Cortical bone deficit and fat infiltration of bone marrow and skeletal muscle in ambulatory children with mild spastic cerebral palsy

Ambulatory children with spastic cerebral palsy have smaller bone area and deficits in trabecular microarchitecture

Cerebral palsy (CP) is a non-progressive neurological syndrome resulting in abnormal muscle tone, movement, and posture. It is unclear whether ambulatory children with CP have deficits in bone quantity or quality. Furthermore, the relationship between abnormal muscle tone, altered function, and bone health remains largely unexplored. This observational study investigated bone mineral density (BMD) and microarchitecture in ambulatory children with spastic CP and associations of BMD with function, muscle spasticity, and gait. Children with spasticity in both lower limbs (n = 12) aged 3-8 years were recruited. Areal BMD was measured with dual energy x-ray absorptiometry (DXA) at the proximal femur and lateral distal femur and compared to normative data. High resolution peripheral quantitative computed tomography (HR-pQCT) was performed at the metaphyseal tibia and radius in a subset of participants (n = 5) and compared to healthy children (n = 7). Gait pathology and cardiopulmonary function were investigated with the Gait Deviation Index, Edinburgh Visual Gait Score, and energy expenditure index. DXA areal BMD (aBMD) Z-scores at the lateral distal femur were within a normal range. However, the CP group's median aBMD Z-score at the proximal femur was -1.8 (IQR: -2.2, -1.2, p = .03) indicating potential skeletal fragility. Strong correlations were found between gait pathology and DXA-based bone outcomes (correlation coefficient 0.62 [p = .04] to 0.73 [p = .01]) as well as energy expenditure index and DXA-based bone outcomes (correlation coefficient -0.63 [p = .03] to -0.98 [p ≤ .001]). At the metaphyseal tibia, children with spastic CP had significant deficits in HR-pQCT-measured bone geometry and trabecular microarchitecture: 35% lower total area, 42% lower trabecular area, and 48% lower trabecular number than controls. HR-pQCT parameters were similar between groups at the metaphyseal radius. These differences in tibial metaphysis size and trabecular microarchitecture are similar to those observed in disuse and thus could be a result of abnormal biomechanics or low levels of physical activity.

Incidence of lymphedema among adults with cerebral palsy

BACKGROUND

Lymphedema is a chronic and progressive condition but is understudied among adults with cerebral palsy (CP).

OBJECTIVE

To compare the 2-year incidence of lymphedema between adults with versus without CP before and after accounting for multimorbidity, cancer diagnosis/treatment, and lymph node/channel surgery.

DESIGN

Retrospective cohort study.

SETTING

Nationwide commercial claims data from January 1, 2011 to December 31, 2017.

PARTICIPANTS

Adults ≥18 years old with and without CP with at least 12 months of continuous health plan enrollment, defined as the baseline period, were included for analysis. The 12-month baseline period was used to establish information on preexisting lymphedema (for exclusion), presence of cancer, including radiation treatment and lymph node surgery, and the Whitney Comorbidity Index (WCI).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The 2-year incidence rate (IR) and IR ratio (IRR) of lymphedema were evaluated. Cox regression estimated the hazard ratio (HR) of 2-year lymphedema after adjusting for age, gender, WCI, cancer diagnosis/treatment, and lymph node/channel surgery.

RESULTS

The 2-year IR of lymphedema was 5.73 (95% confidence interval [CI] = 4.59-6.88) for adults with CP (n = 9922) and 1.81 (95% CI = 1.79-1.83) for adults without CP (n = 12,932,288); the IRR was 3.17 (95% CI = 2.59-3.87) and the adjusted HR was 2.43 (95% CI = 1.98-2.98). There was evidence of effect modification by gender, age, and WCI score. All HRs were elevated, but men with versus without CP had higher HRs than women with versus without CP; HRs for adults with versus without CP were higher for younger participants and those with lower WCI scores.

CONCLUSIONS

Adults with CP had a higher 2-year rate of lymphedema compared with those without CP. Men with CP had a disproportionately higher rate than women with CP when compared with their gender-based reference cohorts without CP.

Perinatal anoxia associated with sensorimotor restriction causes muscle atrophy and microglial activation: Meta-analysis of preclinical studies with implications for cerebral palsy

Several experimental cerebral palsy models have been created to investigate cellular and molecular mechanisms involved in this condition and develop new therapeutic strategies. The model that has come closest to a motor phenotype similar to cerebral palsy is the one that combines perinatal anoxia with hindlimb sensorimotor restriction, as it induces visible changes at the peripheral and central levels. This systematic review with meta-analysis presents the impact of the cerebral palsy model that associates perinatal anoxia with hindlimb sensorimotor restriction on the nervous, muscular and skeletal systems. Studies with perinatal anoxia associated with sensorimotor restriction and which evaluated outcomes related to skeletal, muscle, or nervous tissue were recovered from the databases: Embase, PubMed, Scopus, and Web of Science. The methodological and quantitative assessment was performed after eligibility screening (PROSPERO - ID: CRD42023477770). After screening of 4,641 articles, 21 studies with a moderate quality of evidence were chosen to be included in this review and 11 articles were included in the meta-analysis. The results of the meta-analysis reported a significant reduction in the media area of the soleus muscle fibers, increased number of glia cells and glia/neuron index in the somatosensory cortex, increased microglial activation in the hippocampus, and no changes in the corpus callosum thickness or neuron cells. The combination of perinatal anoxia and sensorimotor restriction entails muscle deficits and excessive activation of glial cells in brain areas. These results contribute to a methodological refinement of cerebral palsy models and favor new studies proposed for methodological elucidation in animal experimentation.

The association between fracture and short-term adverse health outcomes among children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) have a high risk of fracture; yet, little is known about their post-fracture health outcomes. A fracture is an unplanned event in contrast to surgeries or procedures where there is a pre-operative period to optimize body composition and health and planned post-operative follow-up care. Fractures may be associated with significant outcomes due to the unplannable nature and reactionary care. The objective of this study was to determine if fractures were associated with an increased rate of short-term adverse health outcomes among children with CP, and if these associations were dependent on age.

METHODS

This retrospective cohort study used commercial claims from 01/01/2001-12/31/2018. The primary cohort was children 2-18 years old with CP and an incident fracture (CP + Fx). Comparison cohorts were propensity score matched 1:1 to CP + Fx on demographic and health-related indicators: CP without fractures (CPw/oFx); without CP with (w/oCP + Fx) or without (w/oCPw/oFx) a fracture. The incidence rate (IR) and IR ratios (IRR) of 30-day and 31-90-day pneumonia and 90-day emergency department (ED) visit were estimated. Cox regression tested for effect modification by age and sex.

RESULTS

The CP + Fx cohort (n = 1670) had higher IRs of 30-day pneumonia (IRR range, 1.53-4.54) and 90-day ED visit (IRR range, 1.45-2.37) (all P < 0.05), and higher IRs of 31-90-day pneumonia but this did not reach statistical significance (IRR, 1.41 to 2.32, all P > 0.05). Notably, there was evidence of effect modification by age. The rate of 30-day pneumonia became more problematic for CP + Fx with older age relative to comparison cohorts and for 90-day ED visit compared to CPw/oFx. The rate of 90-day ED visit for CP + Fx was more problematic at younger ages compared to w/oCP + Fx.

CONCLUSIONS

Fractures among children with CP were associated with an increased rate of short-term pneumonia and ED visit, which was more problematic with older age.

Association between sarcopenia and osteoporosis: the cross-sectional study from NHANES 1999-2020 and a bi-directions Mendelian randomization study

Background

Osteoporosis (OP) and sarcopenia are prevalent musculoskeletal conditions among the elderly. Nevertheless, the causal relationship between sarcopenia and OP remains a subject of controversy and uncertainty. In this study, we employed cross-sectional analysis and Mendelian randomization (MR) to investigate the intricate relationship between sarcopenia and OP.

Methods

The cross-sectional study utilized data from the National Health and Nutrition Examination Survey (NHANES) spanning 1999-2020, which involved in 116,876 participants. It assessed the correlation between sarcopenia, osteoporosis (OP), and bone mineral density (BMD) using Chi-square tests, T-tests, and a multiple logistic regression model. Additionally, we conducted Mendelian randomization (MR) analysis to investigate the causal effects of sarcopenia-related characteristics (ALM) on OP. We employed IVW, sensitivity analysis, heterogeneity testing, and other methods for MR. The ALM data was sourced from the UK Biobank (n=450,243), while the aggregated data on OP was obtained from GWAS statistics (n=53,236).

Results

In this cross-sectional analysis, we observed that in the multivariate logistic regression model, without adjusting for any variables, OP emerged as a risk factor for sarcopenia [OR 95% CI = 1.90 (1.13-3.18), P = 0.02]. Following adjustments for gender, age, BMI, and biochemical variables, OP retained its status as a risk factor for sarcopenia [OR 95% CI = 3.54 (1.91-6.54), P < 0.001]. Moreover, after accounting for all variables, OP emerged as an independent risk factor for sarcopenia [OR 95% CI = 4.57 (1.47-14.22), P = 0.01].In the MR analysis, we uncovered that femoral neck BMD (FN BMD), lumbar spine BMD (LS BMD), and forearm bone mineral density (FA BMD) exerted a direct causal influence on ALM [FA BMD: OR 95% CI = 1.028 (1.008, 1.049), p = 0.006; FN BMD: OR (95% CI) = 1.131 (1.092, 1.170), p = 3.18E-12; LS BMD: OR (95% CI) = 1.080 (1.062, 1.098), p = 2.86E-19].

Conclusion

Our study has revealed a positive correlation between OP and the prevalence of sarcopenia. It suggests a potentially robust causal relationship between OP and sarcopenia. Notably, OP appears to be associated with a higher likelihood of losing ALM, and a significant loss of ALM may contribute to a decline in LS BMD.

Deficits in recovery of postural stability after stepping are limb- and phase-specific in children with unilateral cerebral palsy

BACKGROUND

Recovery of postural stability after taking a step is necessary to maintain functional mobility. Although children with cerebral palsy (CP) are at an increased risk of falling, their ability to recover stability following a step is unknown.

RESEARCH QUESTION

This study aimed to validate a method to assess step recovery in children with unilateral CP and determine if recovery of postural stability differs between limbs and across phases of step recovery.

METHODS

Children with unilateral CP and matched typically developing controls (5-11 y; n=20/group) stood still on force platforms (quiet stance) and completed a forward step with their more-affected limb. Step recovery was divided into dynamic and static phases using vertical ground reaction force. Postural stability was assessed using center of pressure (COP) sample entropy, distance, and velocity of the more-affected (stepping) and less-affected (trailing) limbs in the anteroposterior and mediolateral directions.

RESULTS

Vertical ground reaction force during the static phase of step recovery and during quiet stance were not different for either limb and were strongly related (intraclass correlations >0.97, p<0.001), indicating concurrent validity of the step recovery method. Children with CP exhibited impaired recovery of postural stability after stepping, with deficits most pronounced in the mediolateral direction during the dynamic phase in the stepping limb as exhibited by lower COP sample entropy and higher COP distance and velocity (Cohen's d (d) range = 1.46-2.19, all p < 0.001). Deficits were present in the anteroposterior and mediolateral directions in the trailing limb, but they were limited to COP sample entropy and distance and the magnitude of the group differences was less pronounced (d range = 0.35-1.34).

SIGNIFICANCE

Step recovery is a valid method to detect deficits in postural stability in children with unilateral CP, and the dynamic phase may be a sensitive target for interventions.

Anxiety, depression, and support needs of the mothers of children with cerebral palsy and determining their opinions: Mixed methods study

PURPOSE

This study aimed to determine the level of anxiety, depression, support needs and opinions of mothers of children with cerebral palsy.

DESIGN AND METHODS

The study used a descriptive qualitative design. The population of the study consisted of children with cerebral palsy who were educated in special education centers in a province of Eastern Turkey. All participants who volunteered for the study were accepted and the study was completed with 126 mothers.

RESULTS

Caregiver mothers with male cerebral palsy patients had higher carer support needs and anxiety total mean scores. The mean scores of depression and anxiety of the mothers who were older were statistically higher. This study found that mothers of children with diseases other than cerebral palsy had statistically higher mean depression scores. The mothers of child with cerebral palsy who had a high gross motor classification score had higher mean carer support needs, depression, and anxiety total scores.

CONCLUSIONS

According to the study, depression and trait anxiety were linked to greater maternal support needs. Qualitative interviews revealed that mothers experienced issues such as stigmatization and withdrawal from social activities as a result of their children's illness.

PRACTICE IMPLICATIONS

This study shows the relationship of need for support of mothers of children with cerebral palsy and mental problems such as depression and trait anxiety. Pediatric nurses should provide emotional support to mothers and guide them towards support groups and training programs.

Estimates of functional muscle strength from a novel progressive lateral step-up test are feasible, reliable, and related to physical activity in children with cerebral palsy

OBJECTIVE

To determine if estimates of functional muscle strength from a novel progressive lateral-step-up test (LSUT) are feasible, reliable, and related to physical activity in children with cerebral palsy (CP).

DESIGN

Cross-sectional; test-retest reliability Subjects/Patients: Children with CP and typically developing control children (n = 45/group).

METHODS

An LSUT with 10, 15, and 20 cm step heights was completed. It was repeated 4 weeks later in 20 children with CP. A composite score of LSUT was calculated based on the step height and number of repetitions completed. Physical activity was assessed using monitors worn on the ankle and hip.

RESULTS

Only 4 (13%) of the children with CP were unable to complete a lateral step-up repetition without assistance. All children were able to complete at least 1 repetition with assistance, though more than twice as many children with CP required assistance at 15 and 20 cm step heights than at the 10 cm step height (p < 0.01). Children with CP had 59 to 63% lower LSUT performance, 37% lower physical activity assessed at the ankle, and 22% lower physical activity assessed at the hip than controls (all p < 0.01). The intra-class correlation coefficient ranged from 0.91 to 0.96 for LSUT performance at the different step heights and was 0.97 for the composite score. All LSUT performance measures were positively related to ankle physical activity in children with CP (r range = 0.43 to 0.47, all p < 0.01). Only performance at 20 cm and the composite score were positively related to hip physical activity (r = 0.33 and 0.31, respectively, both p < 0.05). The relationship between the LSUT performance and physical activity at both the ankle and hip increased when age and sex were statistically controlled (model r range = 0.55 to 0.60, all p < 0.001).

CONCLUSION

Estimates of functional muscle strength from a novel progressive LSUT are feasible, reliable, and positively related to physical activity in children with CP.

Jump Performance and Its Relationship with Lower Body Joint Kinetics and Kinematics in Children with Cerebral Palsy

PURPOSE

The aim was to quantify jump performance in children with cerebral palsy (CP) and determine if the expected deficit is related to their lower body joint kinetics and kinematics.

METHODS

Twenty-four ambulatory ( n = 17 level I and 7 level II in the Gross Motor Function Classification System) children with spastic CP ( n = 13 unilateral and 11 bilateral) and 24 age-, sex-, and race-matched typically developing controls were studied. Jump height and peak power and range of motion at the hip, knee, and ankle of the more affected limb in children with CP and the nondominant limb in controls were assessed during a countermovement jump using three-dimensional motion capture and a force platform.

RESULTS

Compared with controls, children with CP had lower jump height (33%, Cohen's d ( d ) = 1.217), peak power at the knee (39%, d = 1.013) and ankle (46%, d = 1.687), and range of motion at the hip (32%, d = 1.180), knee (39%, d = 2.067), and ankle (46%, d = 3.195; all P < 0.001). Jump height was positively related to hip, knee, and ankle power and range of motion in children with CP ( rs range = 0.474-0.613, P < 0.05), and hip and ankle power and knee and ankle range of motion in controls ( rs range = 0.458-0.630, P < 0.05). The group difference in jump height was no longer detected when ankle joint power, ankle range of motion, or knee range of motion was statistically controlled ( P > 0.15).

CONCLUSIONS

Jump performance is compromised in children with CP and is associated with low power generation and range of motion in the lower limb, especially at the ankle.

Feasibility and reliability of measured glomerular filtration rate with [I125]-iothalamate among young adults with mild-to-moderate cerebral palsy

Objective

Despite the need, measuring glomerular filtration rate (mGFR) is not routinely performed for adults with cerebral palsy (CP), possibly due to unknown feasibility given the secondary complications of CP. This study aimed to assess the feasibility and reliability of mGFR and explore factors associated with eGFR-mGFR discordance among young adults with mild-to-moderate CP.

Methods

This single-center, cross-sectional study included 18- to 40-year-olds with CP gross motor function classification system (GMFCS) I-III. The participants were excluded if they were pregnant/lactating, had cognitive impairments, or had contraindications to mGFR. A routine clinical protocol for mGFR and eGFR was used. mGFR feasibility was assessed based on the number of participants who completed testing. mGFR reliability was assessed using the coefficient of variation (CV) across the four 30 min intervals. The association between age, sex, and GMFCS and the percentage of eGFR-mGFR discordance was assessed.

Results

Of the 19 participants enrolled, 18 completed the testing [mean age (SD), 29.9 (7.4) years, n = 10 female participants, n = 10/3/5 for GMFCS I/II/III] and most (n = 15) of the participants had an mGFR >90 mL/min; 14 participants (77.8%) had a CV <20%, 2 had a CV between 20 and 25%, and 2 had a CV >50%. eGFR overestimated mGFR by a median (interquartile range) of approximately 17.5% (2-38%); the full range of mis-estimation was -20.5 to 174.3%. Increasing age and GMFCS levels exhibited notable, but weak-to-modest, associations with a larger eGFR-mGFR discordance.

Discussion

Obtaining mGFR was feasible and reasonably reliable within this small sample. eGFR overestimated mGFR by a notable amount, which may be associated with patient-level factors.

Perspective: A multi-trait integrative approach to understanding the structural basis of bone fragility for pediatric conditions associated with abnormal bone development

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.

Physical activity is associated with walking and balance ability but not fatigue, knee extension strength, or body composition in adults with cerebral palsy: a pilot cross-sectional study

Common secondary impairments associated with aging in adults with cerebral palsy (CP) decrease physical functions, including walking and balance ability, and increase the sense of fatigue. This motor dysfunction results in decreased physical activity (PA) and could be associated with obesity and sarcopenia. This study examined the association of daily PA levels with fatigue, physical function, and body composition in 22 adults with CP (age, 37.4 ± 14.7 years; Gross Motor Function Classification System level, I: 6, II: 16). The level of daily PA was divided into percent of sedentary behavior, light PA, and moderate-to-vigorous PA (%MVPA) per day. These outcomes were examined for correlation with the Fatigue Severity Scale, knee extension strength, comfortable and maximum walking speed, Timed-Up-and-Go-Test (TUG), and body fat percentage and skeletal muscle mass using Spearman's rank correlation coefficient. An additional partial correlation analysis with sex and age adjustment was performed. The %MVPA correlated positively with comfortable walking speed (rs = 0.424, P  = 0.049) and negatively with TUG (rs = -0.493, P  = 0.020). The partial correlation revealed associations of %MVPA with maximum walking speed (r = 0.604, P  = 0.022) and TUG (r = -0.604, P  = 0.022). The results show that among adults with CP, increased PA is associated with improvements in mobility but not in perceived fatigue or body composition, regardless of sex and age. Maintaining and improving %MVPA and walking and balance ability in adults with CP have a positive impact on each other, and potentially on overall health management.

Body Mass Index, Physical Activity, Cardiorespiratory Endurance and Quality of Life among Children with Physical Disabilities

BACKGROUND

Children with physical disabilities (PD) have reduced levels of physical activity (PA) compared to typically developing children, which increases their risk of becoming overweight and obese, which leads to numerous adverse health consequences. This study aimed to determine the differences between groups classified by body mass index (BMI) percentile in terms of PA levels, cardiorespiratory endurance and quality of life (QoL), and also to evaluate the relationship between BMI percentile and PA levels, cardiorespiratory endurance and QoL in children and adolescents with physical disabilities.

METHODS

A total of 172 children and adolescents with PD aged between 5 and 17 years from Hospital Tunku Azizah were included in this cross-sectional study. The BMI percentile was calculated to determine the weight status. PA levels were assessed with the Physical Activity Questionnaire for Older Children (PAQ-C), cardiorespiratory endurance was measured by the Six-Minute Walk Test (6MWT) and QoL was measured by the Paediatric Quality of Life Inventory version 2.0 (PedsQL 2.0).

RESULTS

According to the BMI percentile, 70.3% had a healthy BMI percentile (50th to 84th percentile), 11.6% were overweight (50th to 84th percentile), 11% were underweight (0-49th percentile) and 7.0% were obese (95th percentile and above). Most children reported a healthy weight, and the rates of being overweight and obese were higher in children who could ambulate without aids (6.4% and 3.5%, respectively) compared to those who used walking aids (5.2% and 3.5%, respectively). Significant differences were found in the PAQ-C, 6MWT and PedsQL 2.0 scores between different BMI percentile groups (p < 0.05). There were also significant correlations between the BMI percentile and the PAQ-C (r = 0.209, p < 0.001), 6MWT (r = 0.217, p < 0.001) and PedsQL 2.0 (r = 0.189, p < 0.001).

CONCLUSION

The rate of being overweight and obese is greater among children who ambulate without aids than among those with aids. An increase in the BMI percentile can reduce the QoL in different ways. This study suggests that children with PD who can walk without aids are at a greater risk of being overweight and obese. Hence, the engagement of this population in PA is crucial for their weight management.

Longitudinal Patterns of Postfracture Outpatient Physical Therapy and Occupational Therapy Use and Its Association With 3-Year Mortality Among Adults With Cerebral Palsy

OBJECTIVE

Fragility fractures are common among adults with cerebral palsy (CP), but clinical rehabilitation use after fracture and its effect on long-term health outcomes have not been sufficiently studied. The objectives of this study were to identify patterns of the use of physical therapy, occupational therapy, or both in the 6-month postfracture period and the association with 3-year mortality in adults with CP.

METHODS

This retrospective cohort study included adults who were ≥18 years old, had CP, and had sustained an incident fragility fracture between January 1, 2014, and December 31, 2016, as identified from a random 20% Medicare fee-for-service dataset. Six-month outpatient physical therapy or occupational therapy use patterns after fracture were identified using group-based trajectory modeling. Cox regression determined the association between physical therapy or occupational therapy use trajectory patterns and mortality from 6 months to 3 years after fracture, adjusting for confounders. Effect modification by key characteristics was tested, including age, sex, and the modified Whitney Comorbidity Index (mWCI), which is a CP-specific comorbidity index that better captures overall medical complexity.

RESULTS

Of the 2429 participants included, the majority (73.2%) were characterized as having little to no probability of physical therapy or occupational therapy use, whereas 16.0 and 10.7% were characterized as having early initiation and later initiation, respectively. Compared to the mortality rate for the little to no physical therapy or occupational therapy group, the mortality rates were 26% lower for the early physical therapy or occupational therapy initiation group (hazard ratio [HR] = 0.74; 95% CI = 0.55-1.00) and were 20% lower for the later initiation group (HR = 0.80; 95% CI = 0.57-1.12). There was effect modification by the mWCI. The mortality rate was lower when the early initiation and later initiation groups were compared to the little to no initiation group across all mWCI values examined (median and interquartile range), but the effect was stronger (ie, lower mortality rate) for lower mWCI values for both early initiation and later initiation groups.

CONCLUSION

Most adults with CP underutilize outpatient physical therapy or occupational therapy services within 6 months postfracture. Early or later initiation versus little to no physical therapy or occupational therapy use was associated with a lower HR of mortality, although the effect was stronger and statistically significant among those with less medical complexity.

IMPACT

Throughout their lives, the use of rehabilitation services in individuals with CP, including physical therapy and occupational therapy, dramatically declines despite the need for continued rehabilitation across their lifespans. This study characterized longitudinal physical therapy or occupational therapy use patterns in the 6 months following a fragility fracture among adults with CP and found that nearly 3 in 4 adults with CP had little to no physical therapy or occupational therapy use during this critical window to optimize postfracture health and function. Further, those who more regularly used physical therapy or occupational therapy services, regardless of the timing of initiation (early vs later), had significantly improved survival up to 3 years after fracture, suggesting the need for greater access to and delivery of clinical rehabilitation services.

Abnormal changes of bone metabolism markers with age in children with cerebral palsy

Cerebral palsy (CP) is a broad range of diseases with permanent and nonprogressive motor impairments, carrying a high cost for both the individual and the society. The characteristics of low bone mineral density and high risk of fractures suggest that bone metabolism disorders are present in CP. This study aims to investigate the association between indicators of bone metabolism and children with CP. A total of 139 children (75 children with CP and 64 healthy controls) were included in this cross-sectional study. Participants were divided into three age groups (0-2 years, 2.1-4 years, and 4.1-7 years). All children with CP were diagnosed according to clinical criteria and furtherly divided into clinical subtypes. The levels of total procollagen type I N-terminal propeptide (TPINP), N-MID osteocalcin (OC), beta-crosslaps (β-CTX), 25-hydroxyvitamin D (25-OHD) and parathyroid hormone (PTH) in the serum were measured with corresponding detection kits according to the manufacturer's instructions. Serum levels of TPINP and 25-OHD were lower with older age, whereas β-CTX and PTH were higher with older age. In the CP group, TPINP (age 0-2 years and 2.1-4 years) and OC (age 2.1-4 years) levels were higher, while β-CTX (age 2.1-4 years and 4.1-7 years) and PTH (age 2.1-4 years) values were lower than the control group. In addition, there were no statistically significant differences in the levels of these indicators among the CP subgroups with different clinical characteristics. Our study shows that bone turnover markers, indicators of bone metabolism, in children with CP differ significantly from healthy controls. The indicators we studied changed with age, and they did not correlate with disease severity.

Lifelong Fitness in Ambulatory Children and Adolescents with Cerebral Palsy I: Key Ingredients for Bone and Muscle Health

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.

Sarcopenia, osteoporosis and frailty

Muscles and bones are intricately connected tissues displaying marked co-variation during development, growth, aging, and in many diseases. While the diagnosis and treatment of osteoporosis are well established in clinical practice, sarcopenia has only been classified internationally as a disease in 2016. Both conditions are associated with an increased risk of adverse health outcomes such as fractures, dysmobility and mortality. Rather than focusing on one dimension of bone or muscle mass or weakness, the concept of musculoskeletal frailty captures the overall loss of physiological reserves in the locomotor system with age. The term osteosarcopenia in particular refers to the double jeopardy of osteoporosis and sarcopenia. Muscle-bone interactions at the biomechanical, cellular, paracrine, endocrine, neuronal or nutritional level may contribute to the pathophysiology of osteosarcopenia. The paradigm wherein muscle force controls bone strength is increasingly facing competition from a model centering on the exchange of myokines, osteokines and adipokines. The most promising results have been obtained in preclinical models where common drug targets have been identified to treat these conditions simultaneously. In this narrative review, we critically summarize the current understanding of the definitions, epidemiology, pathophysiology, and treatment of osteosarcopenia as part of an integrative approach to musculoskeletal frailty.

5-year fracture risk among children with cerebral palsy

BACKGROUND

Epidemiologic evidence documenting fracture risk as children with cerebral palsy (CP) age throughout growth is lacking to inform on when to implement fracture prevention strategies. The objective was to characterize the 5-year risk of fractures by each year of age among <1-13 year olds with CP and effects by patient-level factors.

METHODS

This retrospective cohort study used commercial administrative claims from 01/01/2001 to 12/31/2018 from children <1-13 years old with ≥5 years of insurance enrollment. Fractures were examined during the 5-year follow-up. For the CP cohort, the association between 5-year fracture rate and patient-level factors was assessed using Cox regression.

RESULTS

Children with (n = 5559) vs. without (n = 2.3 million) CP had a higher 5-year fracture risk at the vertebral column, hip, and lower extremities at almost each year of age, but lower 5-year fracture risk at the upper extremities after 6 years old (all P < 0.05). Among children with CP, the 5-year fracture rate was elevated for co-occurring neurological conditions and non-ambulatory status at the vertebral column, hip, and lower extremities (hazard ratio [HR] range, 1.44-2.39), and higher for males at the upper extremities (HR = 1.29) (all P < 0.05).

CONCLUSIONS

This study provides novel epidemiologic evidence of 5-year fracture risk for each year of age for children with CP.

IMPACT

This study provides novel epidemiologic evidence of 5-year fracture risk for each year of age across important developmental stages for children with vs. without cerebral palsy (CP). Children with vs. without CP were more likely to fracture at the vertebral column, hip, lower extremities, and humerus and less likely to fracture at the forearm and hands. The age-related 5-year fracture risk was associated with clinically relevant patient-level factors, but in different ways by fracture region. Study findings may be used to enhance clinical detection of at-risk children and strategize when to implement fracture prevention efforts for children with CP.

A review of the characterizations of soft tissues used in human body modeling: Scope, limitations, and the path forward

Soft tissue material properties are vital to human body models that evaluate interactions between the human body and its environment. Such models evaluate internal stress/strain responses in soft tissues to investigate issues like pressure injuries. Numerous constitutive models and parameters have been used to represent mechanical behavior of soft tissues in biomechanical models under quasi-static loading. However, researchers reported that generic material properties cannot accurately represent specific target populations due to large inter-individual variability. Two challenges that exist are experimental mechanical characterization and constitutive modeling of biological soft tissues and personalization of constitutive parameters using non-invasive, non-destructive bedside testing methods. It is imperative to understand the scope and appropriate applications for reported material properties. Thus, the goal of this paper was to compile studies from which soft tissue material properties were obtained and categorize them by source of tissue samples, methods used to quantify deformation, and material models used to describe tissues. The collected studies displayed wide ranges of material properties, and factors that affected the properties included whether tissue samples were in vivo or ex vivo, from humans or animals, the body region tested, body position during in vivo studies, deformation measurements, and material models used to describe tissues. Because of the factors that affected reported material properties, it is clear that much progress has been made in understanding soft tissue responses to loading, yet there is a need to broaden the scope of reported soft tissue material properties and better match reported properties to appropriate human body models.

Cardiometabolic Risk and Its Relationship With Visceral Adiposity in Children With Cerebral Palsy

Context

Adults with cerebral palsy (CP) display a higher prevalence of cardiometabolic disease compared with the general population. Studies examining cardiometabolic disease risk in children with CP are limited.

Objective

The purpose of this study was to determine if children with CP exhibit higher cardiometabolic risk than typically developing children, and to examine its relationship with visceral adiposity and physical activity.

Methods

Thirty ambulatory children with CP and 30 age-, sex-, and race-matched typically developing control children were tested for blood lipids, glucose, and the homeostatic model assessment of insulin resistance (HOMA-IR). Visceral fat was assessed using dual-energy x-ray absorptiometry. Physical activity was assessed using accelerometer-based monitors.

Results

Children with CP had higher total cholesterol, low-density lipoprotein cholesterol, and non-high-density lipoprotein cholesterol (non-HDL-C), glucose, prevalence of dyslipidemia, prevalence of prediabetes, and visceral fat mass index (VFMI) and lower physical activity than controls (all P < .05). In the groups combined, non-HDL-C and glucose were positively related to VFMI (r = 0.337 and 0.313, respectively, P < .05), and non-HDL-C and HOMA-IR were negatively related to physical activity (r = -0.411 and -0.368, respectively, P < .05). HOMA-IR was positively related to VFMI in children with CP (r = 0.698, P < .05), but not in controls. Glucose was not related to physical activity in children with CP, but it was negatively related in controls (r = -0.454, P < .05).

Conclusion

Children with CP demonstrate early signs of cardiometabolic disease, which are more closely related to increased visceral adiposity than decreased physical activity.

Body Composition in Outpatient Children with Cerebral Palsy: A Case-Control Study

Purpose

The purpose of this study was to identify quantitative (BMI z-score and BMI percentile) and qualitative (BC) differences between high functioning outpatient children with CP (GMFCS levels I/II) vs TD children, using BIA. We hypothesized that: 1) BMI z-score and BMI percentile will be lower in children with CP compared with their TD peers; and 2) body components (BC) directly associated with muscle mass (including fat free mass (FFM%) and skeletal muscle mass (SMM) and predicted muscle mass (PMM)) in children with CP will be lower than in their TD peers.

Patients and Methods

Ninety children with CP (GMFCS levels I/II) aged 8-16 years were enrolled in this study. Due to the fact that there is lack of normative values of particular body components in the pediatric population, ninety typically developing (TD) peers were used as references. The examination consisted of two parts: 1) the height measurement and 2) body composition assessments, both using the bioelectric impedance analysis (BIA).

Results

Average values for height, weight, BMI z-score, and BMI percentile in children with CP were significantly statistically lower than in the reference group. BC's directly associated with muscle mass (including FFM%, SMM, and PMM) in children with CP were lower than those in their TD peers.

Conclusion

Altered body compositions were evident in children with CP.

Haemodynamics and oxygenation in the lower-limb muscles of young ambulatory adults with cerebral palsy

AIM

To evaluate muscle haemodynamics and oxygen metabolism in adults with cerebral palsy (CP) at rest and during exercise.

METHOD

This cross-sectional study included 12 adults with spastic CP (four females, eight males; mean age [SD] 29 years 6 months [7 years 10.8 months]) and 13 typically developing individuals (seven females, six males; mean age [SD] 26 years 6 months [1 year 1.9 months]). Near-infrared spectroscopy was used to assess changes in muscle blood flow (mBF), muscle oxygen consumption (mVO₂ ), and muscle oxygen saturation in the vastus lateralis and rectus femoris muscles during three conditions: rest, low load at 20% maximum voluntary contraction (MVC), and high load at 80% MVC.

RESULTS

MBF was lower in participants with CP than in typically developing participants at rest (p < 0.001) and at 20% MVC (p = 0.007) in both muscles. Increased load caused a reduction in mBF in typically developing participants and an increase in CP. MVO₂ in typically developing participants increased from rest to 20% MVC and was reduced at 80% MVC compared with 20% MVC. In participants with CP, there was no change with load in the rectus femoris muscle; however, there was an increase in the vastus lateralis muscle from rest to 20% MVC, and 80% MVC had a similar value. Muscle saturation was higher in participants with CP across all conditions (vastus lateralis, p < 0.001; rectus femoris, p = 0.0518).

INTERPRETATION

Oxidative metabolism in CP is not limited by oxygen delivery (mBF), because high muscle saturation suggests oxygen availability. Adults with CP demonstrate muscular responses to exercise that are inconsistent with typical high-workload activation, probably because of inefficient fibre recruitment and secondary anomalies.

Skeletal Muscle Measurements in Pediatric Hematology and Oncology: Essential Components to a Comprehensive Assessment

Children with hematologic and oncologic health conditions are at risk of impaired skeletal muscle strength, size, and neuromuscular activation that may limit gross motor performance. A comprehensive assessment of neuromuscular function of these children is essential to identify the trajectory of changes in skeletal muscle and to prescribe therapeutic exercise and monitor its impact. Therefore, this review aims to (a) define fundamental properties of skeletal muscle; (b) highlight methods to quantify muscle strength, size, and neuromuscular activation; (c) describe mechanisms that contribute to muscle strength and gross motor performance in children; (d) recommend clinical assessment measures; and (e) illustrate comprehensive muscle assessment in children using examples of sickle cell disease and musculoskeletal sarcoma.

Changes in adipose bone marrow and bone morphology in X-linked hypophosphatemic rickets

INTRODUCTION

X-linked hypophosphatemic (XLH) rickets causes significant bone deformities in the lower limbs resulting from a bone mineralization defect. According to Frost's Mechanostat theory, compensatory modeling of the bones takes place during increased mechanical loads. In addition, mechanical stimuli modulate the differentiation of mesenchymal stem cells; common precursors to bone marrow adipocytes and osteoblasts.

HYPOTHESIS

Bone deformities of the lower limbs lead to increased femoral bone mass and decreased fatty infiltration of the bone marrow (FIBM) in children with XLH rickets compared to a control group.

PATIENTS AND METHODS

Eleven children (10.3years [6-17]) with XLH rickets and 22 healthy children (10.2years [5-15.5]) underwent lower limb Magnetic Resonance Imaging. A calculation of FIBM was performed at the mid-femur, as well as a calculation of the total bone cross-sectional area (CSA), the cortical CSA, the anteroposterior and mediolateral axes of the femur, bone marrow and the thickness of the femoral cortices.

RESULTS

Total bone CSA, total cortical CSA and bone marrow CSA were higher in the XLH group than in the control group (p<0.05). The mid-lateral diameters of the femur and bone marrow were more elongated than those of the control group (p<0.001). Only the anterior cortex was thinned in the XLH group (p=0.001), while there was no difference with the control group for the posterior, medial and lateral cortices. The total percentage of FIBM was 72.81% [±3.95] and 77.4% [±5.52] for the XLH and control groups respectively (p<0.001).

DISCUSSION

The increase in bone mass in the XLH population reflects an adaptation of bone tissue to the bone deformities present in this pathology. The decrease in FIBM indicates a lower risk of osteoporosis in the XLH population and may constitute a new monitoring parameter in this pathology.

LEVEL OF STUDY

III; Case-control study.

Five-year risk of fracture and subsequent fractures among adults with cerebral palsy

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.

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Fracture prevention efforts are focused on the elderly and postmenopausal women.

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Fragility fracture risk is elevated for those with CP across the adult lifespan.

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For men, the risk for 18–29 year olds (CP) was on par with 65–74 year olds (no CP).

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For women, risk for 30–34 year olds (CP) was on par with 65–74 year olds (no CP).

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CP had a higher risk of subsequent fragility fractures that was also premature.

5-year risk of “adult-onset” chronic diseases during childhood and adolescent transitioning for individuals with cerebral palsy

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“Adult-onset” chronic diseases may begin in childhood for individuals with CP.

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5-year disease risk was < 64.3-fold higher for < 1–13 year olds with vs without CP.

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5-year chronic disease risks were elevated for CP across all developmental stages.

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Patient factors impacted disease risk variably for children with CP.

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Findings may inform when to implement prevention efforts and who is more at-risk.

Epidemiologic evidence documenting risk of chronic diseases as children with cerebral palsy age throughout growth is lacking to inform prevention strategies. The objective was to characterize the 5-year risk of chronic diseases that are typically associated with advanced aging among < 1–13 year olds with cerebral palsy and effects by patient-level factors. This retrospective cohort study used nationwide commercial administrative claims from 01/01/2001–12/31/2018 from children < 1–13 years old with ≥ 5 years of mostly continuous insurance enrollment. The 5-year risk of chronic diseases was examined for the entire cohort with and without cerebral palsy and then by baseline age group (<1–2, 3–5, 6–8, 9–11, 12–13 years old), including cardiorespiratory, metabolic, kidney, and liver diseases, cancer, depression, and osteoarthritis. For cerebral palsy, the association between 5-year chronic disease rate and patient-level factors was assessed using Cox regression. Children with (n = 5,559) vs without (n = 2.3 million) cerebral palsy had a higher 5-year risk of all chronic diseases when comparing the entire cohorts (relative risk, 1.19 to 64.26, all P < 0.05) and most chronic diseases when comparing cohorts for each age group. Among children with cerebral palsy, there were effects by gender, co-occurring intellectual disabilities and/or epilepsy, and wheelchair use for some chronic diseases, which can help to identify at-risk children. This study provides novel epidemiologic evidence of 5-year risk of “adult-onset” chronic diseases for children with cerebral palsy during important developmental stages, and associated patient-level factors (to enhance clinical detection). Findings may inform when to implement prevention strategies and who may be more at risk.

Musculoskeletal Morbidity Among Adults Living With Spina Bifida and Cerebral Palsy

Background

Individuals living with cerebral palsy (CP) or spina bifida (SB) are at heightened risk for chronic health conditions that may develop or be influenced by the impairment and/or the process of aging.

Objectives

The objective of this study was to compare the incidence of and adjusted hazards for musculoskeletal (MSK) morbidities among adults living with and without CP or SB.

Methods

A retrospective, longitudinal cohort study was conducted among adults living with (n = 15,302) CP or SB and without (n = 1,935,480) CP or SB. Incidence estimates of common MSK morbidities were compared at 4 years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident MSK morbidities. The analyses were performed in 2019 to 2020.

Results

Adults living with CP or SB had a higher 4-year incidence of any MSK morbidity (55.3% vs. 39.0%) as compared to adults without CP or SB, and differences were to a clinically meaningful extent. Fully adjusted survival models demonstrated that adults with CP or SB had a greater hazard for all MSK disorders; this ranged from hazard ratio (HR) 1.40 (95% CI, 1.33 to 1.48) for myalgia to HR 3.23 (95% CI, 3.09 to 3.38) for sarcopenia and weakness.

Conclusion

Adults with CP or SB have a significantly higher incidence of and risk for common MSK morbidities as compared to adults without CP or SB. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of MSK disease onset/progression in these higher risk populations.

Body Fat Distribution in Children and Adolescents With Cerebral Palsy

To evaluate the body fat distribution in children with cerebral palsy (CP). The present study focusses on a monocentric retrospective analysis of body fat distribution from children diagnosed with CP. The children participated in a rehabilitation program. Reference centiles were calculated based on data from the National Health and Nutrition Examination Survey (NHANES, 1999-2004). Z-scores for trunk-to-leg fat ratio were calculated. Further, fat mass index (FMI) was evaluated based on percentiles that have already been published. 237 males and 194 females with CP were considered (mean age: 11 years and 11 months [SD 3 years]). These were compared to 1059 males and 796 females from the NHANES (mean age: 14 years and 7 months [SD 3 years and 4 months]). The z-scores for trunk-to-leg fat ratio showed the following values: mean -0.47 (SD 1.50) for males, -0.49 (SD 1.11), for females, -0.48 (SD 1.34) for all. The z-scores for FMI showed the following values: mean -0.29 (SD 0.70) for males, -0.88 (SD 2.0) for females, -0.55 (SD 1.46) for all. The results showed rather a gynoid fat distribution and a lower FMI in children with CP than in the reference population (NHANES 1999-2004).

The Effect of a Horse-Riding Simulator with Virtual Reality on Gross Motor Function and Body Composition of Children with Cerebral Palsy: Preliminary Study

This study aimed to evaluate the effect of a horse-riding simulator (HRS) with virtual reality (VR) on gross motor function, balance control, and body composition in children with spastic cerebral palsy (CP). Seventeen preschool and school-aged children with spastic CP were included; 10 children in the intervention group (HRS group) received 30 min of HRS with VR training twice a week for a total of 16 sessions in addition to conventional physiotherapy. Seven children in the control group were instructed to perform home-based aerobic exercises twice a week for 8 weeks in addition to conventional physiotherapy. Gross motor function measure (GMFM) and body composition were evaluated before the first session and after the last session. Before and after the 2-month intervention, Pediatric Balance Scale and Timed Up and Go test were evaluated for the HRS group. GMFM scores and body composition changed significantly in the HRS group (p < 0.05). However, no significant differences were observed in the control group. Changes in the GMFM total scores, GMFM dimension D scores, and skeletal muscle mass significantly differed between the HRS and control groups (p < 0.05). HRS with VR may be an effective adjunctive therapeutic approach for the rehabilitation of children with CP.

Preventive Care for Adults With Cerebral Palsy and Other Neurodevelopmental Disabilities: Are We Missing the Point?

Preventive care techniques are cornerstones of primary care for people with neurodevelopmental disabilities such as cerebral palsy (CP). However, well-established methods evaluating health constructs may not be applied in the same way for adults with CP, as compared to the general population, due to differences in anatomy/physiology, leading to missed opportunities for interventions, medication modifications, and other primary/secondary prevention goals. One barrier to care prevention comes from misinterpretation of values to capture health constructs, even when measurements are accurate. In this Perspective, we emphasize the need for differential interpretation of values from commonly used clinical measures that assess for well-known medical issues among adults with CP obesity risk, bone health, and kidney health. We provide technical, but simple, evidence to showcase why the underlying assumptions of how some measures relate to the health construct being assessed may not be appropriate for adults with CP, which may apply to other neurodevelopmental conditions across the lifespan.

Clinical bone health among adults with cerebral palsy: moving beyond assessing bone mineral density alone

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.

Characteristics of Interventions to Improve Bone Health in Children With Cerebral Palsy: A Systematic Review

PURPOSE

A systematic review evaluated exercise parameters and ages that produced the most improvement in bone among individuals with cerebral palsy (CP) ages 3 to 21 years.

METHODS

PubMed, Scopus, Ebscohost, and Web of Science identified potential articles. Covidence was used to identify eligible citations and assess bias. The osteogenic index (OI) was used to evaluate intervention parameters.

RESULTS

The database search identified 312 citations. Twelve full-text articles were included. A 1-hour calisthenic exercise program performed 2 to 3 times a week for 8 months targeting each body region had the highest effect size and a substantial OI. Most of the interventions reviewed had low OIs. Activities of longer duration and greater intensity had greater OIs and prepubertal age-enhanced treatment effects.

CONCLUSION

Bone interventions for individuals with CP have low OIs, and principles of mechanostat theory should be applied to exercise dosing.

A possible case of paralysis in early modern Vilnius and the implications for social care

OBJECTIVE

To present a case of possible paralysis from early modern Vilnius and to discuss the potential level of care that was provided in the society of that time.

MATERIALS

A partially disturbed skeleton of a young female from a 16th-17th century Orthodox Christian cemetery.

METHODS

Macroscopic, osteometric and X-ray examinations coupled with a literature review aimed at providing a differential diagnosis.

RESULTS

The skeletal remains showed signs of disuse atrophy most probably due to a neurological disorder acquired in the woman's late teens. Differentials suggest that the observed limb atrophy was most likely a consequence of poliomyelitis.

CONCLUSIONS

The case of a young female with paralysis presented in this paper could serve as an example of care provided by her household.

SIGNIFICANCE

This study substantially contributes to further understanding of the nature and quality of care provided to disabled individuals in their households even in the absence of written sources.

LIMITATIONS

There is a degree of diagnostic ambiguity due to the application of routine clinical criteria to paleopathological cases.

SUGGESTIONS FOR FURTHER RESEARCH

The article makes several recommendations for future research, e.g., systematic investigation of possible cases of bone atrophy in a broader sociocultural context, as well as searching for evidence of gastrointestinal infections, especially poliomyelitis, supplemented by the application of biomolecular technologies.

The Association Between Kidney Disease and Mortality Among Adults With Cerebral Palsy-A Cohort Study: It Is Time to Start Talking About Kidney Health

Objective: Recent evidence shows that adults with cerebral palsy (CP) have an increased risk for kidney disease, but nothing is known about how kidney disease integrates with their overall health. To begin understanding the importance of kidney health, the objective was to determine if kidney disease is associated with mortality among adults with CP after accounting for comorbidities common to CP and kidney disease.

Methods: Data from 2016 to 2018 from adults ≥18 years with CP were used from a random 20% sample fee-for-service Medicare database. Kidney disease in 2016 was ascertained as chronic kidney disease (CKD) stages 1–4, end stage kidney disease (ESKD), nephritic and nephrotic syndrome, and renal osteodystrophy. A modified version of the Whitney Comorbidity Index (modWCI) was used, which includes 24 comorbidities relevant to CP and kidney disease. Mortality rate ratio (MRR) through the year 2018 was estimated for each kidney disease and Cox regression estimated the hazard ratio (HR) of mortality after adjusting for demographics, co-occurring neurological conditions, and the modWCI.

Results: Prevalence of kidney disease was 7.3% among 16,728 adults with CP. MRR was elevated for any kidney disease (MRR = 3.14; 95%CI = 2.76–3.58) and most subtypes (MRR = 2.21–3.56; all p < 0.05). The adjusted HR of mortality remained elevated for any kidney disease (HR = 1.25; 95%CI = 1.09–1.45) and ESKD (HR = 1.38; 95%CI = 1.10–1.74).

Discussion: Kidney disease, especially ESKD, is associated with mortality among adults with CP independent of comorbidities that are relevant to CP and kidney disease. Findings suggest that nephrology care should be considered as part of routine clinical care for this population.

Navigating the Pathway to Care in Adults With Cerebral Palsy

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.

Polypharmacy is a risk factor for mortality, severe chronic kidney disease, and liver disease among privately insured adults with cerebral palsy

BACKGROUND: Adults with cerebral palsy (CP) have an increased risk for polypharmacy, premature mortality, and early development of several morbidities, including conditions associated with excess medication exposure, such as chronic kidney disease (CKD) and liver disease. To date, very little is known about the consequence of polypharmacy for adults with CP. OBJECTIVE: To determine if polypharmacy is associated with an increased risk for mortality, severe CKD, and liver disease among adults with CP, before and after adjusting for comorbid neurodevelopmental disabilities (NDDs) and multimorbidity. METHODS: This is an exploratory treatment effectiveness study. Data from the Optum Clinformatics Data Mart were used for this retrospective cohort study. Adults aged 18 years or older with a diagnosis of CP and without severe CKD (stages IV+) and liver disease were identified from the calendar year 2013 and were subsequently followed from January 1, 2014, to death, severe CKD, liver disease, loss to follow-up, or end of study period (December 31, 2017). Diagnosis codes were used to identify NDDs (intellectual disabilities, epilepsy, autism spectrum disorders, spina bifida) and 24 relevant morbidities at baseline (i.e., calendar year 2013). Polypharmacy was defined as ≥ 5 medications and hyperpolypharmacy was defined as ≥ 10 medications at baseline. Cox regression models were developed to examine the association (as HR and 95% CI) between polypharmacy and hyperpolypharmacy with mortality, severe CKD, and liver disease separately, before and after adjusting for covariates (demographics, NDDs, multimorbidity). Exploratory analyses examined the mediating effect of incident severe CKD or liver disease on the association between the exposure (polypharmacy or hyperpolypharmacy) on outcomes. RESULTS: Of the 9,238 adults with CP, 58.5% had polypharmacy and 29.5% had hyperpolypharmacy. The fully adjusted HR for mortality was 2.14 (95% CI = 1.59-2.89) for polypharmacy and 1.65 (95% CI = 1.31-2.09) for hyperpolypharmacy. The fully adjusted HR for severe CKD was 1.66 (95% CI = 1.17-2.36) for polypharmacy and 1.67 (95% CI = 1.27-2.19) for hyperpolypharmacy. The fully adjusted HR for liver disease was 1.57 (95% CI = 1.27-1.94) for polypharmacy and 1.72 (95% CI = 1.42-2.08) for hyperpolypharmacy. Incident liver disease mediated 5.37% (polypharmacy) and 7.54% (hyperpolypharmacy) of the association between the exposure with incident severe CKD for nonelderly (aged < 65 years), while incident severe CKD mediated 7.05% (polypharmacy) and 6.64% (hyperpolypharmacy) of the association between the exposure with incident liver disease for elderly (aged ≥ 65 years). CONCLUSIONS: Polypharmacy and hyperpolypharmacy are robust risk factors for risk of mortality, severe CKD, and liver disease among privately insured adults with CP. While incidence of severe CKD and liver disease had negligible effects on the association between polypharmacy with mortality, there is evidence that they mediate a considerable portion of one another and require further examination. DISCLOSURES: During the work for this study, Whitney was supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund and American Academy for Cerebral Palsy and Developmental Medicine. The funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The authors have no conflicts of interest to report.

Critical periods of bone health across the lifespan for individuals with cerebral palsy: Informing clinical guidelines for fracture prevention and monitoring

BACKGROUND

Skeletal fragility is a major burden for individuals with cerebral palsy (CP), but little is known clinically about when to prevent fractures or monitor bone health for this population. Critical periods of bone health (CPBH) are important windows for intervention to augment bone growth or mitigate bone loss. However, CPBH from the general population may not align with the needs or timing of skeletal fragility for individuals with CP. The objective of this study was to identify discrepancies when evaluating individuals with CP using CPBH across the lifespan from the general population, and propose new CP-specific CPBH.

METHODS

Data from 2016 administrative claims databases were used, including the Optum's De-identified Clinformatics® Data Mart Database and a random 20% sample of the Medicare fee-for-service database from the Centers for Medicare and Medicaid Services. Sex-stratified fracture prevalence was compared between individuals with and without CP across the lifespan starting at 2 years of age using age groups to capture important stages of development and 3-4-year age bands in adulthood (up to >80 years). Sex-specific CPBH from the general population included: rapid bone accrual, peak bone mass, menopause, and elderly.

RESULTS

There were 23,861 individuals with CP and 9,976,161 individuals without CP. CPBH from the general population did not align with the timing of skeletal fragility for CP. For example, fractures were rare and decreased throughout the CPBH of peak bone mass for males without CP, but males with CP had a greater relative fracture risk (2.9-5.6-fold higher) and a substantially increased rate of fracture (CP-slope 14× higher than non-CP-slope). For females with CP, fracture risk was increased by 18-21 years, with additional inflection points (e.g., decade before menopause and again by 57-60 years). For males with CP, fracture risk in mid-life exhibited a pattern similar to elderly males without CP.

CONCLUSIONS

This study identified discrepancies in evaluating fracture risk for individuals with CP if using established CPBH from the general population. We therefore propose new CP- and sex-specific CPBH for fracture monitoring and prevention.

Effect of levetiracetam and oxcarbazepine on 4-year fragility fracture risk among prepubertal and pubertal children with epilepsy

OBJECTIVE

The objective of this study was to determine whether two commonly prescribed antiseizure medications (ASMs), levetiracetam (LEV) and oxcarbazepine (OXC), were associated with an increased risk of fragility fracture in children with epilepsy when initiating therapy during a crucial period of bone development, namely, pre- and midpuberty.

METHODS

Claims data from January 1, 2009 to December 31, 2018 were extracted from the Optum Clinformatics Data Mart. Children aged 4-13 years at baseline with at least 5 years of continuous health plan enrollment were included to allow for a 1-year baseline (e.g., pre-ASM exposure) and 4 years of follow-up. Children with epilepsy who were ASM naïve were grouped based on whether ASM treatment initiation included LEV or OXC. The comparison group included children without epilepsy and without ASM exposure. Crude incidence rate (IR; n per 1000 person-years) and IR ratio (IRR; with 95% confidence interval [CI]) were estimated for nontrauma fracture (NTFx), a claims-based proxy for fragility fracture, for up to 4 years of follow-up. Cox proportional hazards regression estimated the hazard ratio (HR; with 95% CI) after adjusting for demographic variables, motor impairment, and baseline fracture.

RESULTS

The crude IR (95% CI) of NTFx was 21.5 (21.2-21.8) for non-ASM-users without epilepsy (n = 271 346), 19.8 (12.3-27.2) for LEV (n = 358), and 34.4 (21.1-47.7) for OXC (n = 203). Compared to non-ASM-users, the crude IRR of NTFx was similar for LEV (IRR = .92, 95% CI = .63-1.34) and elevated for OXC (IRR = 1.60, 95% CI = 1.09-2.35); the crude IRR of NTFx was elevated for OXC compared to LEV (IRR = 1.74, 95% CI = 1.02-2.99). The findings were consistent after adjusting for covariates, except when comparing OXC to LEV (HR = 1.71, 95% CI = .99-2.93), which was marginally statistically insignificant (p = .053).

SIGNIFICANCE

Initiating OXC, but not LEV, therapy among 4-13-year-olds with epilepsy is associated with an elevated risk of fragility fracture. Studies are needed to determine whether these children could benefit from adjunct bone fragility therapies.

Meridian acupuncture plus massage for children with spastic cerebral palsy

OBJECTIVE

To evaluate the effect of combination therapy of meridian acupuncture and massage on motor development in children with spastic cerebral palsy (SCP).

METHODS

A total of 113 children with SCP in our hospital were allocated into research group (63 cases, treated with meridian acupuncture plus massage) and control group (50 cases, treated with routine rehabilitation measures). Clinical efficacy and alterations of inflammatory factors were observed. Peabody Developmental Motor Scale (PDMS) and gross motor function measure (GMFM-88; sitting, standing, walking) were employed for the assessment of motor ability. Changes in muscle tension were monitored with the Ashworth scale (AS), and modified Barthel index (MBI) and Gesell's Developmental Schedule (GDS) were used to evaluate children's daily activities, language, fine motor skills, and adaptability. Finally, the development of children in the two groups was monitored.

RESULTS

The research group had higher total effective rate than the control group (P=0.018). After treatment, the levels of interleukin 6 (IL-6) and tumor necrosis factor-α (TNF-α) in the research group were lower than those in the control group (P<0.05); the PDMS and AS scores were reduced in both groups, and the reduction was greater in research group (P<0.05); GFMF-88, Barthel and GDS scores increased in both groups, especially in the research group; children in research group were better developed than those in control group (P<0.05).

CONCLUSION

Meridian acupuncture plus massage contributes to a significant improvement of motor development in children with SCP.

Fracture characteristics by age, sex, and ambulatory status among individuals with cerebral palsy: a descriptive study

PURPOSE

To evaluate clinically relevant fracture characteristics by age, sex, and ambulatory status among individuals with cerebral palsy.

METHODS

Fracture location, energy of fracture, and activities that lead to a fracture were assessed among a clinic-based sample of children (0-17 years; n = 57) and adults (18-70 years; n = 58) with cerebral palsy that sustained a fracture by sex and gross motor function classification system (GMFCS) I-III vs. IV/V.

RESULTS

Proportion of fractures that were low-energy was 67-99% for children and 69-84% for adults. ∼2/3rds of fractures were at the lower extremities, with the distal femur being the most common site for children (44%) and the foot/ankle for adults (40%); however, there were age, sex, and ambulatory effects, such that 43% of adults GMFCS IV/V and 32% of women had a distal femur fracture. GMFCS I-III were more likely to fracture from functionally complex activities, while GMFCS IV/V were more likely to fracture from wheelchair/transfers/limb-stuck and incidental findings.

CONCLUSIONS

The majority of fractures were low-energy and occurred in the lower extremities, with effects by age, sex, and GMFCS. Activities that led to a fracture also differed by age and GMFCS, which can be used to design fracture prevention interventions in addition to bolstering skeletal mass and architecture.Implications for rehabilitationSkeletal fragility is a major problem for individuals with cerebral palsy (CP) across the lifespan leading to an increased risk of fragility fractures.Rehabilitation is a prime clinical intervention to prevent fractures from occurring and improving post-fracture healing and function; yet, effective rehabilitation interventions require knowledge of fracture characteristics, such as where fractures are occurring and the activities that lead to the fracture event specific to individuals with CP.Using a clinic-based sample of 0-70 year olds with CP, we describe salient fracture characteristics based on age, sex, and ambulatory status to enhance translation into clinical and rehabilitation practice.

Measuring skeletal muscle morphology and architecture with imaging modalities in children with cerebral palsy: a scoping review

AIM

To investigate the use of ultrasound and magnetic resonance imaging (MRI) methodologies to assess muscle morphology and architecture in children with cerebral palsy (CP).

METHOD

A scoping review was conducted with systematic searches of Medline, Embase, Scopus, Web of Science, PubMed, and PsycInfo for all original articles published up to January 2019 utilizing ultrasound and/or MRI to determine morphological and architectural properties of lower limb skeletal muscle in children with CP.

RESULTS

Eighty papers used ultrasound (n=44), three-dimensional ultrasound (n=16), or MRI (n=20) to measure at least one muscle parameter in children and adolescents with CP. Most research investigated single muscles, predominantly the medial gastrocnemius muscle, included children classified in Gross Motor Function Classification System levels I (n=62) and II (n=65), and assessed fascicle length (n=35) and/or muscle volume (n=35). Only 21 papers reported reliability of imaging techniques. Forty-six papers assessed measures of Impairment (n=39), Activity (n=24), and Participation (n=3).

INTERPRETATION

Current research study design, variation in methodology, and preferences towards investigation of isolated muscles may oversimplify the complexities of CP muscle but provide a foundation for the understanding of the changes in muscle parameters in children with CP.

WHAT THIS PAPER ADDS

Current evidence is biased towards the medial gastrocnemius muscle and more functionally able children with cerebral palsy (CP). Variations in imaging techniques and joint positioning limit comparisons between studies. Clinimetric testing of parameters of CP muscle is not always considered. Assessment of parameter(s) of muscle with measures of participation is sparse.

The paradoxical relationship between severity of cerebral palsy and renal function in middle-aged adults: better renal function or inappropriate clinical assessment?

PURPOSE

To determine the association between severity of cerebral palsy with serum creatinine (sCr) and sCr-based equations to estimate glomerular filtration rate (eGFR), a marker of renal function.

METHODS

A clinic-based sample of 30-64 year-olds with cerebral palsy was examined and stratified by motor impairment: gross motor function classification system (GMFCS) I/II (n = 79), GMFCS III (n = 78), and GMFCS IV/V (n = 137). sCr, which is influenced by muscle mass, was obtained and sCr-based eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations.

RESULTS

sCr was lower with increasing GMFCS. The opposite pattern was observed for eGFR: GMFCS IV/V had significantly higher eGFR derived from MDRD compared to other GMFCS groups; GMFCS III had significantly higher eGFR compared to GMFCS I/II. The pattern was similar for CKD-EPI derived eGFR.

CONCLUSIONS

According to widely used clinical assessment methods for renal function, higher severity of cerebral palsy among adults is associated with better renal function, which is incongruent with their other biological systems. This paradoxical relationship is likely driven by lower muscle rather than true renal function, and thus, sCr-based eGFR may overestimate renal function, especially for GMFCS IV/V. Further prospective studies are needed.Implications for rehabilitationCommon methods of clinical assessment may over-estimate renal function for adults with cerebral palsy (CP), potentially giving a false positive for normal renal health due to their reliance on muscle mass.This study of a clinic-based sample of middle-aged adults with CP highlights the paradoxical relationship between severity of CP and renal function, which is likely driven by methodological limitations in the presence of low muscle mass rather than actual better renal function.It is recommended that clinicians have a high suspicion of abnormal renal function and the need for a nephrology consultation, especially with changes in creatinine levels, even within the normal range.Rehabilitation for adults with CP must have a strong focus on muscle and kidney health, especially for patients with more severe forms of CP.

Skeletal Muscle in Cerebral Palsy: From Belly to Myofibril

This review will provide a comprehensive, up-to-date review of the current knowledge regarding the pathophysiology of muscle contractures in cerebral palsy. Although much has been known about the clinical manifestations of both dynamic and static muscle contractures, until recently, little was known about the underlying mechanisms for the development of such contractures. In particular, recent basic science and imaging studies have reported an upregulation of collagen content associated with muscle stiffness. Paradoxically, contractile elements such as myofibrils have been found to be highly elastic, possibly an adaptation to a muscle that is under significant in vivo tension. Sarcomeres have also been reported to be excessively long, likely responsible for the poor force generating capacity and underlying weakness seen in children with cerebral palsy (CP). Overall muscle volume and length have been found to be decreased in CP, likely secondary to abnormalities in sarcomerogenesis. Recent animal and clinical work has suggested that the use of botulinum toxin for spasticity management has been shown to increase muscle atrophy and fibrofatty content in the CP muscle. Given that the CP muscle is short and small already, this calls into question the use of such agents for spasticity management given the functional and histological cost of such interventions. Recent theories involving muscle homeostasis, epigenetic mechanisms, and inflammatory mediators of regulation have added to our emerging understanding of this complicated area.

The Effect of Osteoporosis Medication on Risk Attenuation of Non-Trauma Fracture Among Adults with Cerebral Palsy: A Propensity Score-Matched Observational Study

Purpose

The efficacy of osteoporosis medication on reducing the risk of non-trauma fracture (NTFx) among adults with cerebral palsy (CP) has not been comprehensively investigated. There are many logistical and biological factors that may reduce this efficacy, and therefore requires attention. The purpose of this propensity score-matched, observational cohort study was to determine if osteoporosis medication was associated with NTFx risk attenuation among adults with CP and compared to adults without CP.

Materials and Methods

Data from 07/01/2011 to 09/30/2015 were extracted from Optum Clinformatics^® Data Mart. Claims identified adults (≥18 years), CP, osteoporosis medication, pre-index NTFx (6-months), and post-index NTFx (12-months). CP without osteoporosis medication (CP_Meds-) and without CP with Meds (non-CP_Meds+; reflects "background" population) served as controls and were matched (6:1 ratio) to adults with CP with Meds (CP_Meds+; n=306). The Meds groups were further stratified by the initiation of their medication as new users or consistent users. Changes in the prevalence of NTFx from pre- to post-index periods were examined with risk ratios (RR) and the change was compared among groups using the ratio of the RR (RRR) via difference-in-difference analysis.

Results

New users with CP had: a larger risk attenuation of any NTFx compared to CP_Meds- (RRR=0.39; 95% CI=0.22-0.71), which was consistent for vertebral column/hip and lower extremities; a larger risk attenuation for NTFx of the lower extremities compared to consistent users with CP (RRR=0.22; 95% CI=0.05-0.93); and a similar risk attenuation of any NTFx compared to new users without CP (RRR=0.81; 95% CI=0.45-1.43), which was consistent for vertebral column/hip and lower extremities.

Conclusion

The findings suggest that osteoporosis medication is associated with clinically meaningful risk attenuation of NTFx, especially for new users with CP.

The impact of being overweight on the mobility, temporal-spatial and kinematic aspects of gait in children with cerebral palsy

AIM

Obesity causes altered gait patterns in typically developing children, but its effect on gait in children with physical disabilities is largely unknown. This study explores associations between body mass index (BMI), functional mobility and gait in children with cerebral palsy (CP).

METHOD

An observational cross-sectional study was conducted using three-dimensional gait analysis data from 197 children with CP, Gross Motor Functional Classification System (GMFCS) levels I to III. BMI values were categorised using the Centres for Disease Control and Prevention (2000) BMI percentiles, which are specific to age and gender. Regression analyses, with GMFCS level as a covariate, explored associations between BMI category and temporal-spatial, kinematic and functional mobility variables. Analyses included children categorised as healthy weight and overweight/obese only (n = 174), with underweight children excluded (n = 23).

RESULTS

131 children (mean age 10.5 years, SD 3) were categorised as healthy weight and 43 children (mean age 9.6 years, SD 2.5) as overweight or obese. BMI was not associated with most gait variables. Increased double support time, reduced hip extension and increased ankle dorsiflexion were observed in children that were overweight, but most differences were small and of uncertain clinical significance. A lower proportion of overweight children walked independently over 500 m.

CONCLUSION

We found little evidence that BMI has a substantial influence on gait patterns in children with CP but some to suggest it may affect long-distance mobility. Different research strategies are required to improve understanding of relationships between adiposity, strength and function, for effective targeting of interventions to improve mobility.

Designing Exercise to Improve Bone Health Among Individuals With Cerebral Palsy

PURPOSE

Individuals with cerebral palsy (CP), ambulatory or not, have less bone strength and density than their peers. Aging individuals with CP are at a higher risk for nontraumatic fractures, progressive deformity, pain, and spinal stenosis. Critical periods for skeletal formation are during prepuberty and adolescence. Applying mechanostat theory to exercise design for individuals with CP may be beneficial.

METHODS

Principles of mechanostat theory, particularly the osteogenic index, is applied to guide the design of exercise programs based on varying levels of physical capacity.

RESULTS

Recommendations are made for optimizing dosing of a variety of interventions for improving bone health among individuals with CP based on mechanostat theory with specific type, number of repetitions, and frequency.

CONCLUSIONS

Researchers and clinicians are called to action to consider the role of exercise throughout the lifespan for all individuals with CP, regardless of level of severity.

Pattern of bone marrow lipid composition measures along the vertebral column: A descriptive study of adolescents with idiopathic scoliosis

BACKGROUND

There is evidence that the extent of vertebral bone marrow adiposity increases caudally along the vertebral column in children and adolescents. However, no studies have examined the lipid composition of bone marrow along the vertebral column, which may uniquely influence bone acquisition and metabolism during growth independent of the amount of bone marrow adipose tissue. The goal of this study was to characterize the pattern of lipid composition index measures from the thoracic to lumbar spine (T11-L4) among a sample of adolescents with idiopathic scoliosis (AIS) undergoing routine orthopedic surgical care for scoliosis correction.

METHODS

Adolescents between 14 and 18 years of age, with a confirmed diagnosis of AIS, and undergoing routine posterior spinal fusion surgery at our institution were initially included for this descriptive study. The surgery yielded transpedicular vertebral body marrow samples from T11 through L4; 11 participants had bone marrow samples from T11 through L2 and 4 of the 11 participants had marrow samples from T11 through L4. Lipid composition index measures, including the saturated, monounsaturated, and polyunsaturated index, were measured using a targeted lipidomics technique. Linear regression equation for the slope (m) and Pearson correlation coefficient (r) was computed to assess the pattern of lipid composition index measures along the vertebral column from T11 to L2 (n = 11) and extended analysis to L4. Exploratory analyses were performed to examine the association between the pattern of lipid composition measures (individual slopes) and physical characteristics for T11-L2.

RESULTS

For T11-L2, the slope of the saturated index was near 0 (r = 0.08; P = 0.92), whereas the slopes of the unsaturated indices were approximately opposite of one another: the monounsaturated index exhibited a -0.55 change (r = 0.58; P = 0.42) per vertebra and the polyunsaturated index exhibited a 0.52 change (r = 0.72; P = 0.28) per vertebra in the caudal direction from T11-L2. For T11-L4, there were modest changes in slope for the saturated (m = 0.12; r = 0.30; P = 0.57) and monounsaturated (m = -0.68; r = 0.74; P = 0.09) indices, while the polyunsaturated index slope remained similar (m = 0.56; r = 0.89; P = 0.02). Age, sex, height, body mass, and BMI were not associated with the pattern of any of the lipid composition index measures.

CONCLUSIONS

Study findings in this small sample of individuals with AIS suggest that the bone marrow saturated index may be relatively stable across T11-L4, while the monounsaturated index may decrease by 0.55-0.68% per vertebra and the polyunsaturated index may increase by 0.52-0.56% per vertebra in the caudal direction.

Nontrauma fracture increases risk for respiratory disease among adults with cerebral palsy

Individuals with cerebral palsy (CP) manifest skeletal fragility problems early in life and are vulnerable to nontrauma fracture (NTFx), which may exacerbate the risk of respiratory disease (RD)- the main cause of premature mortality for this population. The purpose of this study was to determine if adults with CP had a greater 12-month risk of RD post-NTFx compared to adults without CP. Data from 2011 to 2017 were leveraged from Optum Clinformatics Data Mart; a claims database from a single private payer in the United States diagnostic codes were used to identify adults (≥18 years) with and without CP, NTFx, incident RD, and pre-NTFx cardiometabolic diseases. Cox proportional hazards regression models were used to compare 12-month RD incidence following NTFx with adjustment for sociodemographics and cardiometabolic diseases. Mean age (SD) at baseline was 57.5 (18.4) for adults with CP (n = 646) and 61.8 (19.7) for adults without CP (n = 321,482). During the follow-up, 172 adults with CP (26.6%) and 73 937 adults without CP (23.0%) developed RD. Adults with CP had higher 12-month post-NTFx RD incidence compared to adults without CP (hazard ratio [HR] = 1.20; 95% confidence interval [CI] = 1.03-1.37). When stratified by the RD subtype, adults with CP had a higher incidence of pneumonia (HR = 2.15; 95% CI = 1.56-2.95), interstitial/pleura disease (HR = 2.13; 95% CI = 1.53-2.96), and other RD (eg, respiratory failure; HR = 2.33; 95% CI = 1.82-2.98), but not acute respiratory infection (HR = 0.93; 95% CI = 0.75-1.15) or chronic obstructive pulmonary disease (HR = 1.15; 95% CI = 0.86-1.53). Among privately insured adults with CP, NTFx is associated with greater risk of RD among adults with vs without CP.

The respiratory disease burden of non-traumatic fractures for adults with cerebral palsy

Background

Individuals with cerebral palsy (CP) are vulnerable to non-trauma fracture (NTFx) and premature mortality due to respiratory disease (RD); however, very little is known about the contribution of NTFx to RD risk among adults with CP. The purpose of this study was to determine if NTFx is a risk factor for incident RD and if NTFx exacerbates RD risk in the adult CP population.

Methods

Data from 2011 to 2016 Optum Clinformatics® Data Mart and a random 20% sample Medicare fee-for-service were used for this retrospective cohort study. Diagnosis codes were used to identify adults (18+ years) with and without CP, NTFx, incident RD at 3-, 6-, 12-, and 24-month time points (pneumonia, chronic obstructive pulmonary disease, interstitial/pleura disease), and comorbidities. Crude incidence rates per 100 person years of RD were estimated. Cox regression estimated hazard ratios (HR and 95% confidence interval [CI]) for RD measures, comparing: (1) CP and NTFx (CP + NTFx); (2) CP without NTFx (CP w/o NTFx); (3) without CP and with NTFx (w/o CP + NTFx); and (4) without CP and without NTFx (w/o CP w/o NTFx) after adjusting for demographics and comorbidities.

Results

The crude incidence rate was elevated for CP + NTFx vs. CP w/o NTFx and w/o CP + NTFx for each RD measure. After adjustments, the HR was elevated for CP + NTFx vs. CP w/o NTFx for pneumonia and interstitial/pleura disease at all time points (all P < 0.05), but not chronic obstructive pulmonary disease (e.g., 24-month HR = 1.07; 95%CI = 0.88-1.31). The adjusted HR was elevated for CP + NTFx vs. w/o CP + NTFx for pneumonia at all time points, interstitial/pleura disease at 12- and 24-month time points, and chronic obstructive pulmonary disease at 24-months (all P < 0.05). There is evidence of a time-dependent effect of NTFx on pneumonia and interstitial/pleura disease for CP + NTFx as compared to CP w/o NTFx.

Conclusions

Study findings suggest that NTFx is a risk factor for incident RD, including pneumonia and interstitial/pleura disease, among adults with CP and that NTFx exacerbates RD risk for adults with vs. without CP.