The potential metabolic consequences of cerebral palsy: inferences from the general population and persons with spinal cord injury

Acute Response to One Bout of Dynamic Standing Exercise on Blood Glucose and Blood Lactate Among Children and Adolescents With Cerebral Palsy Who are Nonambulant

PURPOSE

To investigate the acute exercise effects of dynamic standing exercise on blood glucose and blood lactate among children and adolescents with cerebral palsy who are nonambulant.

METHODS

Twenty-four participants with cerebral palsy who are nonambulant performed 30 minutes of dynamic standing exercise using a motorized device enabling assisted passive movements in an upright weight-bearing position. Capillary blood samples were taken from the fingertip for measurement of blood glucose and blood lactate at rest and at the end of exercise.

RESULTS

At rest, the participants had hyperlactatemia that was unaffected after exercise, presented as median and interquartile range at rest 1.8 (1.3:2.7) mmol/L, and after exercise 2.0 (1.1:2.5) mmol/L. Children and adolescents with Gross Motor Function Classification System, level V, had higher lactate levels at rest (2.5 [1.8:2.9] vs 1.4 [1.0:2.0]; P = .030) and after exercise (2.3 [2.0:2.6] vs 1.2 [0.9:2.2]; P = .032) compared with children and adolescents with Gross Motor Function Classification System, level IV, respectively. A statistically significant larger decrease in blood lactate levels after exercise was observed in children and adolescents with higher resting blood lactate levels (ρ = .56; P = .004). There were no statistically significant changes in blood glucose.

CONCLUSIONS

Forty percentage of the participants had mild hyperlactatemia at rest and participants with the highest blood lactate levels at rest had the greatest decrease in blood lactate levels after one bout of exercise. Children and adolescents who were classified with the highest level of the Gross Motor Function Classification Scale had higher blood lactate levels. More studies are needed on how to prevent chronically high resting levels of lactate with exercise in children with cerebral palsy who are nonambulant.

Blood pressure in adults with cerebral palsy: a systematic review and meta-analysis of individual participant data

Objectives:

This systematic review and meta-analysis was designed to determine the overall mean blood pressure and prevalence of hypertension among a representative sample of adults living with cerebral palsy by combining individual participant data. Additional objectives included estimating variations between subgroups and investigating potential risk factors for hypertension.

Methods:

Potential datasets were identified by literature searches for studies published between January 2000 and November 2017 and by experts in the field. Samples of adults with cerebral palsy (n ≥ 10, age ≥ 18 years) were included if blood pressure data, cerebral palsy-related factors (e.g. cerebral palsy subtype), and sociodemographic variables (e.g. age, sex) were available. Hypertension was defined as at least 140/90 mmHg and/or use of antihypertensive medication.

Results:

We included data from 11 international cohorts representing 444 adults with cerebral palsy [median (IQR) age of the sample was 29.0 (23.0–38.0); 51% men; 89% spastic type; Gross Motor Function Classification System levels I–V]. Overall mean SBP was 124.9 mmHg [95% confidence interval (CI) 121.7–128.1] and overall mean DBP was 79.9 mmHg (95% CI 77.2–82.5). Overall prevalence of hypertension was 28.7% (95% CI 18.8–39.8%). Subgroup analysis indicated higher blood pressure levels or higher prevalence of hypertension in adults with cerebral palsy above 40 years of age, men, those with spastic cerebral palsy or those who lived in Africa. BMI, resting heart rate and alcohol consumption were risk factors that were associated with blood pressure or hypertension.

Conclusion:

Our findings underscore the importance of clinical screening for blood pressure in individuals with cerebral palsy beginning in young adulthood.

An Online Physical Activity Intervention for Youth With Physical Disabilities: A Pilot Study

Background: Physical activity (PA) interventions are limited in number and reach for youth with physical disabilities (YPD) who experience systemic barriers that may preclude their in-person participation. Further, a lack of theory in the development and evaluation of PA interventions impedes our understanding and replication of active components of behavior change. These limitations pose challenges in the effective promotion of PA in YPD. Theory-based and more inclusive methods of PA intervention delivery must be explored in our efforts to promote PA and overall health in YPD.

Methods: A pilot study was conducted to evaluate the feasibility and outcomes of an online, 4-week social cognitive theory-based PA intervention for YPD. Intervention feasibility (implementation fidelity, intervention compliance, and intervention acceptability) was evaluated through manual documentation, weekly feedback questionnaires, and open-ended feedback at 1-month post-intervention. Targeted social cognitive (outcome expectations, self-efficacy [task, self-regulatory, barrier] and self-regulation) and PA behavior outcomes were self-reported at baseline and 1-week and 1-month post-intervention.

Results: Sixteen YPD (M_age = 17.4 ± 2.7 years, 69% female) completed the study. Intervention feasibility was supported by high implementation fidelity (100%), high intervention compliance (>90%), and positive ratings on indicators of acceptability for all weeks of the intervention (weekly feedback questionnaire means ranging from 5.74 to 6.19 out of 7). Through open-ended feedback, participants indicated the intervention was easy to use and understand, favorably shifted their self-awareness and personal meaning of PA, and provided value and potential for future use pertaining to the learned self-regulation skills and strategies. Participants also provided formatting and content recommendations for intervention improvement. Repeated measures ANOVAs showed significant and large effect sizes for changes in participants' task (p = 0.01, n²p = 0.28) and barrier (p = 0.02, n²p = 0.24) self-efficacy, goal-setting and planning and scheduling behaviors (ps < 0.001, n²ps = 0.42), and self-reported PA behavior (p = 0.02, n²p = 0.26).

Conclusions: An online PA intervention for YPD is feasible and may offer potential benefit through the enhancement of self-efficacy, self-regulation, and PA behavior. Continued research is necessary to understand the efficacy and longer-term outcomes of online, theory-based interventions for YPD as a PA promotion strategy.

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.

Clinical features and prognosis of COVID-19 in people with spinal cord injury: a case-control study

Study design

Observational case–control study.

Objective

Individuals with spinal cord injury (SCI) develop systemic physiological changes that could increase the risk of severe evolution of coronavirus disease 2019 (COVID-19) and result in atypical clinical features of COVID-19 with possible delay in both diagnosis and treatment. We evaluated differences in clinical features and evolution of COVID-19 between people with SCI and able-bodied individuals.

Setting

The study was conducted in an Italian inpatient rehabilitation referral center for individuals with SCI during the lockdown for the COVID-19 pandemic.

Methods

We compared clinical information between patients with SCI and able-bodied healthcare workers of the same center who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasopharyngeal swab polymerase chain reaction.

Results

Overall, 15 out of the 25 SCI patients admitted to the center and 17 out of the 69 healthcare workers tested positive for SARS-CoV-2. Patients with SCI exhibited a significantly more advanced age and a higher prevalence of comorbidities. Nevertheless, no significant differences in clinical expression of COVID-19 and treatment strategies were observed between the two groups. All hospitalized subjects were treated in nonintensive care units and no deaths occurred in either group.

Conclusions

This study does not support the supposed notion that COVID-19 could exhibit atypical clinical features or a worse evolution in the frail population of people with SCI.

Preferential deficit of fat-free soft tissue in the appendicular region of children with cerebral palsy and proposed statistical models to capture the deficit

BACKGROUND

Cerebral palsy (CP) is a neurological disorder characterized by a profound skeletal muscle deficit. However, whether there is a regional-specific skeletal muscle deficit in children with CP is unknown. The purpose of this study was to determine whether fat-free soft tissue mass (FFST), a commonly used surrogate for skeletal muscle mass, is more compromised in the limbs than in the trunk in children with CP. A second purpose was to determine whether physical characteristics can be used to accurately estimate appendicular FFST (AFFST) in children with CP.

METHODS

Forty-two children with CP (4-13 y) and 42 typically developing children matched to children with CP for sex, age and race were studied. Whole body FFST (FFST_whole), FFST in the upper limbs (FFST_upper), FFST in the lower limbs (FFST_lower), the ratio of AFFST to height (AFFST/ht), the ratio of AFFST to height² (AFFST/ht²) and non-appendicular FFST were estimated from dual-energy X-ray absorptiometry. Statistical models were developed to estimate AFFST, AFFST/ht and AFFST/ht² in both groups of children, and the leave-one-out method was used to validate the models.

RESULTS

Children with CP had 21% lower FFST_whole, 30% lower AFFST, 34% lower FFST_lower, 14% lower non-appendicular FFST, 23% lower AFFST/ht, 19% lower AFFST/ht² and 9% lower AFFST/FFST_whole (all p < 0.05). Statistical models developed using data from typically developing children overestimated AFFST, AFFST/ht and AFFST/ht² by 35%, 30% and 21% (all p < 0.05), respectively, in children with CP. Separate models developed using data from children with CP yielded better accuracy, with the estimated results highly correlated (r² = 0.78, 0.66 and 0.50, respectively; all p < 0.001) and not different from calculated AFFST, AFFST/ht and AFFST/ht² (all p > 0.99). However, when the difference in estimated values and measured values of AFFST, AFFST/ht and AFFST/ht² were plotted against measured values, there was an inverse relationship (r = -0.38, -0.47 and -0.61, respectively, all p < 0.05).

CONCLUSION

Children with CP have a remarkable deficit in FFST that is more pronounced in the appendicular than in the non-appendicular region and more pronounced in the lower than in the upper limbs. Preliminary models developed using data from children with CP can provide reasonable estimates of AFFST and indexes of AFFST relative to height, but further development of the models may be needed.

Noncommunicable disease among adults with cerebral palsy: A matched cohort study

OBJECTIVE

To compare the incidence of noncommunicable diseases between adults with and without cerebral palsy (CP).

METHODS

A cohort study was conducted using primary care data from the Clinical Practice Research Datalink. Cox models, stratified by matched set and adjusted for potential confounders, were fitted to compare the risk of any noncommunicable disease, cancer, cardiovascular disease, type 2 diabetes mellitus, and respiratory disease between adults with and without CP.

RESULTS

The analysis included 1,705 adults with CP and 5,115 age-, sex-, and general practice-matched adults without CP. There was evidence from adjusted analyses that adults with CP had 75% increased risk of developing any noncommunicable disease compared to adults without CP (hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.58-1.94). Specifically, they had increased risk of cardiovascular disease (HR 1.76, 95% CI 1.48-2.11) and respiratory disease (HR 2.61, 95% CI 2.14-3.19). There was no evidence of increased risk of cancer or type 2 diabetes mellitus.

CONCLUSIONS

Adults with CP had increased risk of noncommunicable disease, specifically cardiovascular and respiratory disease. These findings highlight the need for clinical vigilance regarding identification of noncommunicable disease in people with CP and further research into the etiology and management of noncommunicable disease in this population.

Visual kinematic feedback enhances the execution of a novel knee flexion gait pattern in children and adolescents

BACKGROUND

Altered knee motion is one of the most common gait deviations in pediatric populations with gait disorders. The potential for pediatric gait retraining using visual feedback based on knee kinematic patterns is under-explored.

RESEARCH QUESTION

This study investigated whether pediatric participants could successfully modify knee flexion patterns in response to a visual kinematic feedback system (VKFS).

METHODS

Knee flexion angles from twelve typically developing children and adolescents (6 M, 6 F; 11.9 ± 2.7 years) were calculated using wearable inertial measurement units. Participants were tested while walking on a treadmill using pattern based visual feedback (FB). Four novel target patterns which amplified or attenuated swing phase peak knee flexion were tested. No feedback (NFB) tests assessed the participant's ability to independently reproduce the patterns. Mean absolute cycle error (MACE) and magnitude of peak knee flexion error (PK) were calculated during the last 10 strides of FB and NFB trials. Pre-exposure reference values (R) were also calculated.

RESULTS AND SIGNIFICANCE

PK-FB was significantly smaller (p < 0.05) than PK-R for all targets. Average values for PK-NFB were higher than for PK-FB, although PK-NFB remained significantly lower than PK-R for two targets. Contrary to one of the study's hypotheses, MACE-FB and MACE-NFB were larger than MACE-R. The study provided evidence that pediatric participants were able to modify peak knee flexion during gait in the sense targeted by the VKFS. Analysis suggested that MACE increases were explained by increases in gait cycle deviation outside of the changed region.

Cardiovascular disease and related risk factors in adults with cerebral palsy: a systematic review

AIM

To summarize the literature on the prevalence of cardiovascular disease (CVD), risk factors of CVD, and CVD-related mortality in adults with cerebral palsy (CP).

METHOD

A systematic review was conducted by searching the PubMed, Embase, MEDLINE (Ovid), Cochrane, and CINAHL databases. Selection criteria included adults with CP aged 18 years or over. Methodological quality was assessed using the Newcastle-Ottawa scale for observational studies. Data were reported descriptively.

RESULTS

Nineteen studies met the inclusion criteria. Only one study reported directly on the presence of CVD in adults with CP, which found adults with CP reported greater CVD conditions than adults without CP (15.1 vs 9.1%, p<0.001). The most commonly reported risk factor of CVD in adults with CP was overweight/obesity. Five studies included data on CVD-related mortality in persons with CP, where CVD-related and circulatory system-related deaths were elevated and more common at a younger age in adults with CP than in the general population.

INTERPRETATION

The prevalence of CVD and the risk of death because of CVD in this population seems increased, though the knowledge base is fragmented by studies that are small in size and geographically isolated. Further research is required to understand prevalence of risk factors among adults with CP, in particular overweight/obesity.

WHAT THIS PAPER ADDS

Overweight and obesity are risk factors of cardiovascular disease (CVD) that are commonly reported in adults with cerebral palsy (CP). CVD-related and circulatory system-related deaths are elevated in individuals with CP compared to the general population.

Noncommunicable disease and multimorbidity in young adults with cerebral palsy

Purpose

Individuals with cerebral palsy (CP) are at increased risk for frailty and chronic disease due to factors experienced throughout the lifespan, such as excessive sedentary behaviors and malnutrition. However, little is known about noncommunicable diseases (NCDs) and multimorbidity profiles in young adults with CP. The study objective was to compare NCD and multimorbidity profiles between young adults with and without CP.

Methods

A clinic-based sample of adults (18-30 years) with (n=452) and without (n=448) CP was examined at the University of Michigan Medical Center. The prevalence and predictors of 13 NCDs were evaluated, including existing diagnoses or historical record of musculoskeletal, cardiometabolic, and pulmonary morbidities. The level of motor impairment was determined by the Gross Motor Function Classification System (GMFCS) and stratified by less vs more severe motor impairment (GMFCS I-III vs IV-V). Logistic regression was used to determine the odds of NCD morbidity and multimorbidity in adults with CP compared to adults without CP, and for GMFCS IV-V compared to GMFCS I-III in those with CP, after adjusting for age, sex, body mass index, and smoking.

Results

Adults with CP had a higher prevalence of osteopenia, osteoporosis, hypertension, myocardial infarction, hyperlipidemia, asthma, and multimorbidity compared to adults without CP, and higher odds of musculoskeletal (odds ratio [OR]: 6.97) and cardiometabolic morbidity (OR: 1.98), and multimorbidity (OR: 2.67). Adults with CP with GMFCS levels IV-V had a higher prevalence of osteopenia/osteoporosis, osteoarthritis, hypertension, other cardiovascular conditions, pulmonary embolism, and multimorbidity, and higher odds of musculoskeletal (OR: 3.41), cardiometabolic (OR: 2.05), pulmonary morbidity (OR: 1.42), and multimorbidity (OR: 3.45) compared to GMFCS I-III.

Conclusion

Young adults with CP have a higher prevalence of chronic NCDs and multimorbidity compared to young adults without CP, which is pronounced in those with more severe motor impairment. These findings reiterate the importance of early screening for prevention of NCDs in CP.

Does unilateral single-event multilevel surgery improve gait in children with spastic hemiplegia? A retrospective analysis of a long-term follow-up

Single event multilevel surgery (SEMLS) has become a standard intervention for children with cerebral palsy (CP). SEMLS proved to improve the gait in bilateral spastic cerebral palsy and those improvements can be maintained in the long term. However there is no evidence on the long-term outcome of unilateral SEMLS in children with unilateral spastic cerebral palsy. The gait analyses and clinical data of 14 children (9 male/5 female, mean age 12.1) with unilateral CP (6 children Gross Motor Function Classification System Scale level I and 8 children level II) were retrospectively reviewed at four time-points: preoperatively, 1year, 3-5 years and approximately 10 years after unilateral SEMLS. The Gait Profile Score (GPS) of the affected leg was used as a main and the number of fine tuning procedures as well as complications rate (Clavien-Dindo classification) as secondary outcome measures. The gait improved postoperatively and the GPS of the affected leg significantly declined by 3.73° which is well above the minimal clinical important difference of 1.6°. No deterioration of GPS occurred throughout the follow-up period. Therefore the postoperative improvement was maintained long-term. However, additional fine-tuning procedures had to be performed during the follow-up in 5 children and three complications occurred (one level II and two level III). The results indicate that children with unilateral cerebral palsy benefit from unilateral SEMLS and maintain gait improvements long-term.

Greater Adipose Tissue Distribution and Diminished Spinal Musculoskeletal Density in Adults With Cerebral Palsy

OBJECTIVES

To examine differences in adipose tissue distribution, lumbar vertebral bone mineral density (BMD), and muscle attenuation in adults with and without cerebral palsy (CP), and to determine the associations between morphologic characteristics.

DESIGN

Cross-sectional, retrospective analyses of archived computed tomography scans.

SETTING

Clinical treatment and rehabilitation center.

PARTICIPANTS

Adults (N=352) with CP (age, 38.8±14.4y; body mass, 61.3±17.1kg; Gross Motor Function Classification System levels, I-V) and a matched cohort of neurotypical adults. Of the 41 adults with CP included in the study, 10 were not matchable because of low body masses.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Computed tomography scans were assessed for visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) areas, psoas major area and attenuation in Hounsfield units (Hu), and cortical and trabecular BMDs.

RESULTS

Adults with CP had lower cortical (β=-63.41 Hu, P<.001) and trabecular (β=-42.24 Hu, P<.001) BMDs and psoas major areas (β=-374.51mm(2), P<.001) and attenuation (β=-9.21 Hu, P<.001) after controlling for age, sex, and body mass. Adults with CP had greater VAT (β=3914.81mm(2), P<.001) and SAT (β=4615.68mm(2), P<.001). Muscle attenuation was significantly correlated with trabecular (r=.51, P=.002) and cortical (r=.46, P<.01) BMD, whereas VAT was negatively associated with cortical BMD (β=-.037 Hu/cm(2), r(2)=.13, P=.03).

CONCLUSIONS

Adults with CP had lower BMDs, smaller psoas major area, greater intermuscular adipose tissue, and greater trunk adiposity than neurotypical adults. VAT and cortical BMD were inversely associated.

Factors associated with free adult preventive health care utilization among physically disabled people in Taiwan: nationwide population-based study

Background

Few previous studies have specifically addressed the health care utilization situation of the physically disabled. This study aimed to investigate the utilization of free adult preventive health care for physically disabled people and its’ affecting factors.

Methods

The data was obtained from three nationwide databases from 2006 to 2008. This study comprised 329,264 physically disabled people in Taiwan above the age of 40 who had eligible health checks during 2008. We employed descriptive statistics to analyze the use and rate of free preventive health care use by physically disabled adults. Logistic regression analysis was used to explore the factors that affect physically disabled adults’ use of free adult preventive health care.

Results

16.37% of the physically disabled adults used free adult preventive health care. Women (17.66%), married (17.16%), a junior high education level (17.89%), and mildly disabled adults (18.77%) had the highest use rate among various participant subgroups. The variables that significantly influenced the use of free adult preventive health care by the physically disabled included gender, age, education, marital status, urbanization of the residence areas, monthly payroll, aboriginal status, catastrophic illnesses status, relevant chronic diseases, and severity of disability.

Conclusions

Physically disabled using preventive health care tend to be low. Governments should use the media to reinforce propagation and education of these services to specific, low-utilization groups, and encourage doctors to actively provide preventive health care to communities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0610-5) contains supplementary material, which is available to authorized users.

Habitual physical activity and cardiometabolic risk factors in adults with cerebral palsy

Adults with cerebral palsy (CP) are known to participate in reduced levels of total physical activity. There is no information available however, regarding levels of moderate-to-vigorous physical activity (MVPA) in this population. Reduced participation in MVPA is associated with several cardiometabolic risk factors. The purpose of this study was firstly to compare levels of sedentary, light, MVPA and total activity in adults with CP to adults without CP. Secondly, the objective was to investigate the association between physical activity components, sedentary behavior and cardiometabolic risk factors in adults with CP. Adults with CP (n=41) age 18-62 yr (mean ± SD=36.5 ± 12.5 yr), classified in Gross Motor Function Classification System level I (n=13), II (n=18) and III (n=10) participated in this study. Physical activity was measured by accelerometry in adults with CP and in age- and sex-matched adults without CP over 7 days. Anthropometric indicators of obesity, blood pressure and several biomarkers of cardiometabolic disease were also measured in adults with CP. Adults with CP spent less time in light, moderate, vigorous and total activity, and more time in sedentary activity than adults without CP (p<0.01 for all). Moderate physical activity was associated with waist-height ratio when adjusted for age and sex (β=-0.314, p<0.05). When further adjustment was made for total activity, moderate activity was associated with waist-height ratio (β=-0.538, p<0.05), waist circumference (β=-0.518, p<0.05), systolic blood pressure (β=-0.592, p<0.05) and diastolic blood pressure (β=-0.636, p<0.05). Sedentary activity was not associated with any risk factor. The findings provide evidence that relatively young adults with CP participate in reduced levels of MVPA and spend increased time in sedentary behavior, potentially increasing their risk of developing cardiometabolic disease.

Intramuscular fat in ambulant young adults with bilateral spastic cerebral palsy

Background

It is known that individuals with bilateral spastic cerebral palsy (BSCP) have small and weak muscles. However, no studies to date have investigated intramuscular fat infiltration in this group. The objective of this study is to determine whether adults with BSCP have greater adiposity in and around their skeletal muscles than their typically developing (TD) peers as this may have significant functional and cardio-metabolic implications for this patient group.

Methods

10 young adults with BSCP (7 male, mean age 22.5 years, Gross Motor Function Classification System (GMFCS) levels I-III), and 10 TD young adults (6 male, mean age 22.8 years) took part in this study. 11 cm sections of the left leg of all subjects were imaged using multi-echo gradient echo chemical shift imaging (mDixon). Percentage intermuscular fat (IMAT), intramuscular fat (IntraMF) and a subcutaneous fat to muscle volume ratio (SF/M) were calculated.

Results

IntraMF was higher with BSCP for all muscles (p = 0.001-0.013) and was significantly different between GMFCS levels (p < 0.001), with GMFCS level III having the highest IntraMF content. IMAT was also higher with BSCP p < 0.001). No significant difference was observed in SF/M between groups.

Conclusion

Young adults with BSCP have increased intermuscular and intramuscular fat compared to their TD peers. The relationship between these findings and potential cardio-metabolic and functional sequelae are yet to be investigated.

Chronic disease risk among adults with cerebral palsy: the role of premature sarcopoenia, obesity and sedentary behaviour

Premature declines in function among adults with cerebral palsy (CP) are generally attributed to weakness, spasticity and orthopaedic abnormalities, as well as chronic pain and fatigue. Very little research or clinical attention has been devoted to the confluence and consequences of early muscle wasting and obesity as mediators of secondary comorbidity in this population, and perhaps more importantly, to the role of lifestyle to potentiate these outcomes. At present, there are no national surveillance programmes that monitor chronic health in adults with CP; however, mortality records have demonstrated a greater prevalence of coronary heart disease as compared with the general population. Although by definition, CP is a 'non-progressive' condition, secondary factors such as habitual sedentary behaviour, obesity, and premature sarcoepenia may increase the severity of functional impairment throughout adulthood, and lead to cardiometabolic disease, fragility and/or early mortality. Herein we describe the heightened health risk represented in adults with CP, and discuss the hallmark phenotypic features that coincide with ageing, obesity and cardiometabolic disorders. Moreover, we provide discussion regarding the protective role of habitual physical activity to stimulate anti-inflammatory pathways and to ameliorate global risk. Although physical therapeutic modalities are already widely acknowledged as a vital component to improve movement quality in CP, the purpose of this review was to present a compelling case for the value of lifelong physical activity participation for both function and cardiometabolic health preservation.

Secondary muscle pathology and metabolic dysregulation in adults with cerebral palsy

Cerebral palsy (CP) is caused by an insult to or malformation of the developing brain which affects motor control centers and causes alterations in growth, development, and overall health throughout the life span. In addition to the disruption in development caused by the primary neurological insult, CP is associated with exaggerated sedentary behaviors and a hallmark accelerated progression of muscle pathology compared with typically developing children and adults. Factors such as excess adipose tissue deposition and altered partitioning, insulin resistance, and chronic inflammation may increase the severity of muscle pathology throughout adulthood and lead to cardiometabolic disease risk and/or early mortality. We describe a model of exaggerated health risk represented in adults with CP and discuss the mechanisms and secondary consequences associated with chronic sedentary behavior, obesity, aging, and muscle spasticity. Moreover, we highlight novel evidence that implicates aberrant inflammation in CP as a potential mechanism linking both metabolic and cognitive dysregulation in a cyclical pattern.

Could muscle deformity in children with spastic cerebral palsy be related to an impairment of muscle growth and altered adaptation?

Skeletal muscle deformity is common in children with spastic cerebral palsy (CP), but the underlying mechanisms are unclear. This review explores some possible factors which may influence the development of muscle deformity in CP. Normal muscle function and growth appear to depend on the interaction of neuronal, endocrinal, nutritional, and mechanical factors, and also on the development of an appropriate balance between muscle protein synthesis and degradation, and between the development of contractile and non-contractile components. In this context, the changes seen in muscle in children with CP are reviewed and discussed. It is suggested that the development of muscle deformity in children with CP may be related to a multifactorial impairment of muscle growth, on which adaptation of the extracellular matrix due to altered loading may be imposed.

Cerebral palsy: clinical care and neurological rehabilitation

Cerebral palsy (CP) is defined as motor impairment that limits activity, and is attributed to non-progressive disturbances during brain development in fetuses or infants. The motor disorders of CP are frequently accompanied by impaired cognition, communication, and sensory perception, behavioural abnormalities, seizure disorders, or a combination of these features. CP is thought to affect three to four individuals per 1000 of the general population. The incidence, prevalence, and most common causes of CP have varied over time because of changes in prenatal and paediatric care. Medical management of children and adults involves care from primary-care physicians with input from specialists in neurology, orthopaedics, and rehabilitation medicine. Physicians should also work in conjunction with rehabilitation therapists, educators, nurses, social care providers, and schoolteachers. The focus of rehabilitation treatment has recently shifted to neurological rehabilitation in response to increasing evidence for neuroplasticity. This approach aims to improve development and function by capitalising on the innate capacity of the brain to change and adapt throughout the patient's life. As the life expectancy of individuals with CP approaches that of the general population, therapies must be developed that address the needs of adults ageing with disability.

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.