Cerebral Palsy And Its Impact On Heart Function: A Review

Etiology

Write a review on Cerebral Palsy with respect to Heart.

Literature review is an essential part in research process. The main objective of reviewing this topic on cerebral palsy in children is to find out reflect the previous work that has been done with respect to the problem and to find out the strategic interventions. The information from the review will further give clues to conduct future studies. The various disorders responsible for the impairment of motor functioning in the children, Cerebral Palsy (CP) plays a vital role, a common reason behind the physical disability in children throughout the world affecting more than 2.5 children per 1000 births in United States (Pakula, Braun & Yeargin-Allsopp, 2009). An estimation of 8000 infants with addition of approximately 1,500 children of pre-school age is clinically diagnosed with CP each year (Islam et al., 2015).

The term cerebral palsy refers to disorientation in body movement. The disorder relates to posture deformities due to lesion formed in immature brain (Tugui & Antonescu, 2013). The modified definition of cerebral palsy showed the involvement various syndromes such as the motor impairment and abnormalities in the brain during the early development period (Fazzi et al., 2012). Later, the International Classification of Functioning, Disability and Heath (ICF) gave the revised definition of the cerebral palsy disorder by incorporating the concepts developed by the committee proposing that “Cerebral palsy is an umbrella term in which the activities are restrained permanently during body movement and maintaining posture, attributing to hindrance in the developing infant brain. The disorders of the motor system comprise disturbed sensation, abnormal perception and problem in cognitive and communicative behavior with problems in secondary musculoskeletal (Rinehart et al., 2013).

Cerebral palsy is categorized based on the motor impairment prognosis in the developing children. This clinical disorder is a complex group of syndromes manifested at various levels (Fazzi et al., 2012). Importance of categorization into groups is vital in understanding the problem status and its prognosis. Based on the nature of the syndrome the upcoming status can be predicted and therefore the individual variations can be evaluated at various point of time. Understanding all the features of cerebral palsy can help to identify the incidental time and properties and thereby providing education to the family members regarding the prognosis by providing relevant services (Barua, Kaushik & Gulati, 2017). The classification of the disorder is based on topographical distribution, severity level and the kind of disorder related to mobility. The terms linked with CP are hemiplegia, diplegia and quadriplegia. Monoplegia and triplegia are also known (Boyd et al., 2013). Diplegia with muscle spasm is related to problems in the gross motor functioning specially in the lower part of limbs (Dreher et al., 2012). The mobility impairment in all limbs including the trunk portion and disrupted speech with language defect refers to spastic quadriplegia. The hemiplegic affects one side of the body (Moreno-De-Luca, Ledbetter & Martin, 2012). The most prevalent disorder with respect to movement is the spastic cerebral palsy characterized by disrupted voluntary movement with exaggerated reflex action accounting 85 % of the individual with CP (Beyaert, Vasa & Frykberg, 2015). There is little evidence regarding the classification of CP based on severity, thus in order to understand the management of CP, additional features should be considered in future studies.

Categorization of Cerebral palsy

Children suffering with CP recorded autonomic dysfunction linked with altered heart rate including other deficits such as impairment of muscle strength, change in the movement velocity, and increased demand of energy in motor activities with abnormal cardiovascular capacity (Toledo, 2012). The regulation of the heart rate depends on the differentiated sympathetic and the parasympathetic pathways of the efferent nervous system that determines the beats’ oscillations (Olufsen & Ottesen, 2013). Children with CP shows disoriented sympathetic and parasympathetic pathways that arise due to lesion formation in the brain affecting the autonomic modulation (Santos et al., 2017). The pathological reasons behind fast heart rates can be evaluated by studying the varied heart rate in standing and with face upwards termed supine postures.

Experimental study:

The studies conducted on the children with CP and the normal children taken as control with normal development of motor system of same age, showed elevated heart rate both in resting condition and also while performing exercises in case of children with CP in their daily life activities (Robert et al., 2013). The increased heart rate was due to elevated motor impairment and the children with CP were classified in different levels based on Gross Motor Function Classification System (GMFCS) (Grecco et al., 2013). The individuals who lacked mobility was classified as level IV and V whereas the ones who walked without any assistance was level I and III (Kenyon et al., 2017). Thus to understand the effect on heart functionality, it is essential to understand the modulation of the autonomic nervous system by comparing between the children with palsy and the one with normal motor function. In an experiment conducted on children with spastic CP with both male and female individual aged 9±3 years with 12 children having 5 females and 7 males were classified with restricted functions according to GMFCS. The control group which was taken aged 8±2 years with 16 children having 11 female and 5 males. The children with restrained understanding and under medications were not included in the study (Miller et al., 2012).

Results:

All the readings of the varied heart rate and the intervals of R-R were recorded both in supine and in standing position, in which spontaneous breathing recorded 10-20 heart rates (Schäfer & Vagedes, 2013). Each posture was maintained for 15 minutes without any movement and speech. The statistical results showed no significant difference in the values of age and gender both in the experimental and the control group. The R-R intervals analysis in supine position showed high HFnu (High Frequency normalized units) and low LFnu (Low Frequency normalized units) in the control group with respect to experimental group having no significant variation in the intergroup. The data in the standing position showed low HFnu and increased LFnu values in the control group with lowered heart rate in standing posture with respect to supine position (Khodor et al., 2014). The results of the experimental group showed same results as the control group. The assessment showed that individuals didn’t show any gender discrepancies thereby maintaining homogeneity. The variation of the heart rate is dependent on age, as the parasympathetic and the mediated sympathetic system alter with the development resulting in greater heart rate variability (Stein & Pu, 2012).The experimental group in supine posture showed greater dominance of the autonomic sympathetic in the heart rate with respect to the control. This information reflected that the children with CP have elevated energy expenditure due to altered muscular tone and involuntary mobilities. Another point that was observed, the control showed adjusted modulated heart rate during changing from supine to standing posture. This adjustment was absent in the experimental group. This could be related to the findings that apart from the lesions in cerebral of the CP children depriving the hemispherical influences to modulate the autonomic mechanism, there is a consequent decrease in autonomic cardiac regulation (Daulatzai, 2012). Studying the correlation between GMFCS and different frequency unit values gives a positive finding that in standing posture, higher the rate of impairment in motor system, lower the varied heart rate. Thus the children with limited functions show less mobility with increased energy expenses and decreased cardiopulmonary resistance (Brunton & Rice, 2012). The CP children showed lowered parasympathetic deliverables in adjusting the heart rate.

Influence on heart rate due to motor impairment

The children with CP have restrained fitness in daily activities. The levels of fitness are studied through exercise tests. The exercise tests play a primary role in measuring the physical fitness of CP children (Maltais et al., 2014).  The tests are integrated into three fitness categories. The test for measuring the aerobic capacity, termed as the sub maximal exercise tests not considering the maximum effort of the concerned individual with minimal exercise, avoiding any fatigue state. Another test is to record the maximum amount of oxygen consumed per unit time from start to exhaustion stage, the third one is the measurement of the anaerobic potential pathways. The tests performed on the individuals with CP, can offer significant results to see whether improving or declining. As there is no such evidence to particularize the tests based on the CP types, a developed set of exercise based measurements can aid the therapists to upgrade better understandings in conducting particular test on the basis of requirement. Based on this, Delphi tests can be implemented which surveys the individual giving their feedback to bring out the consensus (Dalen et al., 2013).

Minute Walking Test (MWT):

Among the various exercise tests, the walking test is relevant as it is simple to conduct, less expensive, and safe to perform on children with CP (Pathare, Haskvitz & Selleck, 2012). Six minute walk is one of the exercise tests which have been found to be productive to assess the walking ability in the children with CP facing problem in mobility. The twelve minute walk test was modified to examine the problems in the respiratory disorders to determine the maximum oxygen requirement. These tests were later altered to 6 minutes or 2 minutes which were of equal importance and consumes less time. Among the 2 minutes, 12 minutes, 6 minute walk tests, 6MWT was found to be more useful and relevant in measuring the exercising capacity of the children with CP having respiratory and chronic heart disease (Singh et al., 2014). The 6MWT can analyze the fitness level of the cardio respiratory system both in the children with CP and the controlled healthy children.

Evaluation of Minute Walk Test:

In order to evaluate the assessment of the 6MWT on the children with CP, an experiment on children with level I and II according to GMFCS aged between 10 and 16 years divided into two groups was conducted (Grecco et al., 2013). In one group there were twenty children showing hemiplegic syndrome and the other group comprises 4 children with diplegic nature. The division of groups was made on age, gender, height, body mass and CP type. At the initial stage the gas exchange test was conducted on them using the 6WMT which was again performed on one group after a week to record the reproducibility. And the second group finished the walking program in 8 weeks (Shoemaker et al., 2013).

Experimental study

The walking program consists of 3 times walking of 40 minutes per week which was continued for 8 weeks, the intensity of the oxygen uptake peak being 50% (VO₂ peak) recorded in the 6WMT trails. In performing the 6MWT the children were provided with a gas analyzer before starting the test. The test is designed according to standard recommendations in which 2 lines were set with a gap of 20m (Abuín et al., 2015). The children were said to walk depending on capacity for 6 minutes without any external support. The data were recorded at the resting stage, during performing the 6MWT and at the end followed by a recovery period of 5 minutes.

The data obtained from the gas exchange test in 6MWT can be considered as a method in evaluating the exercise test in rehabilitation program.  The importance of the study gives the movement capabilities of the CP children among the level I, II, III and IV (classified by GMFCS) (Grecco et al., 2013). Results showed that the children with level III CP walked 223m less than the children taken as control in 6 minutes walk test in average (Kamp et al., 2014). Same was found in children with CP level I, II and IV walked less than the control children. These results confirm the fact that CP can be one of the reasons that affects the movement ability even in the child with lowest motor CP dysfunction (Cantin, Ryan & Polatajko, 2014). Some of the barriers in performing the 6MWT included the levels of motivating the children in experiment and variation in interpreting the commands so to modify this use of rubber bands or wheels were used as incentive providing the participant an urge to complete the test (Dawson et al., 2013).

One of the statistical studies showed that age was the only factor that imposed significant impact on the 6MWT values but still the prediction value was too low (Casillas et al., 2015). Evaluation of result, correlated with previous studies showed non consistent trend in the results. The age influence on the variation of the 6MWT values agreed with studies carried out by Hugo-Hamman (2017) conducted on children with ages between 4-16 years. Another significance of 6MWT provides a better patient’s index defining the performance on daily basis.

Limitations:

The limitations in conducting the 6MWT had no such assessment to understand the intellectual ability. This led to the defects with children having CP suffering from cognitive abnormalities and experience minimal understanding of commands given to them.

Results

Future prospects:

All the studies conducted by 6MWT on the children with CP at different levels should significant differences with the controlled children. Age being one of the factors in determining the levels of CP requires further research to explore more findings (McIntyre et al., 2013). More research work in assessing the heart rate to investigate the amount of energy expenditure should be done (Reiner et al., 2013). Physiological monitoring can help to understand that whether elevated 6MWT is directly proportional to higher activities performed daily by children with CP.

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