Perception disorder: how to identify it in children with spastic diplegia

INTRODUCTION It is well known that “movement and perception are the two sides of the same coin in Cerebral Palsy (CP)”. In PC, the alteration of perceptive system represents a crucial element for “palsy development”. Central Nervous System (CNS) isn’t able to collect, elaborate, and integrate sensitive and sensorial information to obtain representations that are coherent among them and corresponding to reality[1]. In particular the altered process of collimation between visual and proprioceptive information may produce visual-kinestesic conflict. In children with CP this is mainly expressed through intolerance to movement, emptiness and depth. It is has been surveyed that in diplegic population, the biggest group in CP, perception disorder influences in a determining way functional abilities, in particular motor autonomy and walking quality[2]. The recognition of this perception disorder represents a basic preliminary assumption for a correct diagnostic framing and for the statement of the most appropriate rehabilitation goals and choices. This study intends to research one or more pathognomonic signs of this pathologic pattern in order to identify the perception disorder in a simple, not invasive setting, easy to be applied in territorial services. From data collected in past observations, the startle resulted as one of the most recurring signs. Therefore we want to investigate its presence in a population of diplegic children walking without support and to verify if it is a pathognomonic sign of perception disorder for the group of selected patients. METHODS This is a retrospective blind-randomized study. We evaluated 41 videos, realised with standard modalities, showing children with spastic diplegia while they are walking. Video are randomly selected among those of patients followed at Child Rehabilitation in RE. The inclusion criteria were: spastic diplegia supported by MRI, age between 5 and 15 years old, no surgical intervention since at least one year and no botulinum injection since at least 6 months, walking without support. Then the studied population was divided into two groups through video observation of walking. Group A is composed of subjects presenting clinic sign of startle during the march, while Group B by subjects not showing that sign. According to the information regarding the perception disorder found in clinical documentation (realised by gold standard) the sample studied has been divided again into two groups: children with (Group C) or without (Group D) perception disorder. To identify the importance of the startle clinic sign during walk, we evaluated whether Group A corresponded to Group C and Group B to Group D. We defined motor autonomy level of 41 patients according to the Palisano et al. classification [GMFCS] to assess the possible correlation between this one and the perception disorder. RESULTS Among the 14 patients, whose documentation reported the presence of perception disorder (Group C), the 100% shows startle reaction during walk without support. Among the 27 patients without disorder (Group D), only one subject has startle (3,7%). Among subjects of Group C, 6 patients out of 14 (42,86%) belong to level II of GMFCS and the remaining 8 (57,14%) to level III. In Group D, 17 children belong to level I of GMFCS (62,96%) and the remaining 10 to level II (37,04%). DISCUSSION Thanks to the results obtained, it is possible to assert that startle represents a pathognomonic sign of perception disorder for population able to walk without support. It is interesting to underline how clinical documentation of the only subject from group D presenting startle during walk, highlights previous signs of perception disorder which were not relevant in the last years. The importance of recognizing perception disorder is once again confirmed by the results regarding GMFCS. The presence of the disorder influences in a negative way motor autonomy and its identification is therefore necessary for..