Erratum to: Socioeconomic Status Influences Functional Severity of Untreated Cerebral Palsy in Nepal: A Prospective Analysis and Systematic Review

Several sections of the published study, “Socioeconomic Status Influences Functional Severity of Untreated Cerebral Palsy in Nepal: A Prospective Analysis and Systematic Review” contained errors that require correction or ambiguities that call for clarification.

First, the Conclusions section of the Abstract states: “Children in Nepal with hemiplegic CP have greater functional disability despite less motor impairment compared with children from high-income settings. Targeted interventions to maintain functional status in Nepali children with CP may reduce this disparity.” This section should read: “Children in Nepal with hemiplegic CP display less difficulty in communicating and social engagement (CFCS) despite more-severe upper- and lower-extremity impairments in gross motor function (GMFCS) and manual ability (MACS) than do children with hemiplegic CP from high-income countries. Targeted interventions, including perhaps simple orthopaedic interventions to treat soft-tissue contractures, may therefore provide more-substantial improvements in function and quality of life to Nepali children than could be achieved for the same deployment of resources in more-affluent settings.”

Next, the Discussion section states: “We identified substantial disparities in the motor functional severity of children with spastic hemiplegic CP between the Nepal and high-income settings. These findings suggest that children with CP in low-income settings like Nepal have greater functional disability despite similar or less motor impairment. It is possible that there are relatively fewer Nepali children with profound neurologic impairments because of the lack of access to sophisticated medical services, leading to a lower survival rate for these children in early childhood compared with children with similar degrees of impairment in high-income settings.” This should instead read: “We identified substantial disparities in gross motor function (GMFCS) and manual ability (MACS) of children with spastic hemiplegic CP between the Nepal and high-income settings. These findings suggest that children with CP in Nepal have greater functional disability despite less motor impairment compared with children from high-income settings. It is possible that there are relatively fewer Nepali children with profound impairments in the skills measured on the CFCS score (which deal principally with communication and social engagement with others) because of the lack of access to sophisticated medical services, leading to a lower survival rate for these children in early childhood compared with children with similar degrees of neurologic impairment in high-income settings.”

Also in the Discussion section, a portion reads: “The finding that Nepali children with spastic hemiplegia—a condition with relatively less impairment than spastic diplegia or quadriplegia—had more disability despite similar motor impairment relative to children in high-income countries suggests that untreated early hemiplegic CP leads to greater disability than previously thought. Only two studies to our knowledge have directly compared the differences in CP between low- and high-income settings [6, 9]. Our findings are consistent with a comparison of preschool-aged children with CP in Australia and Bangladesh, which demonstrated that Australian children had better gross motor function and fewer cognitive impairments than Bangladeshi children [6].” In fact, this should read: “The finding that Nepali children with spastic hemiplegia—a condition with relatively less impairment than spastic diplegia or quadriplegia—had more upper- and lower-extremity motor impairment despite less difficulty with communication skills children in high-income countries points to a potentially high-value intervention opportunity. Our data (which suggest these children communicate well, and so can contribute to society if only their problems with mobility and upper-extremity function could be improved upon) is consistent with our observations in the field. We have seen that relatively small orthopaedic interventions applied to a population that has had little or no musculoskeletal care—such as physical therapy, orthotic devices, and simple surgical contracture releases—can rather-dramatically improve the lives of these children, since once they can walk and grasp more effectively, their already-high communication skills allow them to engage meaningfully with those around them. Only two studies to our knowledge have directly compared the differences in CP between low- and high-income settings [6, 9]. Our findings differ slightly with a comparison of preschool-aged children with CP in Australia and Bangladesh, which demonstrated that Australian children had better gross motor function and fewer cognitive impairments than Bangladeshi children [6]. While we are unsure why our study differed with respect to the cognitive impairments; we note that we measured ours with a functional scoring system (the Communication Function Classification System), while that study seemed to use more-qualitative approaches.”

Finally, in the concluding paragraph of the Discussion, one section calls for clarification; the published version reads: “In summary, our study found that Nepali children with spastic hemiplegic CP had greater disability despite similar impairment compared with control subjects from high-income countries. These findings suggest that children with CP in low-income settings like Nepal who survive through early childhood, despite limited to no access to health services, may have greater motor disability than their counterparts in high-income countries with similar clinical diagnoses and similar degrees of neurologic impairment.” This is ambiguous. It should instead state: “In summary, our study found that Nepali children with spastic hemiplegic CP had greater upper- and lower-extremity motor impairment despite less impairment in communication skills compared with control subjects from high-income countries. These findings suggest that children with CP in low-income settings like Nepal who survive through early childhood, despite limited to no access to health services, may gain more from simple interventions to improve their limitations in walking and grasping abilities than might their counterparts in high-income countries, who are likely ultimately to be more limited by more-profound central nervous system deficits, including communication skills, than Nepali children.”

The authors apologize for these errors.