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Whitney DG, Caird MS, Raggio CL, Hurvitz EA, Clines GA, Jepsen KJ. Perspective: A multi-trait integrative approach to understanding the structural basis of bone fragility for pediatric conditions associated with abnormal bone development. Bone 2023; 175:116855. [PMID: 37481149 DOI: 10.1016/j.bone.2023.116855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/16/2023] [Accepted: 07/19/2023] [Indexed: 07/24/2023]
Abstract
Bone development is a highly orchestrated process that establishes the structural basis of bone strength during growth and functionality across the lifespan. This developmental process is generally robust in establishing mechanical function, being adaptable to many genetic and environmental factors. However, not all factors can be fully accommodated, leading to abnormal bone development and lower bone strength. This can give rise to early-onset bone fragility that negatively impacts bone strength across the lifespan. Current guidelines for assessing bone strength include measuring bone mineral density, but this does not capture the structural details responsible for whole bone strength in abnormally developing bones that would be needed to inform clinicians on how and when to treat to improve bone strength. The clinical consequence of not operationalizing how altered bone development informs decision making includes under-detection and missed opportunities for early intervention, as well as a false positive diagnosis of fragility with possible resultant clinical actions that may actually harm the growing skeleton. In this Perspective, we emphasize the need for a multi-trait, integrative approach to better understand the structural basis of bone growth for pediatric conditions with abnormal bone development. We provide evidence to showcase how this approach might reveal multiple, unique ways in which bone fragility develops across and within an array of pediatric conditions that are associated with abnormal bone development. This Perspective advocates for the development of new translational research aimed at informing better ways to optimize bone growth, prevent fragility fractures, and monitor and treat bone fragility based on the child's skeletal needs.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Michelle S Caird
- Department of Orthopaedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Gregory A Clines
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Endocrinology Section, Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Karl J Jepsen
- Department of Orthopaedic Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Moreau NG, Friel KM, Fuchs RK, Dayanidhi S, Sukal-Moulton T, Grant-Beuttler M, Peterson MD, Stevenson RD, Duff SV. Lifelong Fitness in Ambulatory Children and Adolescents with Cerebral Palsy I: Key Ingredients for Bone and Muscle Health. Behav Sci (Basel) 2023; 13:539. [PMID: 37503986 PMCID: PMC10376586 DOI: 10.3390/bs13070539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/10/2023] [Accepted: 06/14/2023] [Indexed: 07/29/2023] Open
Abstract
Physical activity of a sufficient amount and intensity is essential to health and the prevention of a sedentary lifestyle in all children as they transition into adolescence and adulthood. While fostering a fit lifestyle in all children can be challenging, it may be even more so for those with cerebral palsy (CP). Evidence suggests that bone and muscle health can improve with targeted exercise programs for children with CP. Yet, it is not clear how musculoskeletal improvements are sustained into adulthood. In this perspective, we introduce key ingredients and guidelines to promote bone and muscle health in ambulatory children with CP (GMFCS I-III), which could lay the foundation for sustained fitness and musculoskeletal health as they transition from childhood to adolescence and adulthood. First, one must consider crucial characteristics of the skeletal and muscular systems as well as key factors to augment bone and muscle integrity. Second, to build a better foundation, we must consider critical time periods and essential ingredients for programming. Finally, to foster the sustainability of a fit lifestyle, we must encourage commitment and self-initiated action while ensuring the attainment of skill acquisition and function. Thus, the overall objective of this perspective paper is to guide exercise programming and community implementation to truly alter lifelong fitness in persons with CP.
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Affiliation(s)
- Noelle G. Moreau
- Department of Physical Therapy, School of Allied Health Professions, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
| | - Kathleen M. Friel
- Burke Neurological Institute, Weill Cornell Medicine, White Plains, NY 10605, USA;
| | - Robyn K. Fuchs
- Division of Biomedical Science, College of Osteopathic Medicine, Marian University, Indianapolis, IN 46222, USA;
| | | | - Theresa Sukal-Moulton
- Department of Physical Therapy & Human Movement Sciences, Northwestern University, Chicago, IL 60611, USA;
| | - Marybeth Grant-Beuttler
- Department of Physical Therapy, Oregon Institute of Technology, Klamath Falls, OR 97601, USA;
| | - Mark D. Peterson
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Richard D. Stevenson
- Division of Neurodevelopmental and Behavioral Pediatrics, Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA;
| | - Susan V. Duff
- Department of Physical Therapy, Crean College of Health and Behavioral Sciences, Chapman University, Irvine, CA 92618, USA;
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Whitney DG, Clines GA, Leis AM, Caird MS, Hurvitz EA. Five-year risk of fracture and subsequent fractures among adults with cerebral palsy. Bone Rep 2022; 17:101613. [PMID: 36052289 PMCID: PMC9424353 DOI: 10.1016/j.bonr.2022.101613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background Epidemiologic evidence documenting the incidence of fracture and subsequent fractures among adults with cerebral palsy (CP) is lacking, which could inform fracture prevention efforts. The objective was to characterize the 5-year rate of initial and subsequent fragility fractures among adults with CP. Methods This retrospective cohort study used Medicare claims from 01/01/2008–12/31/2019 from adults ≥18 years old with CP (n = 44,239) and elderly ≥65 years old without CP (n = 2,176,463) as a comparison. The incidence rate (IR), IR ratio (IRR), and site distribution were estimated for the initial and subsequent fragility fractures over 5-years by sex and age. Results The IR of fragility fracture at any site over the 5-year follow-up was similar for 18–30-year-old men with CP (IR = 5.2; 95%CI = 4.4–5.9) and 30–34-year-old women with CP (IR = 6.3; 95%CI = 5.3–7.2) compared to the same sex youngest-old (65–74 years old) without CP (IRR = 1.09 and 0.94, respectively, both P > 0.05), and increased with older age for those with CP. The number of fragility fractures and IR of subsequent fragility fractures was similar for young men and middle-aged women with CP compared to elderly without CP, and increased with older age for those with CP. The proportion of fragility fracture at the tibia/fibula decreased while the vertebral column and multiple simultaneous sites (most involved hip/lower extremities) increased with older age. Conclusion Young and middle-aged adults with CP had similar-to-worse initial and subsequent fragility fracture profiles compared to the general elderly population- a well characterized group for bone fragility. Findings emphasize the need for fracture prevention efforts at younger ages for CP, possibly by ~5 decades younger. Fracture prevention efforts are focused on the elderly and postmenopausal women. Fragility fracture risk is elevated for those with CP across the adult lifespan. For men, the risk for 18–29 year olds (CP) was on par with 65–74 year olds (no CP). For women, risk for 30–34 year olds (CP) was on par with 65–74 year olds (no CP). CP had a higher risk of subsequent fragility fractures that was also premature.
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Affiliation(s)
- Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Corresponding author at: Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower, Ann Arbor, MI, USA.
| | - Gregory A. Clines
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Endocrinology Section, Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Aleda M. Leis
- Epidemiology Department, University of Michigan, Ann Arbor, MI, USA
| | - Michelle S. Caird
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Edward A. Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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Whitney DG, Caird MS, Clines GA, Hurvitz EA, Jepsen KJ. Clinical bone health among adults with cerebral palsy: moving beyond assessing bone mineral density alone. Dev Med Child Neurol 2022; 64:469-475. [PMID: 34658010 DOI: 10.1111/dmcn.15093] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/01/2022]
Abstract
AIM To understand associations among bone mineral density (BMD), bone mineral content (BMC), and bone area, and their association with fractures in adults with cerebral palsy (CP). METHOD This retrospective cohort study included 78 adults with CP with a hip dual energy X-ray absorptiometry (DXA) from 1st December 2012 to 3rd May 2021 performed at the University of Michigan. Data-driven logistic regression techniques identified which, if any, DXA-derived bone traits (e.g. age/sex/ethnicity-based z-scores) were associated with fracture risk by sex and severity of CP. BMC-area associations were examined to study the structural mechanisms of fragility. RESULTS Femoral neck area was associated with lower age-adjusted odds ratios (ORs) of fracture history (OR 0.72; 95% confidence interval [CI] 0.49-1.06; p=0.098), while higher BMD was associated with higher odds of incident fracture (OR 3.08; 95% CI 1.14-8.33; p=0.027). Females with fracture had lower area than females without fracture but similar BMC, whereas males with fracture had larger area and higher BMC than males without fracture. The paradoxical BMD-fracture association may be due to artificially elevated BMD from BMC-area associations that differed between females and males (sex interaction, p˂0.05): males had higher BMC at lower area values and lower BMC at higher area values compared to females. INTERPRETATION BMD alone may not be adequate to evaluate bone strength for adults with CP. Further research into associations (or integration) between BMC and area is needed.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Michelle S Caird
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Gregory A Clines
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Endocrinology Section, Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Karl J Jepsen
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
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Hurvitz EA, Whitney DG, Waldron-Perrine B, Ryan D, Haapala HJ, Schmidt M, Gray C, Peterson MD. Navigating the Pathway to Care in Adults With Cerebral Palsy. Front Neurol 2021; 12:734139. [PMID: 34603186 PMCID: PMC8482767 DOI: 10.3389/fneur.2021.734139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/17/2021] [Indexed: 11/25/2022] Open
Abstract
As individuals with cerebral palsy (CP) age, they face unique challenges which complicate their ability to access and receive appropriate health care. These problems exist at the level of the health care system, the clinician, and the individual. At the system level, there is an inadequate number of professionals who are informed of and interested in the care of adults with CP. Pediatric clinicians prefer treating children, and adult caregivers are not knowledgeable about and may feel less competent about CP. Pediatric care does not translate well to the adult population, and information about best practices for adults is just starting to develop. Differences in the physiologic development of individuals with CP render well-established clinical protocols for risk screening of chronic diseases less effective. Moreover, lack of supportive resources decreases a caregiver's sense of self-efficacy in treating this population. The patient's ability to navigate these barriers is complicated by the high prevalence of comorbid cognitive impairment and mental health issues including anxiety, depression, and other psychiatric disorders; a bidirectional relationship between challenges in navigating care/needs and comorbid mental health conditions appears likely. Many patients have additional barriers related to social determinants of health, such as access to transportation, accessible health care facilities, and other personal and environmental factors that may impede health maintenance and wellness. Increasing and disseminating knowledge, harnessing the power of new technologies such as telemedicine, and addressing mental health issues are some of the methods that are available to help adults with CP navigate this road.
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Affiliation(s)
- Edward A. Hurvitz
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brigid Waldron-Perrine
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Dayna Ryan
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Heidi J. Haapala
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mary Schmidt
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Cathryn Gray
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mark D. Peterson
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
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Jensen AK, Low CE, Pal P, Raczynski TN. Relation of Musculoskeletal Strength and Function to Postural Stability in Ambulatory Adults With Cerebral Palsy. Arch Rehabil Res Clin Transl 2021; 2:100074. [PMID: 33543099 PMCID: PMC7853373 DOI: 10.1016/j.arrct.2020.100074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Objective To understand the relation of musculoskeletal strength and function to postural stability in ambulatory adults with cerebral palsy (CP) who have already developed muscle atrophy and osteoporosis. Design Two independent group comparison of adults with CP and those without it. Setting Laboratory study. Participants Thirteen adults with CP with sex (9 women: 4 men), age (21-62y), and Gross Motor Function Classification System I-III, and 13 sex-, age-, and body-weight-matched control participants completed our study (N=26). Intervention Not applicable. Main Outcome Measure Bone mineral density (BMD), structural or geometrical deformities (at the proximal region of the femur at the hip joint), and maximal muscular strength (forearm and thigh) were measured. The primary outcome measure was postural stability (balance measured using an automated balance system and a Berg Balance Test). Results Femoral BMD was significantly lower in the CP group compared to the control group, whereas BMD at lumbar and forearm regions was similar between groups. Geometrical angles, lengths, and diameters at the proximal femur were significantly lower in the CP group. There was a direct relation between BMD in the femoral neck and knee extension peak torque in the control group with no relation in the CP group. Although the control group did not show a relation between muscular strength and balance test, the CP group showed a significant linear relation among improving postural stability with greater levels of muscular strength. Conclusion There were structural differences at the proximal femur and muscular weakness in adults with CP. In adults with CP, balance appears to be more influenced by structural alterations at the femur than muscular strength compared to the control group.
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Affiliation(s)
- Areum K Jensen
- Department of Kinesiology, San José State University, San José, CA
| | - Cory E Low
- Department of Kinesiology, San José State University, San José, CA
| | - Pooja Pal
- Department of Kinesiology, San José State University, San José, CA
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Obst SJ, Bickell R, Florance K, Boyd RN, Read F, Barber L. The size and echogenicity of the tibialis anterior muscle is preserved in both limbs in young children with unilateral spastic cerebral palsy. Disabil Rehabil 2020; 44:3430-3439. [PMID: 33356649 DOI: 10.1080/09638288.2020.1863482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The primary of this study was to compare the volume, length, echo intensity, and growth rate of the medial gastrocnemius (MG) and tibialis anterior (TA) muscle of both limbs (more-involved and less-involved) in children with unilateral spastic cerebral palsy (USCP), with those of an age-matched typically developing (TD) group. A secondary aim in the USCP group was to explore the associations between these muscle parameters and discrete ankle positions during phase of gait. METHODS Muscle parameters were assessed using 3D ultrasound. Maximal ankle dorsiflexion in stance and swing during walking were determined from 2D video analysis. Group differences in muscle size and echo intensity were assessed using a two-way analysis of covariance (age-by-group), with the interaction term used to compare muscle growth rates. Associations between muscle parameters and maximal ankle dorsiflexion in stance and swing were assessed using backwards multiple linear regression analyses. RESULTS The MG of both limbs in children with USCP had signs of impaired muscle development (smaller volume and length, higher echo intensity and lower growth rate). There was no evidence of impaired muscle development of TA between limbs or compared the TD children. Tibialis anterior volume, length, echo intensity and MG volume explained 66% and 83% of the variance in maximal ankle dorsiflexion position in the stance and swing phases of walking, respectively. CONCLUSIONS Unlike the MG, the TA volume and growth rate in children with USCP are equivalent between limbs and compared to TD children. For the more-involved limb only, TA volume, length, and echo intensity appear associated with maximal ankle dorsiflexion during walking and represent important muscle parameters that could be targeted in with early exercise therapy.Implications for rehabilitationTibialis anterior (TA) size and echogenicity appear normal in both limbs in young children with unilateral spastic cerebral palsy (USCP); findings that could indicate sufficient mechanical stimulus and muscle anabolism to maintain normal muscle growth.Tibialis anterior size and echogenicity are associated with maximal ankle dorsiflexion in both stance and swing phase of walking in young children with USCP; though such relations appear isolated to the more-involved limb.Early therapeutic interventions that target TA are likely to be successful in maintaining muscle size and may offset the negative effects of medial gastrocnemius atrophy in the development of fixed ankle equinus of the more-involved limb and improve ankle positioning during gait.
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Affiliation(s)
- Steven J Obst
- School of Health, Medical and Applied Sciences, Central Queensland University, Bundaberg, Australia.,Faculty of Medicine, Queensland Cerebral Palsy and Rehabilitation Research Centre, Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Reuben Bickell
- School of Health, Medical and Applied Sciences, Central Queensland University, Bundaberg, Australia
| | - Kaysie Florance
- School of Health, Medical and Applied Sciences, Central Queensland University, Bundaberg, Australia
| | - Roslyn N Boyd
- School of Health, Medical and Applied Sciences, Central Queensland University, Bundaberg, Australia
| | - Felicity Read
- School of Health, Medical and Applied Sciences, Central Queensland University, Bundaberg, Australia
| | - Lee Barber
- School of Health, Medical and Applied Sciences, Central Queensland University, Bundaberg, Australia.,Faculty of Medicine, Queensland Cerebral Palsy and Rehabilitation Research Centre, Child Health Research Centre, The University of Queensland, Brisbane, Australia.,School of Allied Health Sciences, Griffith University, Brisbane, Australia
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Cappellini G, Sylos-Labini F, Dewolf AH, Solopova IA, Morelli D, Lacquaniti F, Ivanenko Y. Maturation of the Locomotor Circuitry in Children With Cerebral Palsy. Front Bioeng Biotechnol 2020; 8:998. [PMID: 32974319 PMCID: PMC7462003 DOI: 10.3389/fbioe.2020.00998] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/30/2020] [Indexed: 12/26/2022] Open
Abstract
The first years of life represent an important phase of maturation of the central nervous system, processing of sensory information, posture control and acquisition of the locomotor function. Cerebral palsy (CP) is the most common group of motor disorders in childhood attributed to disturbances in the fetal or infant brain, frequently resulting in impaired gait. Here we will consider various findings about functional maturation of the locomotor output in early infancy, and how much the dysfunction of gait in children with CP can be related to spinal neuronal networks vs. supraspinal dysfunction. A better knowledge about pattern generation circuitries in infancy may improve our understanding of developmental motor disorders, highlighting the necessity for regulating the functional properties of abnormally developed neuronal locomotor networks as a target for early sensorimotor rehabilitation. Various clinical approaches and advances in biotechnology are also considered that might promote acquisition of the locomotor function in infants at risk for locomotor delays.
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Affiliation(s)
- Germana Cappellini
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy.,Department of Pediatric Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | | | - Arthur H Dewolf
- Centre of Space Bio-medicine and Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Irina A Solopova
- Laboratory of Neurobiology of Motor Control, Institute for Information Transmission Problems, Moscow, Russia
| | - Daniela Morelli
- Department of Pediatric Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Francesco Lacquaniti
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy.,Centre of Space Bio-medicine and Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Yury Ivanenko
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy
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Abstract
PURPOSE OF REVIEW The goal of this review is to highlight the deficits in muscle and bone in children with cerebral palsy (CP), discuss the muscle-bone relationship in the CP population, and identify muscle-based intervention strategies that may stimulate an improvement in their bone development. RECENT FINDINGS The latest research suggests that muscle and bone are both severely underdeveloped and weak in children with CP, even in ambulatory children with mild forms of the disorder. The small and low-performing muscles and limited participation in physical activity are likely the major contributors to the poor bone development in children with CP. However, the muscle-bone relationship may be complicated by other factors, such as a high degree of fat and collagen infiltration of muscle, atypical muscle activation, and muscle spasticity. Muscle-based interventions, such as resistance training, vibration, and nutritional supplementation, have the potential to improve bone development in children with CP, especially if they are initiated before puberty. Studies are needed to identify the muscle-related factors with the greatest influence on bone development in children with CP. Identifying treatment strategies that capitalize on the relationship between muscle and bone, while also improving balance, coordination, and physical activity participation, is an important step toward increasing bone strength and minimizing fractures in children with CP.
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Affiliation(s)
- Christopher M Modlesky
- Department of Kinesiology, University of Georgia, 330 River Road, Room 353, Athens, GA, 30602, USA.
| | - Chuan Zhang
- Department of Kinesiology, University of Georgia, 330 River Road, Room 353, Athens, GA, 30602, USA
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Noble JJ, Gough M, Shortland AP. Selective motor control and gross motor function in bilateral spastic cerebral palsy. Dev Med Child Neurol 2019; 61:57-61. [PMID: 30203469 DOI: 10.1111/dmcn.14024] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2018] [Indexed: 11/30/2022]
Abstract
AIM To investigate the relationship between selective motor control (SMC), muscle volume, and spasticity with gross motor function in adolescents and young adults with bilateral spastic cerebral palsy (CP). METHOD Eleven male participants with CP (mean age 15y 7mo, standard deviation 3y 6mo, range 12y 1mo-23y 1mo) in Gross Motor Function Classification System (GMFCS) levels I to IV took part in this cross-sectional study. Magnetic resonance imaging (MRI) of both lower limbs of all participants were acquired, from which 18 muscles were manually segmented and muscle volume calculated by a single assessor. Muscle volumes were normalized to body mass and averaged between limbs for each individual. SMC was assessed using Selective Control Assessment of the Lower Extremity (SCALE). Spasticity was assessed using the Modified Ashworth Scale (MAS), and gross motor functional ability was assessed using the Gross Motor Function Measure (GMFM-66). RESULTS GMFM-66 was strongly positively correlated to SCALE (r=0.901, p≤0.001) and lower limb muscle volume normalized to body mass (r=0.750, p=0.008). MAS was significantly correlated with GMFM-66 (r=-0.691, p=0.018). INTERPRETATION SMC is a major factor influencing gross motor function in individuals with CP. Lower limb muscle volume and spasticity also influence gross motor function. WHAT THIS PAPER ADDS Selective motor control is a major factor of gross motor function in adolescents and young adults with bilateral cerebral palsy (CP). Gross motor function is related to muscle size and level of spasticity in adolescents and young adults with bilateral CP.
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Affiliation(s)
- Jonathan J Noble
- One Small Step Gait Laboratory, Evelina London Children's Hospital, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Martin Gough
- One Small Step Gait Laboratory, Evelina London Children's Hospital, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Adam P Shortland
- One Small Step Gait Laboratory, Evelina London Children's Hospital, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,The Rayne Institute, St Thomas' Hospital, King's College London, London, UK
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11
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Chen Y, He L, Xu K, Li J, Guan B, Tang H. Comparison of calf muscle architecture between Asian children with spastic cerebral palsy and typically developing peers. PLoS One 2018; 13:e0190642. [PMID: 29304114 PMCID: PMC5755874 DOI: 10.1371/journal.pone.0190642] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/18/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare the muscle thickness, fascicle length, and pennation angle of the gastrocnemius, soleus, and tibialis anterior between Asian children with spastic cerebral palsy (CP) and typically developing (TD) peers. METHODS This cross-sectional study involved a total of 72 children with hemiplegic CP (n = 24), and diplegic CP (n = 24) and their TD peers (n = 24). Muscle architecture was measured at rest using ultrasound. Clinical measures included gross motor function and a modified Ashworth scale. RESULTS The thicknesses of the tibialis anterior and medial gastrocnemius muscles were smaller in the affected calf of children with CP (p<0.05) than in those of their TD peers. Additionally, the lengths of the lateral gastrocnemius and soleus fascicle were shorter (p<0.05) in children with diplegic CP than in their TD peers. The fascicle length was shorter in the affected calf of children with CP (p<0.05) than in the calves of their TD peers or the unaffected calf of children with hemiplegic CP. However, the length of the lateral gastrocnemius fascicle was similar between the two legs of children with hemiplegic CP. The pennation angles of the medial gastrocnemius and soleus muscles were larger (p<0.05) in the affected calf in children with hemiplegic CP than in the calves of their TD peers. The fascicle length of the lateral gastrocnemius and the thickness of the soleus muscle were positively correlated with gross motor function scores in children with CP (p<0.05). CONCLUSIONS Muscle thickness and fascicle length were lower in the affected tibialis anterior, gastrocnemius, and soleus in children with spastic CP. These changes may limit the ability to stand and walk, and indicate a need to strengthen the affected muscle.
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Affiliation(s)
- Ying Chen
- Department of Rehabilitation, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lu He
- Department of Rehabilitation, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Kaishou Xu
- Department of Rehabilitation, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- * E-mail:
| | - Jinling Li
- Department of Rehabilitation, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Buyun Guan
- Department of Ultrasonography, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hongmei Tang
- Department of Rehabilitation, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
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Vanmechelen IM, Shortland AP, Noble JJ. Lower limb muscle volume estimation from maximum cross-sectional area and muscle length in cerebral palsy and typically developing individuals. Clin Biomech (Bristol, Avon) 2018; 51:40-44. [PMID: 29179032 DOI: 10.1016/j.clinbiomech.2017.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/05/2017] [Accepted: 11/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Deficits in muscle volume may be a significant contributor to physical disability in young people with cerebral palsy. However, 3D measurements of muscle volume using MRI or 3D ultrasound may be difficult to make routinely in the clinic. We wished to establish whether accurate estimates of muscle volume could be made from a combination of anatomical cross-sectional area and length measurements in samples of typically developing young people and young people with bilateral cerebral palsy. METHODS Lower limb MRI scans were obtained from the lower limbs of 21 individuals with cerebral palsy (14.7±3years, 17 male) and 23 typically developing individuals (16.8±3.3years, 16 male). The volume, length and anatomical cross-sectional area were estimated from six muscles of the left lower limb. FINDINGS Analysis of Covariance demonstrated that the relationship between the length*cross-sectional area and volume was not significantly different depending on the subject group. Linear regression analysis demonstrated that the product of anatomical cross-sectional area and length bore a strong and significant relationship to the measured muscle volume (R2 values between 0.955 and 0.988) with low standard error of the estimates of 4.8 to 8.9%. INTERPRETATION This study demonstrates that muscle volume may be estimated accurately in typically developing individuals and individuals with cerebral palsy by a combination of anatomical cross-sectional area and muscle length. 2D ultrasound may be a convenient method of making these measurements routinely in the clinic.
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Affiliation(s)
- Inti M Vanmechelen
- One Small Step Gait Laboratory, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Adam P Shortland
- One Small Step Gait Laboratory, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London SE1 9RT, United Kingdom; School of Biomedical Engineering and Imaging Sciences, King's College London, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas' Hospital, London SE1 7EH, United Kingdom
| | - Jonathan J Noble
- One Small Step Gait Laboratory, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London SE1 9RT, United Kingdom; School of Biomedical Engineering and Imaging Sciences, King's College London, The Rayne Institute, 4th Floor, Lambeth Wing, St Thomas' Hospital, London SE1 7EH, United Kingdom.
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Ficek K, Filipek J, Ficek J, Muzalewska M, Humpa F. Calcaneal CT is a useful tool for identifying Achilles tendon disorders: a pilot study. J Orthop Surg Res 2017; 12:139. [PMID: 28946912 PMCID: PMC5613452 DOI: 10.1186/s13018-017-0638-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/17/2017] [Indexed: 01/19/2023] Open
Abstract
Background In various Achilles tendon disorders, little attention is paid to the bone environment at the tendon insertion sites. The aim of the present study was to assess the calcaneal bone structure in Achilles tendon disorders using computed tomography (CT). Methods This study included 31 male patients diagnosed with various Achilles disorders, including episodes of tendon rupture (TR), conservatively treated tendinopathy (TP), and critical-stage Achilles TP treated with endoscopic surgery (TS). CT scans of both feet were conducted to assess the calcaneal bone structure in the TP and TS groups, which comprised 23 patients. Bone measurements were calculated, including the bone volume-to-total volume ratio (BV/TV), cross-sectional area (CSA), product moment of area (Ipm), and polar section modulus (Zpol). Results The results demonstrated increased BV/TV, CSA, Ipm, and Zpol values in patients who underwent tendinoscopy and in patients with insertional TP. Conclusions CT images are useful for evaluating calcaneal trabecular structural alterations in patients with Achilles pathology and correlate with the TP type.
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Affiliation(s)
- Krzysztof Ficek
- The Jerzy Kukuczka Academy of Physical Education, Mikolowska 72A, 40-065, Katowice, Poland. .,Galen-Orthopaedics, Jerzego 6, 43-150, Bierun, Poland.
| | | | - Joanna Ficek
- Galen-Orthopaedics, Jerzego 6, 43-150, Bierun, Poland
| | - Małgorzata Muzalewska
- Faculty of Mechanical Engineering, Silesian University of Technology, Konarskiego 18A, 44-100, Gliwice, Poland
| | - Filip Humpa
- The Jerzy Kukuczka Academy of Physical Education, Mikolowska 72A, 40-065, Katowice, Poland.,Galen Rehabilitation, Jerzego 6, 43-150, Bierun, Poland
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Simm PJ, Bicknell-Royle J, Lawrie J, Nation J, Draffin K, Stewart KG, Cameron FJ, Scheffer IE, Mackay MT. The effect of the ketogenic diet on the developing skeleton. Epilepsy Res 2017; 136:62-66. [PMID: 28778055 DOI: 10.1016/j.eplepsyres.2017.07.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 07/13/2017] [Accepted: 07/24/2017] [Indexed: 11/26/2022]
Abstract
The ketogenic diet (KD) is a medically supervised, high fat, low carbohydrate and restricted protein diet which has been used successfully in patients with refractory epilepsy. Only one published report has explored its effect on the skeleton. We postulated that the KD impairs skeletal health parameters in patients on the KD. Patients commenced on the KD were enrolled in a prospective, longitudinal study, with monitoring of Dual-energy X-ray absorptiometry (DXA) derived bone parameters including bone mineral content and density (BMD). Areal BMD was converted to bone mineral apparent density (BMAD) where possible. Biochemical parameters, including Vitamin D, and bone turnover markers, including osteocalcin, were assessed. Patients were stratified for level of mobility using the gross motor functional classification system (GMFCS). 29 patients were on the KD for a minimum of 6 months (range 0.5-6.5 years, mean 2.1 years). There was a trend towards a reduction in lumbar spine (LS) BMD Z score of 0.1562 (p=0.071) per year and 20 patients (68%) had a lower BMD Z score at the end of treatment. While less mobile patients had lower baseline Z scores, the rate of bone loss on the diet was greater in the more mobile patients (0.28 SD loss per year, p=0.026). Height adjustment of DXA data was possible for 13 patients, with a mean reduction in BMAD Z score of 0.19 SD. Only two patients sustained fractures. Mean urinary calcium-creatinine ratios were elevated (0.77), but only 1 patient developed renal calculi. Children on the KD exhibited differences in skeletal development that may be related to the diet. The changes were independent of height but appear to be exaggerated in patients who are ambulant. Clinicians should be aware of potential skeletal side effects and monitor bone health during KD treatment. Longer term follow up is required to determine adult/peak bone mass and fracture risk throughout life.
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Affiliation(s)
- Peter J Simm
- Royal Children's Hospital Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia.
| | | | - Jock Lawrie
- Murdoch Childrens Research Institute, Melbourne, Australia
| | - Judy Nation
- Royal Children's Hospital Melbourne, Australia
| | - Kellie Draffin
- Department of Nutrition and Dietetics, Austin Health, Australia
| | | | - Fergus J Cameron
- Royal Children's Hospital Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia
| | - Ingrid E Scheffer
- Royal Children's Hospital Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia; Department of Medicine, University of Melbourne, Austin Health, Australia; Department of Paediatrics, Austin Health, Australia
| | - Mark T Mackay
- Royal Children's Hospital Melbourne, Australia; Murdoch Childrens Research Institute, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia
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