Decreased access to health care and social isolation among young adults with cerebral palsy after leaving school

Characteristics of Children with Cerebral Palsy and Their Utilization of Services in Saudi Arabia

The recent emergence of research on cerebral palsy (CP) in developing countries aims to improve knowledge on affected children and the utilization of the available services. This study seeks to describe children with CP in Saudi Arabia and service utilization as per Gross Motor Function Classification System (GMFCS) levels and geographic regions. A cross-sectional survey of 227 children with CP (Mean age 6.3, SD 3.9 years) was conducted. Parents reported on children's demographics, impairments, and service utilization. Half of the children (n = 113, 49.8%) had ≥3 impairments with speech, visual and learning impairments being the most frequent. The total number of impairments differed significantly by GMFCS, F (4, 218) = 8.87, p < 0.001. Most of the children (n = 86, 83.4%) used 2-5 services. Moreover, 139 (62.3%) did not attend school, 147 (65.9%) did not receive occupational therapy, and only 32 (14.3%) received speech therapy. More children in GMFCS level I did not receive neurologist services. Profiles of children and services were described by GMFCS and by regions. This was the first study to describe children with CP and service utilization in Saudi Arabia. Although many impairments affected the children, there was low utilization of related services. Data on service utilization and on unmet needs support a comprehensive approach to rehabilitation and the proper service allocation.

'Finding what works for me' - a qualitative study of factors influencing community gym participation for young adults with cerebral palsy

PURPOSE

To understand the factors influencing participation in community-based gym exercise for young adults with cerebral palsy (CP).

METHODS

A qualitative study using semi-structured interviews was conducted. Interviews were completed with 39 young adults with CP (15-30 years, GMFCS I-IV) following a peer-supported, gym-based exercise program called FitSkills.

RESULTS

"Finding what works for me" was the overarching theme. Through their gym experiences, young adults with CP identified four interrelated main themes that influenced whether gym participation "worked" for them, or not: (i) psychological factors, (ii) a "social" participation context, (iii) organisational and logistical support, and (iv) cost. The social context of FitSkills was perceived to positively influence psychological health outcomes and attenuate perceived barriers to participation. Organisational support facilitated their initial attendance, while logistical effort and cost affected ongoing or future gym participation.

CONCLUSIONS

Social involvement plays a critical role in positive participation experiences in community exercise settings for young adults with CP. Clinicians supporting exercise participation for this group should prioritise intervention strategies that promote social engagement and mental wellbeing. Collaboration between clinicians, community leisure organisations, and funding bodies may be essential to overcome logistical and financial barriers during the transition to adulthood. Implications for rehabilitationThe main factor influencing the attendance, involvement, and ongoing exercise preferences of young adults with cerebral palsy (CP) was the social context of the participation experience.Altering the social environment through peer-mentoring can facilitate participation in the gym.Young adults with CP consider mental wellbeing to be an important motivator and outcome of gym-based exercise participation.Mental wellbeing should be prioritised for health promotion for this group.Collaboration between recreation organisations, health services, clinicians, and consumers to address logistical and financial factors can facilitate positive physical activity participation experiences in community settings.

Health service use among adults with cerebral palsy: a mixed-methods systematic review

AIM

To determine the proportion of adults with cerebral palsy (CP) using health services and frequency of use, and to explore experiences and perceptions of health services for this population.

METHOD

A mixed-methods systematic review was conducted using the Joanna Briggs Institute methodology. Five databases were searched to September 2020. Observational and qualitative studies were included. Two reviewers screened titles, abstracts, and full texts; extracted data; and assessed the quality of included studies. Separate meta-analyses were used to pool the proportion of adults using each service and frequency of use. A meta-aggregation approach was used to synthesize qualitative data. Quantitative and qualitative findings were integrated using the Andersen and Newman Model of health care utilization.

RESULTS

Fifty-seven studies (31 quantitative, 26 qualitative) of 14 300 adults with CP were included. The proportion of adults using services ranged from 7% (95% confidence interval [CI]: 2-13%) for urologists to 84% (95% CI: 78-90%) for general practitioners. Incidence of visits ranged from 67 (95% CI: 37-123) hospital admissions to 404 (95% CI: 175-934) general practitioner visits per 100 person-years. Qualitative themes highlighted issues regarding accessibility, caregivers' involvement, health workers' expertise, unmet ageing needs, transition, and health system challenges.

INTERPRETATION

Adults with CP used a wide range of health services but faced context-specific challenges in accessing required care. Appropriate service delivery models for adults with CP are required. This review emphasizes a need to develop an appropriate service model for adults with CP to meet their needs.

The Use and Outcomes of Motor Rehabilitation Services Among People With Cerebral Palsy Change Across the Lifespan

Background and Aims

The provision of coordinated and multidisciplinary rehabilitation programs that adapt to the individual with cerebral palsy (CP) evolving rehabilitation needs throughout the different phases of life is highly challenging for healthcare systems. The aim of this study was to report the changes in motor rehabilitation (MR) environmental factors, service use and patient outcomes between children and adults with cerebral palsy and to identify if changes took place earlier or later than the standard division between pediatric and adult healthcare systems at 18 years.

Methods

We used data from the French ESPaCe survey to select a set of indicators for MR environmental factors, service use and patient outcomes, highlighted by patients and families in previous studies. We then compared the distribution of the indicator data between children and adults, as well as between four transition age groups: children under 12, adolescents up to 17 years, young adults, and adults over 25 years of age. We estimated odds ratios adjusted for motor involvement, associated impairments and informant type.

Results

A total of 997 respondents over 2 years of age were included in this study (484 children and 513 adults). Finding an available physiotherapist was very difficult for almost half of the children, and a greater proportion of adolescents and adults. Physiotherapy was provided in a private outpatient practice for twice as many adults over 25 years as children and adolescents. The weekly amount of physical therapy decreased as outpatient practice increased. Multidisciplinary rehabilitation decreased sharply from adolescence and was halved at adulthood. Satisfaction with the MR program decreased from childhood into adolescence and adulthood. Perceived impact of physiotherapy on people with CP and their main carers were less positive in adolescents.

Conclusions

Healthcare policies should focus on accessibility issues at all ages, consider adolescents as a specific population, consider a wide transition phase (12–25 yo) and maintain a multidisciplinary approach at adulthood. There is a strong need for national rehabilitation strategies for individuals with CP.

Determinants of hospital-based health service utilisation in cerebral palsy: a systematic review

OBJECTIVE

To systematically review and synthesize evidence of determinants associated with hospital-based health service utilisation among individuals with cerebral palsy (CP).

DATA SOURCES

Electronic databases MEDLINE, Embase, APA Psycinfo were searched from January 2000 to April 2020.

STUDY SELECTION

Observational studies were included that described people with CP, reported quantitative measures of hospital-based health service utilisation (inpatient, outpatient, emergency department), and based in high-income countries. We excluded studies that included only subsets of people with CP, or those that only reported therapy service utilisation.

DATA EXTRACTION

After initial screen, two reviewers reviewed full texts for inclusion and performed data extraction and risk of bias assessment using the Newcastle Ottawa scale. Determinants of health service utilisation were identified and categorised using the Andersen Behavioural Model.

DATA SYNTHESIS

Seventeen studies met inclusion criteria. Study quality was high. Twenty-six determinants were reported across eight Andersen Model characteristics. Individual predisposing factors such as sex showed no difference in health service utilisation; inpatient admissions decreased with increasing age during childhood and was lower in adults. Increased health service utilisation was associated with "individual need" including severe gross motor disability, epilepsy, developmental/ intellectual disability and gastrostomy-use across inpatient, outpatient and emergency department settings. There was little information reported on socio-demographic and health system contextual determinants.

CONCLUSIONS

CP health service utilisation was associated with age, severity and comorbidities. Improved understanding of determinants of health service utilisation can support health service access for people with CP.

Barriers and facilitators of physical activity participation for young people and adults with childhood-onset physical disability: a mixed methods systematic review

AIM

To understand the attitudes, barriers, and facilitators to physical activity participation for young people and adults with childhood-onset physical disability.

METHOD

Seven electronic databases (Embase, MEDLINE, PsychINFO, AMED, CINAHL, SPORTDiscus, and ERIC) were searched to November 2019. English language studies were included if they investigated attitudes, barriers, or facilitators to physical activity for young people (≥15y) or adults with childhood-onset physical disabilities. Two reviewers applied eligibility criteria and assessed methodological quality. Data were synthesized in three stages: (1) thematic analysis into descriptive themes, (2) thematic synthesis via conceptual framework, and (3) an interpretive synthesis of the thematic results.

RESULTS

Nineteen studies were included. Methodological quality varied, with only four qualitative studies and one quantitative study meeting all quality items. An overarching theme of 'finding the right balance' emerged. Six subthemes relating to capability, opportunity, and motivation contributed to physical activity participation being seen as 'the right fit' or 'all too hard'. The interpretive synthesis found social connections, social environment support, and an appropriate physical environment were essential to 'finding the right balance' to be physically active.

INTERPRETATION

Physical activity participation for young people and adults with childhood-onset physical disabilities is primarily influenced by the social and physical environment. What this paper adds Physical activity participation for young people and adults with childhood-onset physical disabilities is primarily influenced by environmental factors. 'Finding the right balance' between enabling and inhibitory factors was important to physical activity participation being perceived as 'the right fit'. The opportunity for social connection is an important motivator for physical activity participation for young people and adults. The physical environment continues to act as a barrier to physical activity participation for those with physical disabilities.

Disparities in Life Course Outcomes for Transition-Aged Youth with Disabilities

Close to 750,000 youth with special health care needs transition to adult health care in the United States every year; however, less than one-half receive transition-planning services. Using the "F-words" organizing framework, this article explores life course outcomes and disparities in transition-aged youth with disabilities, with a special focus on youth with autism, Down syndrome, and cerebral palsy. Despite the importance of transition, a review of the available literature revealed that (1) youth with disabilities continue to have poor outcomes in all six "F-words" domains (ie, function, family, fitness, fun, friends, and future) and (2) transition outcomes vary by race/ethnicity and disability. Professionals need to adopt a holistic framework to examine transition outcomes within a broader social-ecological context, as well as implement evidence-based transition practices to help improve postsecondary outcomes of youth with disabilities. [Pediatr Ann. 2017;46(10):e371-e376.].

Quantification of Physical Activity and Sedentary Time in Adults with Cerebral Palsy

PURPOSE

The purpose of this study was to determine objective and subjective quantification of habitual physical activity (HPA) and sedentary time in ambulatory and nonambulatory adults with cerebral palsy (CP).

METHODS

We recruited a clinical sample of adults with CP (N = 42; 21 women; mean (SD) age, 33.5 (12.3) yr; Gross Motor Function Classification System (GMFCS) distribution: level I (n = 5), level II (n = 9), level III (n = 10), level IV (n = 11), and level V (n = 7). Objective measures of HPA and sedentary time were obtained by using ActiGraph GT3X accelerometers at both hip and wrist sites. Three previously established cut-point values distinguishing light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) were evaluated across GMFCS levels. The concurrent validity of the self-report Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) was assessed for LPA and MVPA intensities in GMFCS levels II-V.

RESULTS

Participants showed little reluctance to wearing accelerometers; one participant reported discomfort. Nonambulatory adults (GMFCS levels IV-V) differed from ambulatory adults (GMFCS levels I-III) for recorded activity counts (hip and wrist sites), minutes of MVPA with each cut-point value, and breaks from sedentary time (all P < 0.05). For the same measures, adults in GMFCS level III also differed from GMFCS level I (all P < 0.05). The PARA-SCI correlated significantly with accelerometer-derived minutes of MVPA per day (r = 0.396; P = 0.014) and per hour of monitoring time (r = 0.356; P = 0.027).

CONCLUSIONS

Our findings support the use of accelerometers to objectively measure HPA and sedentary behavior in adults with CP across the severity spectrum, regardless of cut-point implementation. The PARA-SCI is a valid tool to capture subjectively reported patterns of MVPA in adults with CP who are GMFCS levels II-V.

Respect for autonomy in the healthcare context: observations from a qualitative study of young adults with cerebral palsy

BACKGROUND

Respect for patient autonomy is a cornerstone of contemporary medical ethics and clinical practice. In its different shapes and forms (e.g. being informed, being engaged in discussions and decisions about medical care and being supported in developing healthcare preferences and choices), patient autonomy has been fostered by both paediatric and adult professional societies. The transition from paediatric to adult care creates a complex situation where autonomy for medical decisions shifts to the developing adolescent. More specific challenges to respect for autonomy may be experienced by young adults with cerebral palsy in the transition period where, for example, language and motor impairments may affect communication skills and this may be conflated with cognitive disability.

AIM

To characterize perspectives towards autonomy in the healthcare context for young adults with cerebral palsy.

METHOD

We carried out semi-structured interviews with 14 young adults (aged 18-25) with cerebral palsy. The audiotaped interviews were transcribed verbatim and analysed using a conventional thematic qualitative content analysis.

RESULTS

Participants displayed a range of attitudes towards autonomy, suggesting that the value of autonomy is considered in light of competing values and of context. Testimonials from participants demonstrated that both contextual (e.g. ill-adapted health care, lack of specialized public transport) and relational (e.g. attitudes towards parental involvement in decision making) factors negatively or positively impact autonomy.

CONCLUSION

We observed that there were four key elements interwoven in participants' characterization of autonomy: the coupling of decisional and physical autonomy, the influences of family and society on autonomy, the influence of healthcare professionals on autonomy and the need for preparation for autonomy.

Perspectives of young adults with cerebral palsy on transitioning from pediatric to adult healthcare systems

Transition from pediatric to adult healthcare is a well-established challenge for individuals with neurodevelopmental disorders like cerebral palsy. With regard to ethics, some of the key aspects to explore include the following: if and how individuals feel respected during the transition process; if and how their values and preferences are developed and integrated within transition; and if and how young patients are prepared to participate in decision making (to be autonomous) within the transition. We carried out a qualitative study on 14 young adults with cerebral palsy. Some participants reported positive experiences. However, several tension points were identified, including before the transition (eg, transition envisaged with fear and apprehension); during the transition (eg, lack of cooperation or communication between providers in the pediatric and adult healthcare systems); and after the transition (eg, feelings of abandonment). We discuss the clinical influence and ethical significance of better capturing ethical values within the transition process and preparing young individuals to engage in discussions about their health and disease management.

Ethics in neurodevelopmental disability

Neurodevelopmental disabilities, like autism spectrum disorders and cerebral palsy are a common health problem in children. Given the impact of these conditions on children, families, and healthcare and social systems, the care of developmentally challenged children raises questions related to values and ethical principles. We review the common features of neurodevelopmental disorders that help understand the associated ethical questions. We focus on three major areas where ethical questions arise for clinicians and those involved in making decisions for or caring for these children: (1) the principles of decision-making and autonomy as they relate to developmental disability; (2) the issues related to quality of life that have long intersected with developmental disability; and (3) the use of unproven therapies and diagnostics that are particularly controversial given the extent that neurodevelopmental disabilities impact children and their families, yet active treatments options are limited.

Ethics in health care services for young persons with neurodevelopmental disabilities: a focus on cerebral palsy

In this article we review and discuss some of the key ethical and social challenges that young persons with cerebral palsy face in health care delivery. We identify and explain these challenges, some of which are rarely discussed in contemporary medicine and biomedical ethics, partly because they are not considered genuine "ethical" challenges per se. Most of these challenges are heavily shaped by broader social context and institutional practices, which highlights the importance of nonbiological aspects of the care of young persons with cerebral palsy from an ethics standpoint.

Adults with a diagnosis of cerebral palsy: a mapping review of long-term outcomes

AIM

Cerebral palsy (CP) is recognized as a lifespan condition. This mapping review identifies outcomes that have been measured in adults with CP between 1970 and 2010 to determine if either the outcomes evaluated or the research methodologies have changed substantially.

METHOD

We performed a literature review. For studies to be included, participants had to be 16 years or older and 80% of the sample had to have a diagnosis of CP. Articles were grouped by decade, and outcomes were categorized using the International Classification of Functioning, Disability and Health (ICF) framework and terminology.

RESULTS

Fifty-eight articles were included in the mapping review. Both the number of studies and the types of outcomes investigated increased from 1970 to 2010. Outcomes representing the ICF component of Body Function and Structure were present across the period reviewed, whereas interest in contextual (personal or environmental) factors has primarily emerged since 2000.

INTERPRETATION

Gaps were identified by the mapping review. Large age ranges and heterogeneity of sample populations made it difficult to determine if the outcomes reported were due to ageing or the long-term consequences of CP. In addition, most reviewed articles described outcomes categorically, with few papers providing explanations or solutions to reported outcomes.

Determinants of functioning of adolescents and young adults with cerebral palsy

PURPOSE

To describe the level of functioning of adolescents and young adults with cerebral palsy (CP) and study determinants of their level of functioning.

METHOD

In the CP Transition study, adolescents and young adults aged 16-20 years, diagnosed with CP without severe learning disabilities (n =103) participated. In this group we assessed subject characteristics, i.e., age, type of CP, gross motor function (GMFCS), level of education as well as outcome measures on functioning in daily activities and social participation (Life Habits questionnaire, Vineland Adaptive Behavior Scale, Functional Independence Measure). Multivariate regression analyses were performed.

RESULTS

About 20-30% of the participants encountered restrictions in daily activities (mobility, self-care, nutrition) and social participation (taking responsibility, community living, leisure activities and employment). The GMFCS level, level of education, and age proved to be important determinants of functioning in daily activities and social participation, explaining 70% and 66% of the variance in outcome respectively.

CONCLUSION

A significant number of adolescents and young adults with CP without severe learning disabilities are restricted in daily activities and social participation. These problems are mainly attributable to restricted gross motor functioning, a low level of education and younger age.