Descriptions of functioning and health and relations to a gross motor classification in adults with cerebral palsy

What Do We Really Know About the Natural History of Spastic Hip Dysplasia and Pain in Total-involvement Cerebral Palsy? A Systematic Review

BACKGROUND

Hip surveillance protocols and surgery for spastic hip dysplasia have become standard of care for children with cerebral palsy (CP) out of concern for long-term sequelae, including pain. It is unclear if available data support that spastic hip dysplasia/dislocation independently correlates with pain in total-involvement CP. A better understanding of this correlation may help guide decision-making for these medically complex patients.

METHODS

We undertook a systematic literature review to assess published data on the association of spastic hip dysplasia and pain in total-involvement CP using PubMed (which includes the MedLine databases) and EMBASE databases. A total of 114 English-language articles were identified. Fifteen articles met the inclusion criteria and were evaluated using the PRISMA guidelines for systematic reviews.

RESULTS

Of 15 articles that specifically assessed the association of spastic hip dysplasia and pain, 5 articles provided strong evidence per our criteria regarding the correlation of pain and spastic hip dysplasia. All 5 articles described the severity of CP in their studied population, radiographically defined hip displacement, included a control group, and described how pain was assessed. Nevertheless, there was no standard classification of dysplasia between studies and the ages of patients and methods of pain determination varied. Four of the articles provided level III evidence and one provided level II evidence. Of these 5 articles with the strongest available evidence, data from 2 did not support a correlation between hip dysplasia and hip pain, 2 supported a correlation, and 1 was equivocal.

CONCLUSIONS

Even the best available evidence on spastic hip dysplasia and pain reveals no consensus or conclusion on whether spastic hip dysplasia and dislocation in total-involvement CP is independently correlated with pain.

LEVEL OF EVIDENCE

Level III-Prognostic study.

Adults with cerebral palsy and functional decline: A cross-sectional analysis of patient-reported outcomes from a novel North American registry

BACKGROUND

Adults with cerebral palsy (CP) have unique healthcare needs and risks, including high risk of functional decline. Understanding functional decline is an area of priority for CP research.

OBJECTIVE

Describe factors associated with patient-reported changes in function among adults with CP living in the community.

METHODS

Cross-sectional analysis of adult patient-reported outcomes collected by the CP Research Network (CPRN) Community Registry.

RESULTS

Participants included 263 respondents (76% female (n = 200); mean age 42 years (SD 14); 95% White (n = 249); 92% non-Hispanic (n = 241)). Many reported functional changes, most commonly a decline in gross motor function since childhood (n = 158, 60%). Prevalence of gross motor decline varied significantly by Gross Motor Function Classification System (GMFCS) level (p < 0.001), but neither hand function decline (p = 0.196) nor communication decline (p = 0.994) differed by GMFCS. All types of decline increased with increasing age, with statistically significant differences between age groups (p < 0.001 gross motor; p = 0.003 hand function; p = 0.004 communication). Those with spastic CP (n = 178) most commonly reported gross motor functional decline (n = 108/178, 60.7%). However, the prevalence of gross motor decline did not significantly differ between those with spastic CP and those without spastic CP (p = 0.789).

CONCLUSIONS

Many adults in the CPRN Community Registry reported functional decline, most commonly in gross motor function. Functional decline across domains increased with age. Further research into risk stratification and preventive and rehabilitative measures is needed to address functional decline across the lifespan.

Range of Motion Limitations in Middle-aged Adults With Cerebral Palsy

Objective

To describe limitations in range of motion (ROM) in middle-aged adults with cerebral palsy (CP), and identify associations with CP subtype, gross motor function, sex and age.

Design

Population-based cohort study.

Setting

Local and regional referral centers.

Participants

Inclusion criteria: diagnosis of CP, born 1959 to 1978 and living in the county of Västra Götaland, Sweden. In the population-based register of CP in Western Sweden, 417 subjects were identified and 139 volunteered to participate. Adults with CP, born elsewhere, who had moved into the area were invited through patient organizations and habilitation units, and eleven chose to participate. In total 150 participants, age 37-58 years (mean 48) 65 women (43%) (N=150). All CP subtypes and Gross Motor Function Classification (GMFCS) levels were represented.

Interventions

Not applicable.

Main Outcome Measures

Passive ROM was measured in the upper and lower extremity and was classified into 4 levels (inspired by The Spinal Alignment and Range of Motion Measure and adapted from the values of the American Academy of Orthopedic Surgeons); good=1, vs mild=2, moderate=3 or severe=4 limitation. The results were summarized to obtain a total score of the participants' ROM limitations.

Results

Moderate to severe limitations were present in 98 % of the participants. There was a correlation to GMFCS level in both the upper and lower extremity (P<.001), but no correlation with age. Upper extremity limitations were most common in dyskinetic CP, lower extremity limitations were most common in dyskinetic CP and bilateral spastic CP. Men had more limitations in the lower extremity (P=.001). The most common limitation in the lower extremity was hamstrings tightness (82%) and hip abduction (80%), and in the upper extremity, limited shoulder abduction (57%).

Conclusions

Limited ROM is common in adults with CP, most pronounced in shoulders, hip joints and hamstrings muscles, with no differences related to age in this age-span.

Impairments and comorbidities in adults with cerebral palsy and spina bifida: a meta-analysis

Introduction

Aging with a childhood-onset disability, such as cerebral palsy (CP), spina bifida (SB), and muscular diseases (MD), comes along with significant impairments and comorbidities. Despite the increasing evidence an overall picture is lacking. This study aimed to review the literature about adults with CP/SB/MD and impairments and comorbidities to perform a meta-analysis.

Materials and methods

Embase, PubMed, Cinahl, and Google Scholar were searched (2000-2020). Search terms included adults with one of the aforementioned disabilities combined with impairments and comorbidities. If specific impairments or comorbidities were reported by at least four studies, these were included in the study. Pooled prevalence (95% Confidence Interval) of impairments/comorbidities were calculated.

Results

The search yielded 7,054 studies of which 95 were included in the meta-analysis (64 CP, 31 SB, 0 MD). In total estimates were calculated for 26 (CP) and 11 (SB) outcomes. In adults with CP, pain [56.4% (95%CI 48.8-63.8)], deformities [44.2% (95%CI 12.9-78.4)], intellectual disability [37.2% (95%CI 26.7-48.3)], and fatigue [36.9% (95%CI 24.6-50.1)] were most prevalent; renal disease [3.0% (95%CI 2.1-4.2)] and stroke/rheumatic diseases {4.8% (95%CI 3.4-6.5; 4.8% (95%CI 1.5-9.9)] respectively} were least prevalent. For adults with SB, bladder incontinence [60.0% (95%CI 50.5-69.2)], bowel incontinence [49.2% (95%CI 34.5-64.0)], pain [44.1% (95%CI 27.4-61.5)], and sleeping problems [30.3% (95%CI 4.7-65.8)] were most prevalent; diabetes [4.8% (95%CI 2.8-7.3)] and renal disease [8.7% (95%CI 2.0-19.9)] were least prevalent. The included studies showed large heterogeneity.

Conclusions

More research is needed to study health issues in adults with MD. Adults with CP or SB deal with a variety of health issues. More attention for the mental health of these adults is needed. There also is a need for accessible and adequate screening, preventive measures and clinical follow-up.

Eating and drinking ability and nutritional status in adults with cerebral palsy

AIM

To describe eating and drinking ability in adults with cerebral palsy (CP) relative to sex, age, subtype, and severity of gross motor and hand function and nutritional status.

METHOD

This was a cross-sectional study based on data of 2035 adults with CP, median age 26 years (range 18-78 years). The Eating and Drinking Ability Classification System (EDACS), Gross Motor Function Classification System (GMFCS), and Manual Ability Classification System (MACS) were used in addition to subtype, body weight, height, body mass index (BMI), skin fold thickness, and gastrostomy. Linear regression models were used to estimate associations between body weight and the other variables.

RESULTS

More than half of the adults (52.5%) eat and drink safely and 32.4% have dysphagia with limitations to eating and drinking safety. Weight, height, and BMI decreased with increasing EDACS levels. In EDACS level V, 86% had a gastrostomy, 23.4% in EDACS levels III to V were underweight, whereas 42.3% in EDACS levels I to II had a BMI over 25, indicating overweight or obesity. Increasing EDACS levels and need of support during meals were associated with lower body weight.

INTERPRETATION

Adults with CP should be routinely screened and treated for dysphagia to avoid nutritional complications. Being dependent on others during mealtimes is a risk factor for low body weight.

Perception of pain in patients with adolescent cerebral palsy: self report or parent's report

PURPOSE

To compare mothers' report on children's pain with patients' own reports and to explore the prevalence, intensity, localisation and the effect of pain on daily living activities of adolescents with CP.

MATERIALS AND METHODS

A total of 75 adolescent with CP (34 females and 41 males) and their mothers were included in this cross-sectional study. Demographical and clinical characteristics were recorded. The adolescent and the mother independently completed the pain questionnaire in a face-to-face interview administrated by a physiatrist.

RESULTS

The prevalance of pain in the previous week was 28% by self report and was 40% by mothers' report. No significant difference was determined between mother's report and self report (p = 0.121). There was no significant difference in the prevalence of pain, pain intensity, and the effect of pain on activities of daily living according to Gross Motor Functional Classification System levels and CP types in terms of mothers' report and self report.

CONCLUSIONS

Pain is a common condition in adolescents with CP and it affects quality of life negatively. While the self-report of pain is ideal, parent's reports in various situations is important for the assessment of pain.

Effect of Lower Extremity Muscle Strength on Aerobic Capacity in Adults with Cerebral Palsy

The purpose of this study is to analyze the effect of lower extremity muscle strength of HIP joint and KNEE joint on the aerobic capacity to provide the basic data for developing an exercise program that can effectively improve the aerobic capacity of adults with cerebral palsy (CP) by identifying the part of the lower extremity muscle. A total of 18 ambulant adults with CP were recruited for this study. Seven ambulant adults with CP were excluded because they did not achieve the criteria of maximal exercise. The data from 11 subjects (11 men) with CP were used for the analysis. The mean (±SD) age, height, weight, and BMI of the subjects were 37.00 ± 12.72 years, 170.45 ± 6.37 cm, 67.02 ± 8.62 kg, and 23.09 ± 2.78 kg/m2, respectively. To measure the muscle strength of HIP joint and KNEE joint in lower extremities, the variables of the isokinetic muscle strength and the muscular endurance were performed using the isokinetic equipment (Biodex Co., Shirley, NY, USA). For the isokinetic muscle strength measurement of HIP joint, the 45°/sprotocol indicating the muscle power and the 300°/s protocol indicating the muscle endurance were used. Additionally, the measurement of KNEE joint was performed once on the left and right side, using the protocol of 60°/s indicating the muscle power and 300°/s indicating the muscular endurance. Progressive exercise tests were conducted on the treadmill (Quinton model—4500) using previously developed protocols targeting CP. The initial protocol speeds were 5 km/h−1 and 2 km/h−1 for the subjects who have been classified as Gross Motor Function Classification System (GMFCS) level I and II, respectively. Using a portable cardiopulmonary indirect breath-by-breath calorimetry system (MetaMax 3B; Cortex Biophysik, Leipzig, Germany), pulmonary ventilation (VE), respiratory exchange ratio (RER), and oxygen uptake (VO2) have been persistently measured. HR monitor (Polar Electro, Kempele, Finland polar Co. RS-800) was used to measure heart rate (HR). A correlation analysis was conducted to find out how the lower extremity muscle strength and aerobic capacity with cerebral palsy are related. Therefore, as a result, VO2peak among aerobic capacity displayed a significant positive correlation in 45° and 300°/s peak torque/BW of HIP joint, and with 60° and 300°/s peak torque/BW of KNEE joint. It was the same with 60°/s Agon/Antag ratio of KNEE Joint (p < 0.05). VEpeak showed a significant positive correlation with 45° and 300°/s peak torque/BW of HIP joint, as well as correlation with 60° and 300°/s peak torque/BW and 60°/s Agon/Antag ratio of KNEE joint (p < 0.05). However, HRpeak showed a significant positive correlation only in 45°/s peak torque/BW of HIP joint (p < 0.05). The result of step-wise analysis was to find out which muscle strength significantly affects VO2peak and HRpeak among aerobic abilities in the lower extremity muscles of those disabled with cerebral palsy. Among the muscle functions of lower extremity muscle strength, 300°/s peak torque/BW of KNEE Joint was found to have the greatest effect on VO2peak (p < 0.001). As a result, 300°/s peak torque/BW of KNEE Joint was found to be the predictable factor that could explain the VO2peak in the disabled people with cerebral palsy at 67% (R2 = 0.661). In particular, among the muscle functions of lower extremity muscle strength at 45°/s peak, torque/BW of HIP Joint was found to have the greatest effect on HRpeak (p < 0.001). As a result, this factor was found to be the predictable factor that could explain the HRpeak in disabled people with cerebral palsy at 39% (R2 = 0.392). In this study, the muscle strength of the lower extremity of CP was closely related to the aerobic capacity, and the muscle endurance of KNEE Joint and the muscle power of HIP Joint were found to be important factors to predict the aerobic capacity of CP.

ASSOCIATION BETWEEN DAILY PHYSICAL ACTIVITY AND CLINICAL ANTHROPOMORPHIC MEASURES IN ADULTS WITH CEREBRAL PALSY

OBJECTIVE

To describe the relationship between activity level and cardiovascular risk measures as well as describe general activity patterns of adults with cerebral palsy Design: Cross-Sectional Setting: Academic Outpatient Rehabilitation Clinic.

PARTICIPANTS

47 adults with cerebral palsy (CP) Interventions: Not applicable Main Outcome Measures: Gross Motor Functional Classification System (GMFCS) level was determined by validated self-report questionnaire. Activity (daily step count, walk time, sitting time, standing time, and transitional movements) over 6 days recorded using an activPAL. Weight, body mass index (BMI), and waist to hip ratio (WHR) were measured. Bivariate relationships between anthropomorphic and activity measures were assessed.

RESULTS

38 participants completed all measurements. Nine were excluded due to incomplete activPAL data. The median age was 28.50 years [interquartile range 24.25,47.00], range 18-77 years. Participants' GMFCS levels were I:13%, II:16%, III:21%, IV:34%, and V:16%. Median steps/day for GMFCS I/II participants were 5258.3[3606.8, 6634.7], while median steps/day were 1681.3 [657.2, 2751.8] and 30.0 [6.8, 54.2] for GMFCS level III and IV/V participants, respectively. Significantly greater steps/day were found for GMFCS I/II or III participants compared to those GMFCS IV/V (p<0.001 and p=0.0074, respectively). 60.5% of the subjects had a BMI in the normal range, 10.5% were obese, 23.6% were overweight, and 5.3% were underweight. For subjects with GMFCS I/II, the Spearman's rank correlation coefficient for time standing and waist circumference was -0.73 (0.01). Subjects GMFCS III and GMFCS IV/V had respective correlations of -0.16 (0.71) and -0.01 (0.98). For subjects with GMFCS I/II, the Spearman's rank correlation coefficient for standing time and BMI was -0.55 (p= 0.08). For the GMFCS III and GMFCS IV/V groups the respective correlation was -0.19 (0.67) and 0.00 (1.00).

CONCLUSIONS

Subjects with GMFCS level I or II who engaged in more activity tended to have more favorable anthropometric profiles. Subjects GMFCS III, IV, or V did not have a similar trend. Our findings suggest factors beyond activity patterns affect anthropometrics to a greater degree in those with higher GMFCS levels.

Intensive voice treatment (the Lee Silverman Voice Treatment [LSVT®LOUD]) for individuals with Wilson's disease and adult cerebral palsy: two case reports

Objective: In this case report, we aimed to examine the effects of an intensive voice treatment (the Lee Silverman Voice Treatment [LSVT^®LOUD]) for Wilson's disease (WD), and adult cerebral palsy (CP), and dysarthria.Method: The participants received LSVT^®LOUD four times a week for 4 weeks. Acoustic, perceptual (GRBAS) analyses were performed and data from the Voice Handicap Index (VHI) were obtained before and after treatment.Results: Besides the Harmonics-to Noise Ratio (HNR) value (dB) of the participant with WD, for both participants' fundamental frequencies (Hz), jitter (%), and shimmer (%) values showed significant differences (p < .05) after therapy. Both participants showed significant improvements (p < .05) in the duration (s) and the sound pressure level (dB, SPL) of sustained vowel phonation (/a/), in SPL (dB) of pitch range (high and low /a/) and reading and conversation (p < .01). There was a positive improvement in the high-frequency values (Hz) of both participants but not in the low-frequency values (Hz) in the participant with WD. Perceptual analysis with GRBAS judgements of sustained vowel (/a/) and paragraph reading of two participants also showed improvement. After therapy, perceived loudness of the participants' voice increased.Conclusions: The findings provide some preliminary observations that the individuals with WD and the adult individuals with CP can respond positively to intensive speech treatment such as LSVT^®LOUD. Further studies are needed to investigate speech treatments specific to WD and adult CP.

Adults with Cerebral Palsy Require Ongoing Neurologic Care: A Systematic Review

Cerebral palsy (CP) neurologic care and research efforts typically focus on children. However, most people with CP are adults. Adults with CP are at increased risk of new neurologic conditions, such as stroke and myelopathy, that require ongoing neurologic surveillance to distinguish them from baseline motor impairments. Neurologic factors could also contribute to the motor function decline, chronic pain, and chronic fatigue that are commonly experienced by adults with CP. Based on a systematic literature review, we suggest (1) guidelines for neurologic surveillance and neurologist referral and (2) clinical research questions regarding the evolving neurologic risks for adults with CP. ANN NEUROL 2021;89:860-871.

Physical performance outcome measures used in exercise interventions for adults with childhood-onset disabilities: A scoping review

BACKGROUND

People with childhood-onset disabilities face unique physical and social challenges in adulthood. Exercise interventions may improve physical performance in children, but there is a lack of research on adults.

OBJECTIVE

To describe studies that investigate exercise interventions and to evaluate the quality of physical performance outcome measures for adults with childhood-onset disabilities.

METHODS

Eligible studies reported on exercise interventions for adults (ages 16+) with cerebral palsy, spina bifida, or acquired brain injuries. Only randomized controlled trials published in English from 2008 to 2019 were included. MEDLINE, CINAHL, PEDro, EMBASE, and Cochrane Central Register of Controlled Trials were searched. Two reviewers independently screened studies and abstracted data.

RESULTS

This scoping review included 4 trials reporting on cerebral palsy only. Three strength training programs found significant improvements in gait, and one mixed training program found significant improvements in strength and fitness. Only two outcome measures used are valid/reliable for adults (6 Minute Walk Test and Borg-20 Grades).

CONCLUSION

Certain interventions may improve physical performance, but there is a lack of research on appropriate exercise interventions and physical performance outcome measures for adults with childhood-onset disabilities. Different exercise interventions should be investigated using larger sample sizes and outcome measures should be standardized.

Bone and joint complications and reduced mobility are associated with pain in children with cerebral palsy

AIM

To investigate the relationships between pain in the lower extremities and back, and spasticity, bone/joint complications and mobility.

METHODS

Retrospective population-based registry study. Participants (N = 3256) with cerebral palsy (CP), 2.5-16 years of age, participating in the Swedish Cerebral Palsy Follow-up Program were included. Spasticity was measured using scissoring and the Modified Ashworth Scale. Bone/joint complications consisted of hip displacement, range of motion, windswept posture and scoliosis. Mobility was measured using the Functional Mobility Scale (5-, 50- and 500-metres), wheelchair use (outdoors) and the ability to stand/get up from sitting/use stairs, respectively. Pain was measured as presence of pain in hips, knees, feet and back. Data were analysed using structural equation modelling.

RESULTS

Bone/joint complications had the strongest direct pathway with pain in the lower extremities (standardised regression coefficient = 0.48), followed by reduced mobility (standardised regression coefficient = -0.24). The pathways between spasticity and pain, and age and pain were not significant. The R² of the model was 0.15.

CONCLUSION

Bone/joint complications and reduced mobility were associated with pain in the lower extremities when controlling for sex. Considering the R² of the model, other factors not included in the model are also associated with pain in the lower extremities in children with CP.

Novel insights into cerebral palsy

Cerebral palsy (CP) is a neurodevelopmental disorder characterized by abnormalities of muscle tone, movement and motor skills, and is attributed to injury to the developing brain. CP affects about 1 in 500 neonates. CP shows clinical features which evolve with age, and these may over time lead to deterioration of motor function although the lesion to the developing brain is non-progressive. The underlying causes for CP remain unclear. Based on recent research we are able to give a physiological explanation on the appearance and development of the condition. The damage to the central nervous system causes a change in collagen structure, with a higher level of deposition of collagen around the muscles, increasing throughout life. Assuming this premise is correct, the question is, will it by any treatment be possible to delay or prevent this collagen accumulation in the CP muscles, thereby giving CP patients a better prognosis in the future.

Pain in adults with cerebral palsy: A systematic review and meta-analysis of individual participant data

BACKGROUND

There is little focus on adults with cerebral palsy (CP) in research and health care and insufficient knowledge on how to identify and manage pain in this population.

OBJECTIVES

This systematic review and meta-analysis aimed to determine whether pain prevalence in adults with CP is high and to explore variations in pain prevalence of subgroups, pain locations, pain severity and pain interference.

METHODS

Potential datasets were identified by experts in the field and literature searches in Embase, MEDLINE, and Cochrane, from January 2000 to October 2016. Included studies had a representative sample of ≥25 adults with CP and ≥1 pain outcomes. Methodological quality assessment, pain prevalence estimates and logistic regression models for subgroup effects on pain prevalence were conducted.

RESULTS

In total, 17 eligible studies were identified from 4584 publications. A meta-analysis was performed with individual participant data from 15 studies totalling 1243 participants (mean [SD] age 34.3 [12.6] years). Overall mean pain prevalence was 70% (95% CI 62-78). Women were more likely to have pain than men (P<0.001). The odds of pain was increased in adults with gross motor function level II (odds ratio [OR] 1.92, 95% CI 1.22-3.12) and IV (OR 1.77, 95% CI 1.03-4.29). Participants with pain reported pain predominantly in the legs (76%, 95% CI 66-84), and mean pain severity was 3.7/10 (95% CI 2.7-4.7) and pain interference 3.5/10 (95% CI 2.5-4.5).

CONCLUSIONS

This meta-analysis provides the first reliable pain prevalence estimate in a large international sample of adults with CP. The high prevalence of pain, 70%, suggests that adults with CP should be routinely screened for pain and treated accordingly. The range of measurement instruments used by the included studies emphasizes using common outcome measures specific to pain internationally.

Epidemiology of Cerebral Palsy in Adulthood: A Systematic Review and Meta-analysis of the Most Frequently Studied Outcomes

OBJECTIVE

To describe the epidemiology of health status, impairments, activities and participation in adults with cerebral palsy (CP).

DATA SOURCES

Embase, MEDLINE, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, Cochrane, and Google Scholar were searched for 3 themes ("cerebral palsy," "adult," and "outcome assessment") in literature published between January 2000 and December 2018.

STUDY SELECTION

Full-article peer-reviewed English journal articles on descriptive, observational, or experimental studies describing the most studied outcomes in adults with CP (n≥25, age≥18y) were included. Studies were included in the analyses if frequently studied outcomes were described in at least 3 studies using similar methods of assessment.

DATA EXTRACTION

Data were extracted independently by 2 authors from 65 articles (total N=28,429) using a standardized score sheet.

DATA SYNTHESIS

Meta-analyses revealed that overall, on average 65.1% (95% confidence interval [CI], 55.1-74.5) of adults with CP experienced pain, 57.9% (95% CI, 51.1-64.6) were ambulant, 65.5% (95% CI, 61.2-69.7) had little or no limitation in manual ability, 18.2% (95% CI, 10.6-27.2) had tertiary education, 39.2% (95% CI, 31.5;47.1) were employed, and 29.3% (95% CI, 9.0-55.3) lived independently. In adults without intellectual disability, proportions of individuals who were ambulant (72.6% [95% CI, 58.8-84.5]) and lived independently (90.0% [95% CI, 83.8-94.9]) were higher (P=.014 and P<.01, respectively). The Fatigue Severity Scale score was 4.1 (95% CI, 3.8-4.4). Epilepsy (28.8% [95% CI, 20.1-38.4]) and asthma (28.3% [95% CI, 18.7-38.9]) were especially prevalent comorbidities.

CONCLUSIONS

The present systematic review and meta-analysis on the epidemiology of adults with CP provided state-of-the-art knowledge on the most frequently studied outcomes. On average, adults with CP are fatigued, and a majority experience pain, are ambulant, and have little or no difficulty with manual ability. On average, 40% are employed and 30% live independently. More uniformity in assessment and reports is advised to improve knowledge on epidemiology and gain insight in more outcomes.

Pain, fatigue, depressive symptoms and sleep disturbance in young adults with cerebral palsy

PURPOSE

Investigate pain, fatigue, depressive symptoms and sleep disturbance in young adults with cerebral palsy compared to references.

MATERIALS AND METHODS

Young adults with cerebral palsy (n = 97, aged 21-34 years) and age-matched references from the general population (n = 190) rated pain using a numeric rating scale and fatigue, depressive symptoms, sleep disturbance and global health using Patient-Reported Outcomes Measurement Information System® short forms. Scores were compared between cerebral palsy subgroups and the reference population. Correlation coefficients and linear regression analyses assessed interrelationships of health issues and associations with global health.

RESULTS

Individuals with Gross Motor Function Classification System level I had less pain, fatigue and depressive symptoms, while individuals with levels II and III-V had more pain (53% and 56%, p < 0.001) and those with levels III-V more fatigue (39%, p = 0.035) than references (pain: 26%, fatigue: 14%). Pain and fatigue were more interrelated (correlation coefficients: 0.71 vs. 0.41) and stronger associated with global mental health in individuals with cerebral palsy.

CONCLUSIONS

Young adults with Gross Motor Function Classification System levels II-V report more pain and those with levels III-V report more fatigue than references. Pain and fatigue are highly interrelated and specifically relate to mental health in individuals with cerebral palsy.Implications for rehabilitationExcept for those in the highest level of motor function, young adults with cerebral palsy report higher levels of pain and fatigue compared to the general population of the same age.Pain and fatigue are strongly interrelated and associated with mental health in young adults with cerebral palsy.The present study recommends to monitor pain and fatigue in young adults with cerebral palsy with low levels of gross motor function.We advise rehabilitation professionals to consider combined treatment for both pain and fatigue.

Hip pain in children with cerebral palsy: a population-based registry study of risk factors

Background

Hip pain is prevalent in children with cerebral palsy (CP). Hip displacement is a known risk factor for hip pain. However, many children do not have displaced hips but still have hip pain and the aetiologies are poorly understood. The aims of this study were to investigate: 1. the prevalence of hip pain related to age, gender, gross motor function, degree of hip displacement and 2. the associations between hip pain and age, gender, gross motor function, degree of hip displacement, ranges of hip and knee motion (ROM) and degree of spasticity in the muscles around the hip.

Methods

This was a cross-sectional retrospective register study based on data from the Swedish follow-up programme and national healthcare registry CPUP, which includes > 95% of children with CP in Sweden. The participants were born in 2000 or later and 4–16 years of age. Data from the latest examination were used. In Aim 1, the prevalence of hip pain was calculated using frequencies and crosstabs. Differences between groups were calculated using chi-square tests and independent samples t-tests. In Aim 2, associations between hip pain and the variables were analysed using logistic regression.

Results

The overall prevalence of hip pain was 7%. No significant gender difference was found. Hip pain prevalence increased with age, lower gross motor function and higher degree of hip displacement. The median migration percentage (MP) in painful hips was 26%, compared to 21% in hips where pain was not reported. In the multivariable analysis, significant associations with hip pain were found for MP > 30% and decreased ROM in abduction, flexion and inwards rotation of the hip (p < 0.05).

Conclusion

Hip displacement was associated with hip pain. However, hip displacement was not present in the majority of painful hips. In addition to hip displacement, decreased ROM was also associated with hip pain.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2449-8) contains supplementary material, which is available to authorized users.

Needs for Medical and Rehabilitation Services in Adults With Cerebral Palsy in Korea

OBJECTIVE

To investigate medical comorbidities and needs for medical and rehabilitation services of adults with cerebral palsy (CP) in Korea.

METHODS

This was a prospective cross-sectional study. One hundred fifty-four adults with CP were enrolled in the study between February 2014 and December 2014. Information was obtained from participants regarding functional status, demographic and socioeconomic data, medical problems, and requirements for and utilization of medical and rehabilitation services.

RESULTS

The participants included 93 males and 61 females with a mean age of 40.18±9.15 years. The medical check-up rate of adults with CP was lower than that of healthy adults and the total population with disabilities (53.2% vs. 58.6% vs. 70.4%). A quarter of the subjects failed to visit the hospital during the past year, and the main reason was the financial burden. Due to a cost burden and lack of knowledge, more than one-third of the subjects had unmet needs for rehabilitation services; the majority reported needs for rehabilitation services, such as physical therapy for pain management.

CONCLUSION

The medical check-up rate was lower in the adults with CP, even though their medical comorbidities were not less than those of healthy people. Several non-medical reasons hindered them from receiving proper medical and rehabilitation services. Such barriers should be managed effectively.

Longitudinal study showed that the quality of life of Finnish adolescents with cerebral palsy continued to be relatively good

AIM

This longitudinal study examined what perceptions paediatric patients with cerebral palsy (CP) and their caregivers had of the patient's quality of life (QoL). It examined changing trends as children with CP became adolescents and examined the feasibility of the Finnish version of the CP QOL-Teen questionnaire.

METHODS

Carried out in autumn 2015, this study formed part of the multi-centre Finnish national CP project and aimed to validate the CP QOL-Teen questionnaire, which was posted to 54 adolescents and their caregivers. They included 24 who had responded to CP QOL-Child questionnaire in 2013.

RESULTS

The questionnaires were returned by 27 pairs of adolescents and caregivers and one extra caregiver also responded. Of these, 24 pairs had taken part in the 2013 survey. The internal consistencies of the sum variables were found to be acceptable in all cases. Overall QoL showed an average score of 81.8 on a scale from 0 to 100. Adolescents reported significantly higher QoL than their caregivers. There were no significant differences between the responses of the children and adolescents.

CONCLUSION

We showed that QoL was relatively good in childhood and adolescence. The Finnish version of the CP QOL-Teen questionnaire was an appropriate clinical tool for assessing QoL.

Postural asymmetry in non-ambulant adults with cerebral palsy: a scoping review

PURPOSE

Non-ambulant adults with cerebral palsy are vulnerable to development of postural asymmetry and associated complications. The primary aim of this scoping review was to identify postural deformities in non-ambulant adults with cerebral palsy.

MATERIALS AND METHODS

Comprehensive searches were undertaken in EMBASE, CINAHL, AMED, Cochrane, Psych INFO, and Joanna Briggs (1986-Jan 2017), supplemented by hand searching. Two reviewers independently extracted data using a customised tool focusing on study design, participant characteristics, postural descriptors, measurement tools, and interventions.

RESULTS

From 2546 potential records, 17 studies were included. Variability in populations, reporting methodology, and measurement systems was evident. Data suggest more than 30% of this population have hip migration percentage in excess of 30%, more than 75% experience "scoliosis", and more than 40% demonstrate pelvic obliquity. Estimates ranged from 14% to 100% hip and 32% to 87% knee contracture incidence. Conservative interventions were infrequently and poorly described.

CONCLUSION

Many non-ambulant adults with cerebral palsy experience postural asymmetry associated with windswept hips, scoliosis, pelvic obliquity, and limb contracture. Options for non-radiographic monitoring of postural asymmetry should be identified, and conservative interventions formally were evaluated in this population. Implications for rehabilitation The common postural asymmetries of windswept hips, scoliosis, pelvic obliquity, and limb contracture require standardised clinical measurement. Radiography is most commonly used to monitor postural asymmetry in this population, but standardised positioning is not applied and may not be feasible indicating a need for alternate methods and rigorous documentation. The Posture and Postural Ability Scale may be considered for use in the management of body shape in adults with CP.

Health-Related Quality of Life and Care Giver Burden Following Spinal Fusion in Children With Cerebral Palsy

STUDY DESIGN

A prospective longitudinal cohort.

OBJECTIVE

The objective of this study was to evaluate changes in caregivers' perceptions of health-related quality of life (HRQOL) and caregiver burden in children with severe cerebral palsy (CP) following spinal fusion.

SUMMARY OF BACKGROUND DATA

Progressive scoliosis is common in nonambulatory children with CP; the utility of spine fusion has been long debated and prospective evaluations of patient reported outcomes are limited.

METHODS

Children 3 to 21 years old, gross motor classification system (GMFCS) IV-V CP, scheduled for spine fusion were enrolled consecutively from September 2011 to March 2014. Caregivers completed the CPCHILD and ACEND pre-operatively and at 6 weeks, 3, 6, 12, and 24 months postoperatively. Changes in CPCHILD and ACEND scores from preoperative to 1 and 2 years after surgery were assessed using paired t tests. Correlations between preoperative Cobb angle and CPCHILD and ACEND scores were evaluated using Pearson's correlation analysis.

RESULTS

Twenty-six GMFCS IV-V CP patients with severe scoliosis treated with spine fusion were included. Mean age was 14 years, 50% male, and 46% had instrumentation to the pelvis. Average preoperative Cobb angle was 68.9° (SD 25.68) with an average improvement of 76%. The CPCHILD score increased by 9.8 points above baseline [95% confidence interval (95% CI): 3.4-16.2] at 1 year postoperatively (P = 0.005). However, at 2 years, the CPCHILD score regressed to baseline (P = 0.40). ACEND scores did not change from baseline scores at 1-year (P = 0.09) and 2-year (P = 0.72) follow-up, reflecting that caregiver burden is little changed by spine fusion. There was no correlation between preoperative Cobb angle and CPCHILD score (P = 0.52) or ACEND score (P = 0.56) at 1-year or 2-year follow-up (P = 0.69, P = 0.90). Children with Cobb angle ≤75° experienced more improvement 1 year after surgery than children with Cobb angle >75°.

CONCLUSION

HRQOL improves 1 year following spine fusion but regresses to baseline after 2 years. Caregiver burden was unchanged following spine fusion.

LEVEL OF EVIDENCE

2.

Exercise interventions for cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disorder resulting from an injury to the developing brain. It is the most common form of childhood disability with prevalence rates of between 1.5 and 3.8 per 1000 births reported worldwide. The primary impairments associated with CP include reduced muscle strength and reduced cardiorespiratory fitness, resulting in difficulties performing activities such as dressing, walking and negotiating stairs.Exercise is defined as a planned, structured and repetitive activity that aims to improve fitness, and it is a commonly used intervention for people with CP. Aerobic and resistance training may improve activity (i.e. the ability to execute a task) and participation (i.e. involvement in a life situation) through their impact on the primary impairments of CP. However, to date, there has been no comprehensive review of exercise interventions for people with CP.

OBJECTIVES

To assess the effects of exercise interventions in people with CP, primarily in terms of activity, participation and quality of life. Secondary outcomes assessed body functions and body structures. Comparators of interest were no treatment, usual care or an alternative type of exercise intervention.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, nine other databases and four trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of children, adolescents and adults with CP. We included studies of aerobic exercise, resistance training, and 'mixed training' (a combination of at least two of aerobic exercise, resistance training and anaerobic training).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and potentially relevant full-text reports for eligibility; extracted all relevant data and conducted 'Risk of bias' and GRADE assessments.

MAIN RESULTS

We included 29 trials (926 participants); 27 included children and adolescents up to the age of 19 years, three included adolescents and young adults (10 to 22 years), and one included adults over 20 years. Males constituted 53% of the sample. Five trials were conducted in the USA; four in Australia; two in Egypt, Korea, Saudi Arabia, Taiwan, the Netherlands, and the UK; three in Greece; and one apiece in India, Italy, Norway, and South Africa.Twenty-six trials included people with spastic CP only; three trials included children and adolescents with spastic and other types of CP. Twenty-one trials included people who were able to walk with or without assistive devices, four trials also included people who used wheeled mobility devices in most settings, and one trial included people who used wheeled mobility devices only. Three trials did not report the functional ability of participants. Only two trials reported participants' manual ability. Eight studies compared aerobic exercise to usual care, while 15 compared resistance training and 4 compared mixed training to usual care or no treatment. Two trials compared aerobic exercise to resistance training. We judged all trials to be at high risk of bias overall.We found low-quality evidence that aerobic exercise improves gross motor function in the short term (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.02 to 1.04, N = 65, 3 studies) and intermediate term (mean difference (MD) 12.96%, 95% CI 0.52% to 25.40%, N = 12, 1 study). Aerobic exercise does not improve gait speed in the short term (MD 0.09 m/s, 95% CI -0.11 m/s to 0.28 m/s, N = 82, 4 studies, very low-quality evidence) or intermediate term (MD -0.17 m/s, 95% CI -0.59 m/s to 0.24 m/s, N = 12, 1 study, low-quality evidence). No trial assessed participation or quality of life following aerobic exercise.We found low-quality evidence that resistance training does not improve gross motor function (SMD 0.12, 95% CI -0.19 to 0.43, N = 164, 7 studies), gait speed (MD 0.03 m/s, 95% CI -0.02 m/s to 0.07 m/s, N = 185, 8 studies), participation (SMD 0.34, 95% CI -0.01 to 0.70, N = 127, 2 studies) or parent-reported quality of life (MD 12.70, 95% CI -5.63 to 31.03, n = 12, 1 study) in the short term. There is also low-quality evidence that resistance training does not improve gait speed (MD -0.03 m/s, 95% CI -0.17 m/s to 0.11 m/s, N = 84, 3 studies), gross motor function (SMD 0.13, 95% CI -0.30 to 0.55, N = 85, 3 studies) or participation (MD 0.37, 95% CI -6.61 to 7.35, N = 36, 1 study) in the intermediate term.We found low-quality evidence that mixed training does not improve gross motor function (SMD 0.02, 95% CI -0.29 to 0.33, N = 163, 4 studies) or gait speed (MD 0.10 m/s, -0.07 m/s to 0.27 m/s, N = 58, 1 study) but does improve participation (MD 0.40, 95% CI 0.13 to 0.67, N = 65, 1 study) in the short-term.There is no difference between resistance training and aerobic exercise in terms of the effect on gross motor function in the short term (SMD 0.02, 95% CI -0.50 to 0.55, N = 56, 2 studies, low-quality evidence).Thirteen trials did not report adverse events, seven reported no adverse events, and nine reported non-serious adverse events.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions is low to very low. As included trials have small sample sizes, heterogeneity may be underestimated, resulting in considerable uncertainty relating to effect estimates. For children with CP, there is evidence that aerobic exercise may result in a small improvement in gross motor function, though it does not improve gait speed. There is evidence that resistance training does not improve gait speed, gross motor function, participation or quality of life among children with CP.Based on the evidence available, exercise appears to be safe for people with CP; only 55% of trials, however, reported adverse events or stated that they monitored adverse events. There is a need for large, high-quality, well-reported RCTs that assess the effectiveness of exercise in terms of activity and participation, before drawing any firm conclusions on the effectiveness of exercise for people with CP. Research is also required to determine if current exercise guidelines for the general population are effective and feasible for people with CP.

An exploratory study investigating the multidimensional factors impacting the health and well-being of young adults with cerebral palsy

BACKGROUND

For young adults with cerebral palsy, changes in psychological and social development, in conjunction with the progression of musculoskeletal deformities and the onset of secondary conditions, make the transition to adulthood a difficult developmental phase. Preliminary evidence shows that many of the physical impairments reported in adults with cerebral palsy begin during late adolescence; however, there is little information about prevalence of impairments and the combined role impairments, psychological and social factors have on the health and well-being of young adults with cerebral palsy.

METHODS

A cross-sectional, multidimensional survey approach was used to examine the ambulatory decline, pain, pain interference, depression, fatigue, locus of control, emotional support, overall health status and satisfaction with life of young adults with cerebral palsy, age 18-30 years.

RESULTS

Ninety-seven surveys (57 self-report and 40 proxy report) were completed across all gross motor function classification system levels. No significant differences were found amongst functional levels for pain, pain interference, fatigue or depression. Only pain interference significantly contributed to the variance in health status, while emotional support significantly contributed to the variance in satisfaction with life.

CONCLUSIONS

The large percentage of young adults in this study reporting pain, fatigue and depression indicates that the onset of these impairments may begin at an earlier age. This study found that emotional support from family facilitates improved health status and enhanced satisfaction with life in young adults with cerebral palsy. Similar to physical impairments, social and psychological factors also contribute to the health and well-being of young adults with cerebral palsy, a holistic approach to care that includes preventative strategies to address both mental and physical health outcomes should begin well in advance to their transition into young adulthood in order to mitigate the impact these factors have on health and well-being during this critical developmental time. Implications for Rehabilitation Pain, fatigue and depression were reported for all levels of GMFCS and should be assessed and addressed with appropriate treatment early in order to determine whether there are surgical, pharmacological, rehabilitative or counseling services that could be implemented at a younger age to improve outcomes in young adulthood. For young adults with CP, emotional support plays a significant role in the health status and satisfaction with life and strategies to enhancing support beyond the family could enhance health status and satisfaction with life.

Ageing with cerebral palsy; what are the health experiences of adults with cerebral palsy? A qualitative study

OBJECTIVE

To enhance understanding of the experiences of ageing with cerebral palsy (CP) in adulthood with a particular focus on experiences with health services.

DESIGN

A qualitative descriptive methodology was applied to capture adults' views of ageing with CP and related interactions with health services. Semistructured interviews were undertaken with data systematically coded and interpreted by grouping information into categories. Themes that encompassed the categories were identified through thematic analysis.

SETTING

All healthcare settings.

PARTICIPANTS

28 adults (14 women) with CP, aged 37-70 years.

RESULTS

5 themes covered the breadth of participants' experiences: (1) acceptance of change; (2) exploring identity: cerebral palsy as only one part of self; (3) taking charge of help; (4) rethinking the future and (5) interacting with health professionals. Being seen and being heard were the features described in positive healthcare interactions. Participants also valued health professionals who reflected on who holds the knowledge?; demonstrated a willingness to learn and respected participants' knowledge and experience.

CONCLUSIONS

Our findings could, and arguably should, inform more responsive strategies for disabled people in health services and, indeed, all health consumers. Our study supports other findings that impairments related to CP change and, for many, severity of disabling impact increases with age. Increased interactions with health and rehabilitation professionals, as a consequence of these changes, have the potential to impact the person's healthcare experience either positively or negatively. A 'listening health professional' may bridge their knowledge gap and, in recognising the person's own expertise, may achieve three things: a more contextualised healthcare intervention; a better healthcare experience for the person with CP and positive impact on the person's sense of autonomy and identity by recognising their expertise. Future research should identify whether this approach improves the healthcare experience for adults living with CP.

Medication, rehabilitation and health care consumption in adults with cerebral palsy: a population based study

Objective:

To evaluate medication, rehabilitation and healthcare consumption in adults with CP as a function of Gross Motor Function Classification System (GMFCS) level.

Design:

Questionnaire-based cross-sectional study.

Setting:

Brittany, a French county.

Subjects:

Adults with cerebral palsy.

Interventions:

Questionnaires relating to drugs, orthotic devices, mobility aids, rehabilitation and medical input were sent to 435 members of a unique regional French network dedicated to adults with cerebral palsy. The questionnaire was completed by the participant or a helper if necessary.

Results:

Of the 282 responders, 7.8% had a GMFCS level of I, 14.2% II, 17.7% III, 29.1% IV and 31.2% V. Participants consumed a large amount of healthcare. Almost three-quarters took orally administered drugs, of which antispastic and antiepileptic drugs were among the most frequent. Nearly all patients had at least one type of rehabilitation, 87.2% had physiotherapy, 78% used at least one mobility aid and 69.5% used at least one orthotic device. The frequency of numerous inputs increased with GMFCS level. Specificities were found for each GMFCS level, e.g. participants with GMFCS level IV and V had a high level of medical input and a greater use of trunk-supporting devices, antireflux and laxative. Profiles could be established based on GMFCS levels.

Conclusions:

Adults with cerebral palsy use a large amount of drugs, mobility aids, orthotic devices, rehabilitation and medical input. Healthcare is targeted at cerebral palsy-related issues. GMFCS is a determinant of healthcare consumption and thus a useful tool for clinical practice to target care appropriately.

The lived body — experiences from adults with cerebral palsy

Objective : To get a deeper understanding into how adults with cerebral palsy experience living with a disability and how they manage daily life.

Design : Interviews with open-ended questions were carried out. They were analysed by one person according to the Empirical Phenomenological Psychological method (EPP).

Setting and subjects : Twenty-two community-living adults (35—68 years) with cerebral palsy from five counties in Sweden participated. All had mobility problems and all had cognitive abilities making it possible to carry on a conversation.

Results : The varied experiences resulted in themes including (1) perceptions of living with a disability and (2) strategies used for managing the described perceptions. The perceptions were: a dys-appearing body, a not-appearing body, difference, being in-between, normality, restricted autonomy and autonomy. The strategies were: to fight one's way, to plan, to get used to it, to hide and to give one's all.

Conclusion : These interviews expressed heterogeneity in lived experiences showing the importance for professionals to meet people with cerebral palsy as individual subjects in relation to functional problems, self-image and autonomy together with seeing the consequences of different coping strategies.

Quality of life in young adults with cerebral palsy

BACKGROUND

Little is known about the quality of life (QOL) of young adults with cerebral palsy.

OBJECTIVE/HYPOTHESIS

This cross-sectional analysis compares the QOL of a cohort of young Australian adults with CP with a cohort of able-bodied peers to explore the relationship between QOL and impairments, functioning, and social participation.

METHODS

Young adults identified from the Victorian Cerebral Palsy Register were invited to complete a survey about QOL, gross motor function, independence in self-care, and social participation. QOL was assessed with the Quality of Life Instrument for Young Adults (YAQOL). A general population sample of young North American adults, who had completed the YAQOL was selected for comparison.

RESULTS

Surveys and consent forms were completed by 335 young adults or their proxies, an overall participation rate of 63% of those located. The mean age of the study participants was 24.7 [s.d = 2.8] years; 51% were male and 49% female. Two hundred and seven (62%) of the 335 participants self-reported their QOL. When compared with the general population sample, self-reporting participants had similar QOL scores for the social relationship and environmental context domains (p > 0.05), while QOL scores were lower for the physical health, psychological well-being, and role function domains (p < 0.001). There was no association between psychological well-being and variables related to body structure and gross motor function in young adults with CP.

CONCLUSIONS

Contrary to the assumption that young adults with severe CP have low psychosocial well-being, it is apparent that these individuals can have good psychosocial well-being regardless of their disability.

The clinimetric properties of aerobic and anaerobic fitness measures in adults with cerebral palsy: A systematic review of the literature

OBJECTIVE

To analyze the clinimetric properties of maximal aerobic and anaerobic fitness measurement protocols in adults with cerebral palsy (CP).

DATA SOURCES

A systematic search through March 2015 of databases PubMed, Embase, SPORTDiscus and PsycINFO was performed with medical subject heading terms for 'cerebral palsy' combined with search terms adults or adolescents and multiple text words for fitness and exercise tests that yielded 864 articles.

STUDY SELECTION

Abstracts were screened by two reviewers to identify use of maximal fitness measurements in adolescents (14-18yrs) or adults (>18yrs) with CP of all abilities. Ninety-four articles were reviewed. No studies of adolescent (14-18yrs) qualified. Eight articles reported clinimetric properties for adults with CP who walk or propel a wheelchair independently. Five articles reported on aerobic capacity, one reported on anaerobic capacity and two reported on both.

DATA EXTRACTION

Methodological quality of the studies was rated using portions of the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist. Quality of the measurement protocols was evaluated based on statistical strength of the clinimetrics. Synthesis of the overall evidence was based on the Cochrane review group guidelines which combine methodological quality and statistical strength.

DATA SYNTHESIS

Eight articles reported on 4 aerobic and 1 anaerobic protocols. Overall synthesis revealed that for ambulatory adults with CP there is (i) moderate evidence for good reliability and good construct validity of maximal aerobic and anaerobic cycle tests, (ii) moderate evidence for good criterion validity of sub-maximal aerobic cycle tests, and (iii) strong evidence for poor criterion validity of the six-minute walk test as a maximal aerobic test. And for adults who propel a wheelchair there is limited evidence of good reliability for maximal aerobic wheelchair ergometer tests.

CONCLUSIONS

Limited quality research exists on the clinimetric properties of aerobic and anaerobic capacity measures for adults with CP who have independent mobility. Quality aerobic and anaerobic measures for adults with more severe mobility impairments are absent.

Cross-Sectional Study of Bowel Symptoms in Adults With Cerebral Palsy: Prevalence and Impact on Quality of Life

OBJECTIVES

To determine the prevalence and type of bowel symptoms, and their impact on health-related quality of life (HRQOL) in adults with cerebral palsy (CP).

DESIGN

Prospective cross-sectional study.

SETTING

Urban, outpatient rehabilitation facility.

PARTICIPANTS

Adults with CP (N=91; 46 men, 45 women; mean age, 36y; age range, 18-79y).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Participants were interviewed using standardized instruments to assess the frequency and types of bowel dysfunction. The International Consultation of Incontinence Questionnaire-Bowel was used to assess bowel incontinence and impact on quality of life, and constipation presence was determined using the Rome III criteria for constipation. Constipation symptoms were rated by the Patient Assessment of Constipation-Symptom Scale. Participants' mobility status was classified using the Gross Motor Function Classification System (GMFCS). Interactions between mobility measures, anthropometric measures, and bowel symptoms were assessed.

RESULTS

Of the 91 participants enrolled, 62.6% were GMFCS IV or V. Twenty-eight participants (30.8%) reported severe difficulty with control of liquid stool (rating never or rarely); these participants were more likely to have a greater GMFCS level (P=.0004). Twenty-six participants (28.6%) reported that bowel function caused embarrassment some/most/all of the time. Fifty-nine participants (64.8%) met criteria for chronic constipation, which did not differ by GMFCS levels. Overall, 57.1% of participants reported that bowel symptoms interfered with life; 40.7% reported moderate to severe interference.

CONCLUSIONS

Bowel symptoms were frequent, a source of embarrassment, and impacted HRQOL in these adults with CP. Addressing bowel-related symptoms has the potential to improve HRQOL in these adults.

Surgical correction of scoliosis in patients with severe cerebral palsy

INTRODUCTION

There is a lack of data in the literature on surgical correction of severe neuromuscular scoliosis in patients with serious extent of cerebral palsy. The purpose of this retrospective cohort study was to analyze the radiological and clinical results after posterior-only instrumentation (group P) and combined anterior-posterior instrumentation (group AP) in severe scoliosis in patients with Gross Motor Function Classification System grades IV and V.

MATERIALS AND METHODS

All eligible patients who underwent surgery in one institution between 1997 and 2012 were analyzed, and charts, surgical reports, and radiographs were evaluated with a minimum follow-up period of 2 years.

RESULTS

Fifty-seven patients were included (35 in group P, 22 in group AP), with a median follow-up period of 4.1 years. The preoperative mean Cobb angles were 84° (34 % flexibility) in group P and 109° (27 % flexibility) in group AP. In group P, the Cobb angle was 39° (54 % correction) at discharge and 43° at the final follow-up, while in group AP the figures were 54° (50 % correction) at discharge and 56° at the final follow-up. Major complications occurred in 23 vs. 46 % of the patients, respectively. Preoperative curve flexibility was an important predictor for relative curve correction, independently of the type of surgery.

CONCLUSION

Posterior-only surgery appears to lead to comparable radiological results, with shorter operating times and shorter intensive-care unit and hospital stays than combined surgery. The duration of surgery was a relevant predictor for complications.

Excitability properties of motor axons in adults with cerebral palsy

Cerebral palsy (CP) is a permanent disorder caused by a lesion to the developing brain that significantly impairs motor function. The neurophysiological mechanisms underlying motor impairment are not well understood. Specifically, few have addressed whether motoneuron or peripheral axon properties are altered in CP, even though disruption of descending inputs to the spinal cord may cause them to change. In the present study, we have compared nerve excitability properties in seven adults with CP and fourteen healthy controls using threshold tracking techniques by stimulating the median nerve at the wrist and recording the compound muscle action potential over the abductor pollicis brevis. The excitability properties in the CP subjects were found to be abnormal. Early and late depolarizing and hyperpolarizing threshold electrotonus was significantly larger (i.e., fanning out), and resting current-threshold (I/V) slope was smaller, in CP compared to control. In addition resting threshold and rheobase tended to be larger in CP. According to a modeling analysis of the data, an increase in leakage current under or through the myelin sheath, i.e., the Barrett-Barrett conductance, combined with a slight hyperpolarization of the resting membrane potential, best explained the group differences in excitability properties. There was a trend for those with greater impairment in gross motor function to have more abnormal axon properties. The findings indicate plasticity of motor axon properties far removed from the site of the lesion. We suspect that this plasticity is caused by disruption of descending inputs to the motoneurons at an early age around the time of their injury.

An examination of motor unit number index in adults with cerebral palsy

Spinal motor neuron loss may be a factor contributing to weakness in central disorders. The aim of this study was to assess whether motor unit numbers are reduced in the hand musculature of adults with cerebral palsy (CP) using the motor unit number index (MUNIX) technique. In this prospective, case-control study, 10 adults with CP were matched with healthy controls. MUNIX was computed using area and power of voluntary surface hypothenar electromyographic (EMG) signals and the compound muscle action potential (CMAP) recorded with ulnar nerve stimulation. The motor unit size index (MUSIX) was calculated based on maximum CMAP amplitude and MUNIX value. Gross Motor Function Classification Scale (GMFCS) and Manual Abilities Classification Scale (MACS) levels were rated for CP subjects. MUNIX was significantly lower for CP participants (Mean 167.8 vs. 214.4, p=.022). MUNIX values did not correlate with GMFCS or MACS. MUSIX values were higher, though not significantly, for CP subjects (p=.11). MUSIX increased with increasing MACS levels (r(2)=.4017, p=.049). Thus, motor unit numbers in ulnar hand muscles may be decreased with CP. MUSIX values are associated with greater hand impairment. Therefore, peripheral motor unit loss as a component of the weakness found with CP deserves further evaluation.

Health, functioning, and participation of adolescents and adults with cerebral palsy: a review of outcomes research

With medical advances, more individuals with cerebral palsy (CP) syndromes who reside in developed countries are surviving to adolescence and adulthood. However, there continues to be a paucity of research examining long-term health, functional activities, and participatory outcomes over their life-course. This article reviews the current literature assessing adult outcomes for individuals with CP within the framework of the International Classification of Functioning (ICF), Disability, and Health model of enablement. Preliminary data over the last decade indicate that among adults with cerebral palsy without intellectual disability, 60-80% completed high school, 14-25% completed college, up to 61% were living independently in the community, 25-55% were competitively employed, and 14-28% were involved in long term relationships with partners or had established families. These outcomes occurred with biomedical advances in the management of spasticity, deformity, and medical co-morbidities, as well as with concurrent policy initiatives to increase access to a continuum of habilitative and education services. Although we have incomplete population data to inform comprehensive life-course planning, there are opportunities to create clinical and translational community networks with improved measures of functioning and participation that can better inform us about the factors influencing lifespan development of people with CP.

Social outcomes of young adults with cerebral palsy

BACKGROUND

Functional abilities and social outcomes of young adults with cerebral palsy (CP) are relatively under-researched. Improvements in paediatric care have extended the expectation of achieving adulthood to 90%.

METHOD

Young adults aged 20-30 years with CP (n = 335) were compared to a population-based control group (n = 2,152) of the same age. Motor function, self-care abilities, educational level, and social outcomes were determined by questionnaire.

RESULTS

Half the study group walked independently, but only 35.5% were independent in self-care. In comparison to their peers without disability, the study group's highest educational level was lower (p < .0001), as were rates of employment (36.3% compared with 80%), they were more likely to be living with parents (80% compared with 21%), to be single, and to have limited financial resources.

CONCLUSION

Young adults with CP are functionally and socially disadvantaged in contrast with their peers without disability. Self-care dependence, intellectual disability, and communication impairments contribute to these outcomes but are not solely responsible.

Performance of adults with cerebral palsy related to falls, balance and function: a preliminary report

AIM

To describe performance on standardised measures of functional mobility and identify relationships between gait decline, falls history and risk scores, and Gross Motor Function Classification System (GMFCS) level.

METHOD

Adults with cerebral palsy (CP) aged 30-65 years, GMFCS Levels I-III underwent a single assessment to complete performance and questionnaire measures of balance, mobility and falls.

RESULTS

Twenty-five ambulant community dwelling adults with CP participated (mean 41 years) in this study. Fifteen participants (60%) reported gait decline (>age 18). The most frequent self-reported cause of decline was reduced balance (n = 12). Seventeen participants (68%) reported prior falls. Group differences were found between GMFCS levels and falls risk (falls risk for older people-community, p = 0.025), balance (Berg Balance Scale, p = 0.005) and mobility (6 min walk test p = 0.004; timed up and go, p = 0.011).

CONCLUSION

Adults with CP experience mobility decline in early to middle adulthood, with reduced balance performance and elevated falls risk evident. There is urgent need for further research into falls risk factors using prospective falls data.

The psychosocial impact on standing devices

PURPOSE

The aim of this study was to explore the psychosocial impact of standing devices as experienced by users.

METHOD

This is the second part of a comprehensive survey in five counties in Sweden where all the subjects with standing devices were invited to participate. The impact of standing devices on functional independence, quality of life and wellbeing was assessed using a questionnaire, Psychosocial Impact of Assistive Devices Scale (PIADS).

RESULTS

The psychosocial impact of the standing devices was perceived as positive. The highest PIADS scores in relation to age were found in the oldest group, aged 65 years and older. The ability to walk and independence in ambulation resulted in higher scores than the use of a wheelchair and/or dependence on others. Those who stood often awarded higher scores in the PIADS questionnaire compared to those who used the device less frequently. When standing was integrated in various activities, its psychosocial impact received high scores.

CONCLUSION

The psychosocial impact of standing devices was generally experienced positively. The main results indicated that standing in a standing device had a value and we as professionals should ask the users about the intended purpose of their standing in order to prescribe the optimal device.

IMPLICATIONS FOR REHABILITATION

Standing in standing devices has positive psychosocial impact for the user. As professionals we should broaden our view of the use of standing devices, i.e. to see the standing device as an aid that not only treats the body's structures or improves the user's abilities in activities, but also provides a psychosocial impact on the user's daily life, and to find meaningful goals for the user from a psychosocial perspective.

Gait function and decline in adults with cerebral palsy: a systematic review

PURPOSE

The aim of this systematic review was to identify, appraise and synthesize the evidence describing gait decline in adults with cerebral palsy (CP).

METHOD

Comprehensive searches were conducted in MEDLINE (1970-), EMBASE (1980-), CINAHL (1982-) and AMED (1985-) databases to June 2012. Two reviewers independently completed data extraction and analysis using a modified version of the Downs and Black quality tool.

RESULTS

From the 485 papers identified, 16 met the inclusion criteria. Most studies used samples of convenience. The reported mean ages of the study groups varied from 22 to 42.6 years. Decline in gait function was measured variably with the period of decline undefined or from an unknown reference time during childhood. Results suggest that mobility decline occurs in 25% or more of adults with CP. Those at higher risk of gait decline are those with worse initial gait ability, bilateral rather than unilateral motor impairment, older age and higher levels of pain or fatigue.

CONCLUSION

Many ambulant adults with CP experience mobility decline earlier than their nondisabled peers. More information regarding the natural history of mobility change over the lifespan in adults with CP augmented with self-efficacy qualitative data is needed to direct health advice and appropriate interventions for this group.

IMPLICATIONS FOR REHABILITATION

The literature suggests 25% or more of ambulant adults with cerebral palsy experience gait decline. Higher risk of gait decline occurs in those who are older, less independent in gait, have bilateral motor impairment and higher levels of pain or fatigue. Use of standardized gait measurement tools augmented with self-efficacy measures will aid provision of health advice and interventions.

Functional outcomes of childhood dorsal rhizotomy in adults and adolescents with cerebral palsy

OBJECT

In this descriptive study the authors evaluated medical outcomes, interventions, satisfaction with life, and subjective impressions about selective dorsal rhizotomy (SDR) in older adolescents and adults who had undergone the procedure as children.

METHODS

A survey was administered to older adolescents (16-20 years old) and adults with CP who had undergone SDR between 1986 and 2000 at two academic centers. The patients or their caregivers participated in telephone or clinic interviews. Subjective impressions about the SDR and a history of post-SDR medical interventions were obtained. Current functional status, history and ratings of pain, educational achievement, living situation, and subjective health status were also recorded. The Diener Satisfaction with Life Scale (SWLS) was administered.

RESULTS

Eighty-eight participants, mean age 25.6 ± 4.8 years (mean ± standard deviation), were interviewed at a mean of 19.6 ± 3.0 years after surgery. The distribution of current reported Gross Motor Function Classification System levels was as follows: I, 7%; II, 18%; III, 23%; IV, 36%; and V, 16%. Moreover, 56% of respondents were living with parents and 25% were living alone. Thirty-five percent were employed, and 39% were still in school. The mean overall SWLS score was 26.0 ± 7.3, indicating a high level of satisfaction with life. According to 65% of the patients, the SDR was helpful; 31% were uncertain about the procedure's efficacy. Sixty-five percent would recommend the procedure to others. Fifty-eight percent reported excellent to very good health. Forty-four percent reported pain in the past week. Fifty-one percent reported chronic back pain in general. Logistic regression analysis suggested that an increased satisfaction with life was a predictor (p = 0.01) of an affirmative response to the question about recommending the procedure to others and that better overall health showed a trend toward being such a predictor (p = 0.08). Additional interventions were frequently performed after the SDR. Seventy-four percent of participants underwent orthopedic surgery. Thirty-eight percent were currently taking oral medications for tone, and 53% had received botulinum toxin injections for spasticity treatment. Thirteen patients (15%) had an intrathecal baclofen pump placed.

CONCLUSIONS

The majority of adults who had undergone SDR as children would recommend the procedure to others. Very few reported negative impressions of the procedure. Levels of satisfaction with life were generally high. Pain prevalence was similar to what has been reported in the literature for adults with cerebral palsy. Despite the SDR, further interventions, both surgical and nonsurgical, were used in the majority of patients.

Interrater reliability and construct validity of the Posture and Postural Ability Scale in adults with cerebral palsy in supine, prone, sitting and standing positions

Objective:

To evaluate reliability, internal consistency and construct validity of the Posture and Postural Ability Scale for adults with cerebral palsy.

Design:

Psychometric evaluation of a clinical assessment tool.

Setting:

Rehabilitation centres in Sweden and Iceland.

Subjects:

Thirty adults with cerebral palsy aged 19–22 years, six people at each level I–V of the Gross Motor Function Classification System.

Main measures:

The Posture and Postural Ability Scale contains a 7-point ordinal scale for postural ability in supine, prone, sitting and standing, and items for assessment of posture. Posture and postural ability was rated from photos and videos by three independent assessors. Interrater reliability was calculated using weighted kappa. Internal consistency was analysed with Cronbach’s alpha if item deleted and corrected item–total correlation. Construct validity was evaluated based on known groups, using Jonckheere Terpstra for averaged values of the three raters relative to the Gross Motor Function Classification System.

Results:

There was an excellent interrater reliability (kappa = 0.85–0.99) and a high internal consistency (alpha = 0.96–0.97, item–total correlation = 0.60–0.91). Median values differed ( P < 0.02) between known groups represented by the levels of gross motor function, showing construct validity for all items.

Conclusion:

The Posture and Postural Ability Scale showed an excellent interrater reliability for experienced raters, a high internal consistency and construct validity. It can detect postural asymmetries in adults with cerebral palsy at all levels of gross motor function.

Chronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsy

AIM

To investigate the prevalence and co-occurrence of chronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsy (SBCP) and explore associations of chronic pain and fatigue with depressive symptoms and daily functioning.

METHOD

Fifty-six adults with SBCP without severe cognitive impairment participated (35 males, 21 females; mean age 36y 5mo, SD 5y 10mo; Gross Motor Function Classification System level I [13], II [28], III [11], IV [4]). Chronic pain (>3mo), severity and nature of fatigue (Fatigue Severity Scale; Multidimensional Fatigue Inventory), and depressive symptoms (Center for Epidemiological Studies Depression Scale) were assessed. Associations were explored using multivariable logistic regression analyses.

RESULTS

The study sample had a higher prevalence of chronic pain (75% vs 39%; p<0.001), mean fatigue (Fatigue Severity Scale, 4.4 [SD 1.3] vs 2.9 [SD 1.1]; p<0.001), and prevalence of depressive symptoms (25% vs 12%; p=0.004) than Dutch healthy reference samples. Chronic pain and severe fatigue co-occurred in 34% and in combination with depressive symptoms in 16% of the participants. Severity of fatigue was associated with depressive symptoms (OR 3.38; p<0.01). Chronic pain and fatigue were not associated with limitations in daily functioning.

INTERPRETATION

These findings suggest that adults with SBCP are severely affected by chronic pain, fatigue, and depressive symptoms, in addition to their spastic paresis.

Impact of cerebral palsy on health-related physical fitness in adults: systematic review

OBJECTIVE

To conduct a systematic review of the impact of cerebral palsy (CP) on the level of health-related physical fitness (body composition, cardiorespiratory endurance, flexibility, muscular endurance, and strength) in adults with CP compared with able-bodied adults.

DATA SOURCES

The Cochrane Library, MEDLINE, CINAHL, EMBASE, and PEDro were searched up to December 2010 for relevant comparative studies.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria (adults, comparative design, components of physical fitness) to select potential relevant studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodological quality. A consensus method was used to solve disagreements.

DATA SYNTHESIS

Pooling data was not possible, but a best-evidence synthesis was conducted. Also, a description of the level of health-related physical fitness in CP was given (expressed as a percentage of able-bodied controls). Nine case-control studies were included (average age ± SD of subjects with CP, 21±3y): 3 investigated body composition; 5, cardiorespiratory endurance; 3, muscular strength; and 1, muscular endurance. Two of the studies investigated multiple fitness components. No studies on flexibility were found. Muscular strength (34%-60%), muscular endurance (27%-52%), and cardiorespiratory endurance (14%) showed significantly lower values in adults with CP compared with able-bodied controls. Studies on body composition reported conflicting results on the impact of CP.

CONCLUSIONS

The results of this review point to a reduction in 3 components of health-related physical fitness in young adults with CP compared with controls: muscular strength, muscular endurance, and cardiorespiratory endurance. However, the level of evidence varies from moderate (muscular strength) to limited (muscular endurance and cardiorespiratory endurance). Additional studies of high methodological quality are recommended before firm conclusions can be made.

Balance in relation to walking deterioration in adults with spastic bilateral cerebral palsy

BACKGROUND

Balance function is central in walking, and impaired balance function may be related to walking deterioration in adults with spastic bilateral cerebral palsy (CP).

OBJECTIVES

The purposes of this study were: (1) to compare balance confidence, fear of falling, and balance ability in adults with spastic bilateral CP, with and without self-reported walking deterioration; (2) to characterize balance confidence, fear of falling, and balance ability across all participants; and (3) to examine the relationship between balance confidence and balance ability across all participants.

DESIGN

A case-control design was used.

METHODS

Sixteen adults from a 7-year follow-up study who had spastic bilateral CP and were under 40 years of age in the 2006 survey participated. Eight participants reported walking deterioration (cases), and 8 participants did not report walking deterioration (controls). Outcome variables were: the Activities-specific Balance Confidence (ABC) Scale, the Falls Efficacy Scale-International (FES-I), and the Balance Evaluation Systems Test (BESTest).

RESULTS

No differences in any of the outcome variables were found between the cases and the controls. Across all participants, the ABC Scale and FES-I scores were 62% and 24 points, respectively. Reduced ABC Scale scores and increased FES-I scores were found when using escalators, walking in crowds, and walking on slippery surfaces. The BESTest subscale scores were 60% to 79% of the maximum score, but only 31% and 42% of the maximum score in postural responses and anticipatory adjustments, respectively. Balance confidence correlated positively with postural responses, sensory orientation, stability in gait, and BESTest total score.

LIMITATIONS

The lack of reliability and validity tests for the outcome variables in this study population and the small number of participants were limitations of the study.

CONCLUSIONS

Self-reported walking deterioration in this group could not be explained by differences in balance confidence, fear of falling, or balance ability. Across all participants, most balance problems seemed related to reduced postural responses and anticipatory adjustments.

Cycling with functional electrical stimulation in an adult with spastic diplegic cerebral palsy

BACKGROUND AND PURPOSE

Adults with cerebral palsy (CP) are at risk for decreased mobility and health complications, and exercise may combat some of these negative changes. Because people with CP have difficulty generating sufficient muscle force, exercise augmented with functional electrical stimulation (FES) is an option for increasing exercise intensity. This mixed-method (quantitative-qualitative) case report describes the effects-across the International Classification of Functioning, Disability and Health (ICF) model-of cycling with FES (FES cycling) in an adult with CP.

CASE DESCRIPTION

An ambulatory 49-year-old man with spastic diplegic CP cycled with FES at home for 30 minutes, 3 times per week, for 12 weeks. Volitional efforts were augmented by FES of the bilateral quadriceps, gastrocnemius, and gluteal muscles. Testing was performed before and after the intervention and 4 weeks after intervention withdrawal.

OUTCOMES

After training, quadriceps muscle strength (force-generating capacity) improved by 22.2%, hamstring muscle strength improved by 18.5%, and the Timed "Up & Go" Test time decreased from 11.9 to 9.0 seconds. The patient reported increased performance and satisfaction for self-identified goals at the ICF level of participation, and his score on the Medical Outcomes Study 36-Item Health Survey questionnaire increased from 62.1 to 77.6. However, he reported increased back pain, which he attributed to positioning while cycling. Qualitative interviews provided context (the patient's perspective) for some of the quantitative results.

DISCUSSION

The patient made gains in body structure and function, activity, and participation (ICF levels) after FES cycling. The mixed-method approach provided insight into his experiences and perceptions about the measures assessed quantitatively. Further investigation on FES cycling in this population as well as positioning during cycling is warranted.