GMFM score. However, skinfold thickness 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 most children with cerebral palsy (CP) were male. 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 that reported a higher proportion of males compared to females among children with CP.[21,22]
This study also revealed that the average age of the participants (children with CP) was 37.69±27.36 months, with a majority (72.9%) falling within the 12-48 months age group. A possible reason for this finding could be the fact 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, the average weight of the children was found to be 10.70±4.21 kg. This finding was compared to the results of a study by Adekoje et al.,[24] in which the average weight (12.0 ± 4.5 kg) of children with cerebral palsy (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 in 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 most had severe impairment (GMFCS III-V), which could impact motor function and cause associated gastrointestinal co-morbidities like feeding difficulties and constipation, resultantly leading to malnutrition and underweight.
The waist circumference and waist-hip ratio (WHR) were measured at an average of 43.13±6.75 cm and 0.98±0.25 cm, respectively. The normal WHR cut-off is 0.85-0.96, indicating that most 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 greater than 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 skinfold thickness measurements, the triceps skinfold thickness (ST), ST over thighs, and ST 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 lower compared to the control group of the same age range in a study conducted by Adekoje et al. [24]. This indicates that the participants in this study exhibit muscle wasting, which may be attributed to undernutrition and reduced physical activity.
The motor function of the children was assessed using the Gross Motor Function Measure (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 may have been influenced by the children’s age and developmental stage, as the majority of participants (72.9%) were within the 12-48-month age range at the time of the study. 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 gross motor function measure score of less than 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 children were at level 5 on the GMFCS, even though none of them was 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 possible stigma attached to wheelchair use in an African setting where this study was carried out.
The results of this study demonstrate a significant linear relationship between gross motor function 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 has a detrimental impact on gross motor skills and overall motor proficiency in children with cerebral palsy (CP).
Furthermore, we found a weak significant positive linear relationship between gross motor function and waist circumference in children with CP. This implies that as the waist circumferences of children with CP increase, there is a corresponding weak positive increase in their GMFM score. This finding aligns with the results of a study by Tomoum et al.,[29] which reported a significant decrease in waist circumference in non-ambulatory children with cerebral palsy (CP) who exhibited reduced motor function.
The results of this study also revealed a weak but statistically significant positive relationship between the GMFM and skinfold thickness in children with CP. However, no significant relationship was observed between gross motor function and thigh skinfold thickness in these children. Using the percentile references for triceps skinfold thickness 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 majority of the participant in this study were slightly underweight which can be explained by likely feeding difficulties as a result of the severity of motor impairment in 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 due to spasticity can impair movement and postural control, potentially altering 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, waist circumference, 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, skinfold thickness measurements may be altered due to spasticity, affecting fat distribution.[32,33] The negative relationship between GMFM and waist-hip ratio (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 such as DXA.
Limitations
The study, while providing valuable insights into the relationship between gross motor function 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, comprising 32 males and 16 females, may limit the generalisability of the findings. Additionally, most 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 such as BMI, waist circumference, and skinfold thickness, which, although valid, may not provide a comprehensive understanding of muscle mass versus fat mass —a critical factor in understanding gross motor function 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 highlights the significant influence of body composition on gross motor function among children with cerebral palsy aged 1–12 years. The results demonstrated that weight and triceps skinfold thickness positively correlate with and significantly predict gross motor function, as measured by the GMFM score. Conversely, skinfold thickness at the thigh and abdomen showed a significant negative effect on motor function. While other anthropometric indices such as BMI and waist circumference showed weaker associations, the overall regression model accounted for 85.2% of the variance in GMFM scores, indicating a strong predictive value. These findings underscore the importance of monitoring and optimising body composition to support motor function development in children with cerebral palsy.
Ethical approval
The research/study approved by the Institutional Review Board at University of Ibadan/ University College Hospital Health Research Ethics Committee, number UI/EC/23/0197, dated 21st March 2023.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
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.
References
- Validity of body-composition methods across racial and ethnic populations. Adv Nutr. 2021;12:1854-62.
- [Google Scholar]
- Body composition, its significance and models for assessment. Pakistan J Nutrition. 2009;8:198-202.
- [Google Scholar]
- Obesity: Epidemiology, pathophysiology, and therapeutics. Front Endocrinol (Lausanne). 2021;12:706978.
- [Google Scholar]
- Predicting 3D body shape and body composition from conventional 2D photography. Med Phys. 2020;47:6232-45.
- [Google Scholar]
- The effects of intermittent fasting combined with resistance training on lean body mass: A systematic review of human studies. Nutrients. 2020;12:2349.
- [Google Scholar]
- Effectiveness of exercise interventions for children with cerebral palsy: A systematic review and meta-analysis of randomized controlled trials. J Rehabil Med. 2021;53:jrm00176.
- [Google Scholar]
- Correlation between BMI, leisure habits and motor abilities in childhood (CHILT-project) Int J Obes Relat Metab Disord. 2004;28:22-6.
- [Google Scholar]
- Obesity and motor skills among 4 to 6-year-old children in the United states: Nationally-representative surveys. BMC Pediatr. 2012;12:28.
- [Google Scholar]
- Relationship between motor skill and body mass index in 5- to 10-year-old children. Adapt Phys Activ Q. 2009;26:21-37.
- [Google Scholar]
- Correlation between BMI and motor coordination in children. J Sci Med Sport. 2012;15:38-43.
- [Google Scholar]
- Fundamental movement skills and self-concept of children who are overweight. Int J Pediatr Obes. 2011;6:e464-71.
- [Google Scholar]
- Examination of the relation between body mass index, functional level and health-related quality of life in children with cerebral palsy. Turk Pediatri Ars. 2014;49:130-7.
- [Google Scholar]
- Body mass index measure in children with cerebral palsy related to gross motor classification: A clinic-based study. Am J Phys Med Rehabil. 2008;87:395-403.
- [Google Scholar]
- The gross motor function measure: A means to evaluate the effects of physical therapy. Dev Med Child Neurol. 1989;31:341-52.
- [Google Scholar]
- Reliability of the Gross Motor Function Measure in the evaluation of children with cerebral palsy: Validation for Colombia. Bol Med Hosp Infant Mex. 2022;79:33-43.
- [Google Scholar]
- Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214-23.
- [Google Scholar]
- Content validity of the expanded and revised gross motor function classification system. Dev Med Child Neurol. 2008;50:744-50.
- [Google Scholar]
- Profile of children with cerebral palsy attending outpatient physiotherapy clinics in southwest Nigeria. Af Jrl. Phys Rehab Sci. 2016;7:32.
- [Google Scholar]
- Caregivers or care providers: Who should assess motor function in cerebral palsy? J Pediatr Neurol. 2015;06:345-50.
- [Google Scholar]
- Association of motor performance of children with cerebral palsy and burnout level of their informal caregivers in African community. J Pediatr Rehabil Med. 2023;16:203-9.
- [Google Scholar]
- Anthropometry of children with cerebral palsy at the Lagos University Teaching Hospital. J Clin Sci. 2016;13:96-104.
- [Google Scholar]
- Prevalence of obesity in children with cerebral palsy. J Clin Diagn Res. 2014;8:BC08-11.
- [Google Scholar]
- Pattern of cerebral palsy seen in children attending the outpatient pediatric physiotherapy clinics in Osun State tertiary hospitals in Nigeria. South Afr J Child Health. 2018;12:52-57.
- [Google Scholar]
- Relationship between motor proficiency and body composition in 6- to 10-year-old children. J Paediatr Child Health. 2017;53:348-53.
- [Google Scholar]
- Anthropometry and body composition analysis in children with cerebral palsy. Clin Nutr. 2010;29:477-81.
- [Google Scholar]
- The contribution of spasticity to the movement disorder of cerebral palsy using pathway analysis: does spasticity matter? Developmental Medicine and Child Neurology. 2011;53:7-9.
- [Google Scholar]
- Impaired motor planning and motor imagery in children with unilateral spastic cerebral palsy: challenges for the future of pediatric rehabilitation. Developmental Medicine and Child Neurology. 2013;55:43-46.
- [Google Scholar]
- Differences in body composition according to gross motor function in children with cerebral palsy. Archives of Physical Medicine and Rehabilitation. 2017;98:2295-2300.
- [Google Scholar]
- The relationship between body composition and muscle tone in children with cerebral palsy: A case-control study. Nutrients. 2020;12:864.
- [Google Scholar]
- Does spasticity affect the postural stability and quality of life of children with cerebral palsy? J Taibah University. Med Sci. 2021;16:761-766.
- [Google Scholar]
