Cerebral palsy was a major presenting disorder in our Neurology Clinic and majority of the subjects had severely limited gross motor function, were physically dependent on caregivers for mobility and had limited utilization of assistive mobility devices. The high prevalence of cerebral palsy among neurological disorders in our study corresponds with findings in reports from other regions of the country [8
]. It underscores the significance of cerebral palsy among childhood neurodevelopmental disorders in the country.
Studies on motor function using the GMFCS classification indicate a variable distribution among populations with cerebral palsy [9
]. A high proportion of cases in the lower GMFCS levels has been reported from other regions in Nigeria [9
] , Brazil [24
] and Japan [25
] while a higher GMFCS levels have observed in population based studies from Holland [26
], Australia [27
], and Sweden [28
]. The finding in our study, and in other studies with a similar outcome [9
], could have been influenced by the tertiary health care setting in which the study was conducted. Tertiary health institutions are apt to receiving more severe cases of cerebral palsy whose management could not be addressed at lower levels of health care delivery or at home.
The high prevalence of lower level GMFCS functioning in the subjects might have negative implications for their nutritional status, HRQoL and long term survival [9
]. Okeke et al. [9
] and Tella et al. [2
]1 in their studies, which were conducted in similar circumstances as in our study, observed a significantly negative association between lower GMFCS levels and these variables (nutrition and HRQoL). Also Touyama et al. [25
] reported a significantly lower long term survival rate for those in GMFCS level V. In their cohort study, 85.3% of those with cerebral palsy that died were in GMFCS level V.
The setting of our study could also have influenced the predominantly upper social class distribution of the subjects. This is at variance with the observation that cerebral palsy is more prevalent in more deprived socio-economic population [29
]. The subjects’ social class distribution could have been as result of their caregivers’ class capacity to access and afford health care. In addition to increased accessibility to rehabilitative care, increased opportunities for child play activities and social support, and greater family resources could confer a better motor outcome in subjects in the upper social classes [14
Being less than 2 years of age was significantly associated with having severe impairment of gross motor function and been in the lower GMFCS levels. Early and severe manifestations of motor abnormalities have been found accountable for early presentation in cerebral palsy [9
]. Additionally, caregiver discontentment with outcome of treatment has also been adduced as reason for reduction in the number of older children with cerebral palsy visiting tropical child neurology clinics [7
]. Attainment of motor milestones such as sitting independently before 2years of age has been associated with more successful pre-walking and walking abilities [13
]. This would imply that there is a less favorable outcome with regards to pre- walking and walking abilities in the subjects. It is important to note that children classified before 2 years of age are less likely to display GMFCS level stability over time [31
] The enormous variation associated with development of gross motor abilities in this age group has been advanced as one of the reasons [32
] However Palisano et al observed that change in GMFCS level was less likely in those classified at levels I and V, and that those classified at age less than 6 years were likely to be reclassified at a lower level [31
] Consequently the possibility of a change in GMFCS level conferring a better outcome in gross motor function among subjects in the lower GMFCS levels is unlikely.
Spastic cerebral palsy was the dominant clinical type and this has also been reported severally among children with cerebral palsy [3
]. Also the high number of those with spastic cerebral palsy in the lower GMFCS levels buttresses the reported association between spasticity and higher levels of disability [13
The use of assistive technology in achieving mobility in cerebral palsy is well established in developed countries [16
] In these settings classification and monitoring of motor function, the availability of skilled manpower, a variety of assistive and adaptive mobility devices, and a well suited environment ease mobility constraints. Less than ten percent (6.8%) of the subjects who required assisted mobility utilized a manually operated device for transport. This could be adducible to one or a combination of factors that includes: poor awareness about the existence of such devices, lack of the devices, inadequate rehabilitative facilities, and inability to access these facilities where they are available. The implication is that majority of the subjects are manually transported. This increases the burden of physical care and exposes the child to a hazard such as trauma during transportation. About one-fifth of the study population had milder impairment indicating the need for adaptive devices such as truncal and pelvic braces, and hand-held assistive mobility devices.
The consequences of immobility are grim. Children with impaired mobility could be denied benefits of physical activity which could be physical (increased mobility, reduced contractures, increased muscular strength and endurance), social (developing relationships and social skills) or psychological (enhanced self-esteem and body image) [34
] Impaired mobility could result in bed sores, hypostatic pneumonia, disuse muscular atrophy, development of contractures and fractures [36
]. These could increase the risk of mortality which is higher in cerebral palsy than in the normal population [41
]. In addition other normal systemic functions that might be mildly affected such as intellectual function could become under developed as a result of isolation that is commonly associated with immobility. Impaired motor function also increases the physical and psychosocial burden on caregivers [42
]. Overwhelming burden in these caregivers could result in child abuse or neglect, psychopathology
and abdication of other social responsibilities [42
Preventing the consequences of immobility would improve outcomes in cerebral palsy. This would require a multi-dimensional approach. The objectives of such an approach should include: the identification of the magnitude of cerebral
palsy in any given population and its mobility needs, provision of comprehensive rehabilitative services and tackling the risk factors of cerebral palsy. These objectives should be championed by the health system in respective countries and in collaboration with other relevant agencies.