a)
b)
c)
/ BRIEF RESUME OF THE STUDY
INTRODUCTION:
Cerebral palsy refers to a non-progressive insult to the central nervous system during pregnancy, at birth or during the first 18 months of life and is characterized by impairments in motor control that contribute to functional limitations to posture and mobility and with involvement of oral motor function.1
Cerebral palsy is invariably associated with many deficits such as mental retardation, speech, language, oromotor dysfunction, spasticity, muscle weakness, visual impairments, epilepsy and cognitive disorders.2
Feeding is a common developmental and health challenge of children and adolescent with cerebral palsy. Any or all the levels of feeding process including gathering, preparation, ingestion, swallowing, and digestion may be involved.3
The human feeding cycle is dependent on an integrated sequence of events requiring the co-ordination of over 20 different muscles for the movement of saliva or ingested foods from the mouth to the stomach. Four distinct stages have been identified: the preparatory or anticipatory phase which involves food getting and anticipatory reactions; the oral stage involving bolus management and transfer, sucking, munching, and mastication; the pharyngeal phase during which swallowing occurs and finally esophageal phase which
begins with relaxation and opening of the upper esophageal sphincter. There may be
dysfunction of this highly complex process at any one or more levels resulting in feeding
difficulties.4
The incidence of cerebral palsy is 2-2.5 cases in every 1000 live births. There are an
estimate 4-5 million children and people in India with cerebral palsy.2 The majority (58%)
of children reported with feeding problem, including 35% with mild/ moderate feeding
impairment and 23% with severe feeding impairment. Feeding problems have been
reported in 86% of children with quadriplegia and 37% withdiplegia or hemiplegic.3
Dysphagia is known as inability to eat or swallow lumpy food. Childrenwho drooled most of the times were more likely to have dysphagia, choke and needed help with feeding. These children needmore time to feed.5
Aspiration of food either during swallowing or after more commonly results in chronic lung disease rather than acute aspiration pneumonia.Oral feeding interventions for children with cerebral palsy may be effective in promoting oral motor functions.3
Oral motor and swallowing dysfunction, poor nutritional statue and poor growth are reported frequently in young children with cerebral palsy may impact on physical and cognitive development and quality of life in later childhood.6
Cerebral palsy is frequently associated with poor growth and children with cerebral palsy tend to be shorter and lighter than their normal counterparts. Growth failure is related to the type of cerebral palsy- spastic or athetoid and to the topographical distribution, Oralmotor dysfunction also has been associated with poorer growth.7
Oral Motor Assessment Scale (OMAS) consist of evaluation of 7components - mouth closure, lip closure on the utensil, lip closure during deglutition, control of the food during swallowing, mastication, straw suction, control of liquids during deglutition. The Oral Motor Assessment Scale is found to have good reliability and validity. Good inter-examiner (kappa >0.85) and intra examiner (kappa> 0.90) agreement was obtained for the majority of the OMAS. OMAS is an accurate and valid methodof assessment of oral motor skills in children and adolescent with neurological damage. This study includes children with cerebral palsy within 3 to 13 years of age.8
The nutritional status of the children with cerebral palsy is taken by measuring height and weight of children using National Center for Health Statistics/ Centre for Disease Control and Prevention (NCHS/CDC) growth charts.9

NEED FOR THE STUDY:
Oral motor dysfunctions can hamper the growth of children with cerebral palsy.Review of literature suggests that there is paucity of studies on nutritional status of children with cerebral palsy worldwide with a wide variation in the prevalence of malnutrition in reported cases.15 In this part of India no studies have been done to find the co-relation of growth and oral motor dysfunctions in children with cerebral palsy which can be tackled to enhance the rehabilitation process. So the need arises to find the co-relation of severity of oral motor dysfunction on growth of cerebral palsy children as prognosis of the physiotherapy is depending on it.

RESEARCH HYPOTHESIS:
NULL HYPOTHESIS (H0) - There will be no Co-relation between growth and severity of oral motor dysfunction in children with cerebral palsy.
ALTERNATE HYPOTHESIS (H1) - There will be Co-relation between growth and severity of oral motor dysfunction in children with cerebral palsy.

REVIEW OF LITRETURE:
A study done on prevalence of feeding problems where showed that 90% of population of children with cerebral palsy had oral motor dysfunction. Moderate to severe oral motor dysfunctions were more prevalent among children with tetraplegia. More severe the functional motor impairments, more severe the oral motor dysfunctions.10
The swallowing impairment focuses on oral phase performance including masticatory functions, lip function, tongue function, and the duration of the oral phase, are altered in normal feeding cycles.11,12
A study done on feeding methods and health outcomes showed that percent body fat, muscle area and oral motor functions are important factors for weight gain and linear growth of children with cerebral palsy. The identification of the nutritional problem has a great potential to help improve weight, muscle mass, decrease irritability and circulation in order to halt the incidence of malnutrition in children with cerebral palsy. 3
A study done on the incidence of malnutrition in children with cerebral palsy tells about feeding problem which was usually complicated by the lack of awareness of parents. The main reasons for lack of awareness in parents were illiteracy, misconception about the neurological disorders and their associated complications in cerebral palsy. The psychological impact of having a child with severe chronic neurological disease is so deep that parents do not appreciate the feeding problems to the extent that they should.13
A studydone on Indian population on feeding problems in children with cerebral palsy in 2001 considered the prevalence and severity in each type of cerebral palsy children. Oral motor dysfunction in spastic cerebral palsy children is severely affected and indiplegic and hemiplegic cerebral palsy children is mild to moderately affected.14
There is a paucity of studies on the nutritional status of children with cerebral palsy worldwide with a wide variation in the prevalence of malnutrition in reported cases. A range of 30 to 81% using different measures of nutritional status is reported. A review study in 1996 was conducted on growth of children with cerebral palsy which revealed 14 studies over 40 years period which assessed prevalence and type of nutritional problem amongst CP children and to compared the nutritional status with those of control matched for age, sex and social class.15
The study developed Oral Motor Assessment Scale (OMAS) and evaluated its performance in terms of construct validity and reliability in a cohort of 53 children with cerebral palsy. The reliability was defined as the ratio between subject variance and total variance. The study protocol was approved by the Ethics in research committee of the School of
Dentistry, University of Sao Paulo in 2009. The scale proved that qualitatively categorized oral motor skills to be one of the diagnostic tools used by the clinician. OMAS is a viable assessment instrument with adequately established validation and reproducibility.8
A study done on normal growth charts by National Center for Health Statistics/ Center for Disease Control and Prevention 1977-1978. The Advanced data of this study in December 2000 was published with improved data and statistics.The percentile growth chart includes percentile height and weight of children with cerebral palsy at every age of either of sexes.9

OBJECTIVE OF THE STUDY:
  1. To find out severity of oral motor dysfunction in cerebral palsy children.
  2. To find out growth in children with cerebral palsy.
  3. To find out co-relation between growth and severity of oral motor dysfunction in children with cerebral palsy.

PROCRDURE, METHOD AND MATERIALS:

SOURCE OF THE DATA COLLECTION:
Department of Physiotherapy
Sri Dharmasthala Manjunatheshwara (SDM)College Of Medical Sciences And
Hospital Dharwad.

METHOD OF COLLECTION OF DATA:
Ethical Clearance is been obtained from SDM college of Medical Science And Hospital. All the subjects from 3years to 13years of age children with cerebral palsy will be included in the study. After finding their suitability as per their inclusion criteria and exclusion criteria, subjects who are willing to participate in this study, informed written consent will be taken from the parents of these children. The demographic data will be collected on the basis of personal data taken from the parents.
MATERIAL:
  1. Demographic data collecting sheet.
  2. Digital weighing machine.
  3. Stediometer.
  4. Different eating materials (soft, semi-solid, hard textures of food stuffs as per the child’s likes) and drinking water.
  5. Oral Motor Assessment Scale.
  6. Measuring tape.
INCLUSION CRITERIA:
  1. Children with cerebral palsy
  2. Age range from 3 to 13 years.8
  3. Either of sexes.
EXCLUSION CRITERIA:
  1. Child on Ryle’s tube or gastric tube.
  2. Congenital malformations of oral cavity like cleft lip and/or palate.
  3. Unconscious patients.
STUDY DESIGN: Cross-sectional study.
STUDY DURATION: 1 year
SAMPLE SIZE: 100
( As per number of patient with cerebral palsy between 3-13years of
age who visited Physiotherapy Outpatient department, Sri Dharmasthala
Manjunatheshwara College Of Medical Sciences And Hospital between
September 2009 to September 2010).
PROCEDURE:
Ethical clearance is obtained from Institutional Ethical Committee of the SDM College of
Medical Sciences and Hospital Dharwad.
All the children with cerebral palsy childrenwho will consult to SDM outpatient
Department of Physiotherapy will be taken as samplesize for the data collections.The
study will be briefly explained to the parents or guardianand written consent will be taken.
The method of assessment will be exclusively based on the observation of the individual ,
without the interference by the researcher.8

OUTCOME MEASURES:
  1. To assess the severity of oral motor dysfunctionby usingOral Motor Assessment Scale (OMAS).8
  2. To assess the Growth by using percentile Center for Disease Control and Prevention/ National Center for Health Statistics (CDC/NCHS) Growth charts.9
STASTISTICAL TEST:
  1. Karl Pearson’s co-relation coefficient.
  2. Unpaired t-test.
  3. One way ANOVA.

Does the study require any investigations or intervention to be conducted on Patients
or other humans or animals? if so describe briefly: No
Ethical clearance has been obtained by you: Yes
REFERENCE:
1)Bax MCO. Terminology and classification of cerebral palsy. Dev Med Child
Neurol. 1964;39;295-297.
2)ChitraSankar, NandiniMundkar. Cerebral Palsy- Definition, Classification, Etiology, and Early Diagnosis. Indian J Pediatr .2005; 72 (10) : 865-868.
3)RozerB. Feeding Method and Health Outcomes of Children with Cerebral Palsy. J Pediatr. 2004; 145: S28-S32.
4)J Pediatr 2004;145:S28-S32. Reilly S,Skuse D, Mathisen B, Wolke D. The objective rating of oral-motor functions during feeding. Dysphagia 1995; 10; 177-191.
5)Sullivan PB, Lambart B, Rose M, Ford-Adam M, Johnson A, Griffiths P. Prevalence and severity of feeding and nutritional problems in children with neurological impairment: oxford feeding study. Dev med child neurol 2000,42; 674-680.
6)Bell et al. A prospective, longitudinal study of growth, nutrition and sedentary behavior in young children with cerebral palsy. BMCPublic Health 2010, 10:176.
7)Bruce K. Shapiro, Pauline Green, Jackie Krick, Darlene Allen, Arnold J. Capute. Growth of severely impaired children: neurological verse nutritional factors. Dev Med Child Neurol.1986, 28, 729-733.
8)A. De Oliveira Lira Ortega et al. Assessment scale of the oral motor performance of children and adolescents with neurological damages. Journal of Oral Rehabilitation. 2009 36; 653-659.
9)Kuczmarski R J, Ogdan C L et al. Advance Data CDC Growth Chart: United State, Number 314 December4, 2000 (Revised). U.S Department of Health and Human Services, Centers for Disease Control and Prevention/ National Center for Health Statistics.
10) Reilly S, Skuse D, Poblete X. prevalence of feeding problems and oral motor dysfunctions in children with cerebral palsy: a community survey. J pediatr
1996;129:877-82.
11)Palmer JB, Drennan JC, Mikoto Baba. Evaluation and Treatment of Swallowing
Impairments. Am FamPhycisian 2000;61:2453-62.
12)Fucile S. et al. Functional oral motor skills- do they change with the age?
Dysphagia1998;13:195-201.
13)Incidence of malnutrition in individuals with cerebral palsy.
Available from: http.//
14)Gangil A, Patwari A K, Aneja S, Ahuja B, Anand V K. Feeding Problems in children with cerebral palsy. Indian Pediatrics 2001; 38: 839-846.
15)Okeke IB, Ojinnaka NC. Nutritional status of children with cerebral palsy in enugu Nigeria. European journal of scientific research 2010; 39: 505-513.