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

Pregnancy outcome in women with cerebral palsy: A nationwide population-based cohort study

INTRODUCTION

Cerebral palsy (CP) is a lifelong disorder with a high rate of comorbidities and complications. We hypothesized that women with CP are at increased risk of adverse pregnancy outcome.

MATERIAL AND METHODS

In this nationwide population-based cohort study 1997-2011, we examined the outcome of 770 births in women with CP vs 1 247 408 births in women without a CP diagnosis using the Swedish Medical Birth Register. We used unconditional logistic regression, adjusting for maternal age, smoking, parity, year of birth and epilepsy, to calculate adjusted odds ratios for adverse pregnancy outcome. Main adverse outcome was preterm birth. Secondary outcomes were cesarean section, induction of labor, low 5-min Apgar score, small for gestational age, large for gestational age, and stillbirth.

RESULTS

After adjusting for potential confounders, maternal CP was associated with increased risk of preterm birth (12.9% vs 4.9%; adjusted odds ratio [aOR] 2.8, 95% CI 2.3-3.5), cesarean delivery (aOR 1.9, 95% CI 1.6-2.2), induced delivery (aOR 1.4, 95% CI 1.1-1.6), low 5-min Apgar score (aOR 1.8, 95% CI 1.1-2.9) and small of gestational age birth (aOR 1.6, 95% CI 1.2-2.3). We found no increased risk of large for gestational age or stillbirth.

CONCLUSIONS

Women with CP are at increased risk of preterm birth and other adverse pregnancy outcomes, suggesting that they deserve extra surveillance during antenatal care. Further studies, with information on type of CP and gross motor function, are warranted to better understand the association between CP and pregnancy outcome.

Development of nursing quality care process metrics and indicators for intellectual disability services: a literature review and modified Delphi consensus study

Background

Nursing process quality care metrics and indicators are quantifiable measures of the nursing care delivered to clients. They can be used to identify and support nurses’ contribution to high quality, safe, client care and are lacking in specialist intellectual disability nursing. In a national Nursing Quality Care-Metrics project for Irish intellectual disability services, a set of nursing quality care process metrics and associated indicators were established for intellectual disability services.

Methods

A two-stage design approach was undertaken; a broad scoping review of the literature and a modified Delphi consensus process. The Delphi included a four round e-Delphi survey and a consensus meeting. Four hundred one intellectual disability nurses working in Ireland were recruited for the surveys and 20 stakeholders attended the consensus meeting.

Results

From the review, 20 existing and 16 potential intellectual disability nursing metrics were identified for nurses to prioritise in the e-surveys. After the four survey rounds, 12 intellectual disability nursing metrics and 84 associated indicators were identified. Following the consensus meeting, these were reduced to 12 metrics and 79 indicators.

Conclusions

This first set of intellectual disability nursing process metrics and associated indicators has been identified for implementation in practice. These metrics while developed in Ireland have international relevance and their application and appropriateness in practice needs to be evaluated.

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.

Prevalence of Mental Health Disorders Among Adults With Cerebral Palsy: A Cross-sectional Analysis

BACKGROUND

Persons with cerebral palsy (CP) have an increased risk for secondary chronic conditions during childhood, including mental health disorders. However, little is known about how these disorders affect adults with CP.

OBJECTIVE

To determine the prevalence of mental health disorders among adults with CP compared with those without CP.

DESIGN

Cross-sectional.

SETTING

2016 Optum Clinformatics Data Mart.

PATIENTS

8.7 million adults (including 7348 adults with CP).

MEASUREMENTS

Other neurodevelopmental comorbid conditions (intellectual disabilities, autism spectrum disorders, epilepsy) and 37 mental health disorders (as 6 categories) were identified on the basis of diagnosis codes. Direct age-standardized prevalence of the mental health disorder categories was estimated by sex for adults with CP alone, adults with CP and neurodevelopmental disorders, and adults without CP.

RESULTS

Men with CP alone had higher age-standardized prevalence than men without CP for schizophrenic disorders (2.8% [95% CI, 2.2% to 3.4%] vs. 0.7%), mood affective disorders (19.5% [CI, 18.0% to 21.0%] vs. 8.1%), anxiety disorders (19.5% [CI, 18.0% to 21.0%] vs. 11.1%), disorders of adult personality and behavior (1.2% [CI, 0.8% to 1.6%] vs. 0.3%), and alcohol- and opioid-related disorders (4.7% [CI, 3.9% to 5.5%] vs. 3.0%). The same pattern was observed for women. Compared with adults with CP alone, those with CP and neurodevelopmental disorders had similar or higher age-standardized prevalence of the 6 mental health disorder categories, except for the lower prevalence of alcohol- and opioid-related disorders in men.

LIMITATIONS

Single claims code was used to define the cohort of interest. Information on the severity of CP was not available.

CONCLUSION

Compared with adults without CP, those with CP have an elevated prevalence of mental health disorders, some of which may be more pronounced in patients with comorbid neurodevelopmental disorders.

PRIMARY FUNDING SOURCE

National Institute on Disability, Independent Living, and Rehabilitation Research.

Nutritional Status and Cardiometabolic Risk Factors in Institutionalized Adults with Cerebral Palsy

Background and Objectives: Cerebral palsy (CP) is a set of permanent disorders that limit physical activity and increase the risk of developing other diseases, such as metabolic syndrome (MS). Adequate nutrition can contribute to the prevention of associated symptoms. The main objective of this study is to evaluate the nutritional status and the prevalence of cardiometabolic risk factors in adults with CP and Gross Motor Function Classification System (GMFCS) levels between IV and V. Materials and Methods: A sample of 41 adults with CP and GMFCS levels from IV to V were studied. The variables used in the study were age, sex, weight, height, mean age, and GMFCS level range. To evaluate nutritional status, body mass index and the Mini Nutritional Assessment (MNA), a nutritional screening tool, were used. To assess cardiometabolic risk, data on obesity, central obesity, blood pressure, fasting plasma glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides were collected. Results: More than 80% of the population studied was malnourished or at risk of malnutrition, according to the MNA tool classification ranges, and around 35% of the studied population was within the underweight range. Regarding cardiometabolic risk factors, only one adult with CP was diagnosed with MS. Conclusions: The studied population of adults with CP and GMFCS levels between IV and V is not a population at risk of MS; however, the high prevalence of malnutrition, as well as some of the most prevalent cardiovascular risk factors, should be taken into consideration.

Prevalence of metabolic syndrome and cardiovascular disease risk factors in adults with cerebral palsy

AIM

To investigate the prevalence of metabolic syndrome and cardiovascular disease (CVD) risk factors and the association between common metabolic markers and Gross Motor Function Classification System (GMFCS) levels in ambulatory adults with cerebral palsy (CP).

METHOD

Metabolic markers and GMFCS levels were evaluated in a cross-sectional study of 70 ambulatory adults with CP (34 males, 36 females; mean age 24y 5mo [SD 5y 4mo], range 18y 6mo-48y 8mo) to determine the prevalence of metabolic syndrome and CVD risk factors, and were compared to age-matched, population norms from the National Health and Nutrition Examination Survey (NHANES) registry. The Framingham Heart Study (FHS) CVD risk estimation was also used to evaluate an individual's risk for CVD.

RESULTS

Metabolic syndrome was identified in 17.1% of the cohort, higher than the 10% in the NHANES registry. The FHS CVD 30-year lipid and body mass index (BMI)-based risk factor results showed that 20% to 40% of the cohort was at greater risk of developing CVD (BMI-based: 39.7% 'full' CVD risk factor; lipid-based: 26.5% 'full' CVD risk factor) as compared to the FHS normative population data. There was a positive correlation between GMFCS level, waist circumference (r=0.28, p=0.02), and waist-to-hip ratio (r=0.28, p=0.02).

INTERPRETATION

Adults with CP are at higher risk of CVD and metabolic syndrome compared to the general population, which is probably because of impaired mobility.

Age-related trends in cardiometabolic disease among adults with cerebral palsy

AIM

To examine the longitudinal trends of cardiometabolic diseases in a large sample of adults with cerebral palsy (CP).

METHOD

The Optum Clinformatics Data Mart is a de-identified nationwide claims database of beneficiaries from a single private payer. Beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification code for a diagnosis of CP. Adults with at least 3 years of continuous enrollment on a single plan between 2002 and 2009 were included in the final analyses (n=2659). We examined the longitudinal trends of incident diabetes mellitus, hypercholesterolemia, hypertension, cardiac dysrhythmias, and atherosclerosis, stratified by age categories: 18 to 39 years, 40 to 59 years, and 60 years and over. Kaplan-Meier product-limit survival curves were compared across age categories for each of the cardiometabolic outcomes, and a Cox proportional hazards regression was run to determine adjusted hazard ratios.

RESULTS

The cumulative incidence of each of the cardiometabolic diseases ranged from 6.0% for atherosclerosis to 34.4% for hypercholesterolemia at 3 years and over. Risk-adjusted Cox proportional hazard models revealed that age was a robust predictor of survival for each outcome, with higher hazard ratio ranges in middle age (hazard ratio 1.41-2.72) and older adults (hazard ratio 2.20-5.93) compared with young adults.

INTERPRETATION

Adults with CP have high rates of cardiometabolic diseases; and disease-free survival shortens significantly with higher ages.

WHAT THIS PAPER ADDS

Adults with cerebral palsy have high rates of cardiometabolic diseases. Disease-free survival of all cardiometabolic diseases shortens significantly with higher ages. The highest rates were for hypercholesterolemia and hypertension.

Sarcopenia among Adults with Cerebral Palsy in South Korea

BACKGROUND

Most adults with cerebral palsy encounter newly developing physical health problems and premature functional decline with aging. These physical and functional losses along with the characteristic symptoms of cerebral palsy may heighten the risk of sarcopenia.

OBJECTIVE

To determine the prevalence of sarcopenia among a selected group of adults with cerebral palsy and to identify the factors associated with their sarcopenia among them.

DESIGN

Cross-sectional study.

SETTING

University hospitals and communities for persons with disabilities.

PARTICIPANTS

A total of 80 adults with cerebral palsy (46 men and 34 women with mean age of 42.8 ± 8.86 years) were included.

METHOD

Muscle mass, strength, and physical performance were measured to diagnose sarcopenia. Participants also completed a structured questionnaire for physical, psychological, or socioeconomic attributes and health-related quality of life.

MAIN OUTCOME MEASURES

Prevalence of sarcopenia in adults with cerebral palsy.

RESULTS

The prevalence of sarcopenia was 47.9%. Sarcopenia was significantly associated with sex, the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), body mass index (BMI), and trunk fat. Male, higher GMFCS and lower BMI were significant risk factors of sarcopenia. Sarcopenic adults with cerebral palsy showed significantly lower health-related quality of life.

CONCLUSION

The prevalence of sarcopenia in adults with cerebral palsy was higher than that of general population despite the young age of the selected group. Modifiable risk factor was a low BMI.

LEVEL OF EVIDENCE

III.

The risk, burden, and management of non-communicable diseases in cerebral palsy: a scoping review

AIM

To examine the risk, burden, and management of non-communicable diseases (NCDs) among people with cerebral palsy (CP).

METHOD

Databases (Ovid MEDLINE, Embase Ovid, CINAHL Plus) were systematically searched up to August 2017. Data on the prevalence of risk factors for, and the burden and management of, cardiovascular diseases, diabetes, cancers, and respiratory diseases were extracted.

RESULTS

Thirty-six studies that examined the prevalence of risk factors among people with CP were identified. There was inconsistent evidence that people with CP had higher prevalence of metabolic risk factors such as hypertension, hyperlipidaemia, and obesity, but strong evidence that they participated in low levels of physical activity, compared with people without CP. Seven studies reported on the burden of NCDs. Adults with CP had a higher risk of NCDs, including stroke, chronic obstructive pulmonary disease, and other heart conditions, and death due to NCDs, including cancers, chronic obstructive pulmonary disease, stroke, and ischaemic heart disease, compared with the general population. Only one study reported on the management of NCD, specifically the uptake of breast cancer screening among females.

INTERPRETATION

The burden of NCDs is higher among adults with CP compared with the general population. Further research is required to determine the prevalence of metabolic risk factors and management of NCDs among people with CP.

WHAT THIS PAPER ADDS

Adults with cerebral palsy (CP) have an increased risk of non-communicable diseases (NCDs) and increased risk of death because of NCDs. Evidence is inconsistent about the elevated prevalence of metabolic risk factors for NCDs. Evidence is consistent that people with CP participate in reduced physical activity. Only one study reported on management of NCD among people with CP. Available evidence suggests people with CP are less likely to receive preventive medicine.

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.

Genetic and environmental (physical fitness and sedentary activity) interaction effects on cardiometabolic risk factors in Mexican American children and adolescents

Knowledge on genetic and environmental (G × E) interaction effects on cardiometabolic risk factors (CMRFs) in children is limited.  The purpose of this study was to examine the impact of G × E interaction effects on CMRFs in Mexican American (MA) children (n = 617, ages 6-17 years). The environments examined were sedentary activity (SA), assessed by recalls from "yesterday" (SAy) and "usually" (SAu) and physical fitness (PF) assessed by Harvard PF scores (HPFS). CMRF data included body mass index (BMI), waist circumference (WC), fat mass (FM), fasting insulin (FI), homeostasis model of assessment-insulin resistance (HOMA-IR), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), systolic (SBP) and diastolic (DBP) blood pressure, and number of metabolic syndrome components (MSC). We examined potential G × E interaction in the phenotypic expression of CMRFs using variance component models and likelihood-based statistical inference. Significant G × SA interactions were identified for six CMRFs: BMI, WC, FI, HOMA-IR, MSC, and HDL, and significant G × HPFS interactions were observed for four CMRFs: BMI, WC, FM, and HOMA-IR. However, after correcting for multiple hypothesis testing, only WC × SAy, FM × SAy, and FI × SAu interactions became marginally significant. After correcting for multiple testing, most of CMRFs exhibited significant G × E interactions (Reduced G × E model vs. Constrained model). These findings provide evidence that genetic factors interact with SA and PF to influence variation in CMRFs, and underscore the need for better understanding of these relationships to develop strategies and interventions to effectively reduce or prevent cardiometabolic risk in children.

Shared meanings of success, happiness, and health among adults with cerebral palsy and physiotherapists: implications for practice and research

PURPOSE

To describe shared meanings of success, happiness, and health of adults with cerebral palsy and physiotherapists.

MATERIALS AND METHODS

Ethnography employed open ended/semi-structured interviews and structured questionnaires (Satisfaction with Life Scale, Beck Depression Inventory-II^®, Oxford Happiness Questionnaire, Life Habits Questionnaire, Medical Outcomes Study-Social Support Survey, and PROMIS^® Pain Interference Scale). Content analysis of qualitative data and principal components analysis of questionnaire responses identified shared meanings.

RESULTS

Fourteen adults with cerebral palsy and 15 physiotherapists (median age 46) had similar levels of education. For both groups, social achievements, personal goals, employment, and supporting a family defined success. Adults with cerebral palsy more frequently identified tenacity and persistence as important for success. Both groups described happiness as spending time with loved ones, recreational activities, and having purpose in life. Adults with cerebral palsy identified the importance of self-acceptance for happiness. For both, health included self-care of mind/spirit, cardiovascular and musculoskeletal wellness, and physical fitness (the ability to perform physical tasks). Analysis of questionnaire responses identified shared meanings (eigenvalue 41, 95% explained variance).

CONCLUSIONS

Adults with cerebral palsy and physiotherapists share similar experiences, behaviors, and feelings about success, happiness, and health. This knowledge may improve communication, enhance evidence-based practice, and foster services to support wellbeing. Implications for rehabilitation Cerebral palsy is a life-long condition, but we know little about social and physical outcomes for adults with cerebral palsy. Lack of understanding about meanings of success, happiness, and health may be a barrier for consumers accessing and for providers delivering evidence-based services. Physiotherapists and adults with cerebral palsy share similar meanings (feelings, experiences, beliefs, behaviors) of success, happiness, and health- or wellbeing. Knowledge of this common ground may result in improved communication between providers and consumers, and foster more relevant and meaningful services to support the wellbeing of adults with cerebral palsy.

Cerebral palsy

Cerebral palsy (CP) is a lifespan motor disorder arising from damage to the developing brain before or shortly after birth. People with CP may experience problems with muscle coordination and difficulties with the organization and processing of sensory information. Functional mobility is impaired and commonly influenced by spasticity and musculoskeletal system problems such as contractures or bony torsion. Around 60% of individuals with CP are able to walk independently or with aids when entering adulthood. However, many adults with CP experience increasing balance and mobility dysfunction associated with premature aging. Falls and reduced falls efficacy are commonly experienced, with associated physical and psychosocial consequences. There is evidence that ambulant adults with CP may be able to enhance their functional balance and mobility as a result of an individualized exercise program of sufficient duration and intensity. However, whether such programs result in a reduction in falls is unknown. Given the high number of falls with injury experienced by this population, attention to fall risk factors and provision of basic fall prevention strategies are warranted.

Long-term impact of childhood selective dorsal rhizotomy on pain, fatigue, and function: a case-control study

AIM

Selective dorsal rhizotomy (SDR) is a surgical treatment for spasticity in children with cerebral palsy (CP). Studies suggest long-lasting effects of SDR on spasticity; long-term effects on symptoms and function are not clear. This study tested whether adults with CP (average 22y after SDR) report less pain, fatigue, and functional decline than a retrospectively assessed non-surgical comparison group.

METHOD

This was a case-control study. Eighty-eight adults with CP (mean age 27y; SDR=38 male/female/missing=20/16/2; non-surgical [comparison]=50, male/female=19/31) recruited from a tertiary care center and the community completed a battery of self-reported outcome measures. Regression models were used to test whether SDR status predicted pain, fatigue, functional change, and hours of assistance (controlling for Gross Motor Function Classification System level).

RESULTS

SDR status did not significantly predict pain interference (p=0.965), pain intensity (p=0.512), or fatigue (p=0.404). SDR related to lower decline in gross motor functioning (p=0.010) and approximately 6 fewer hours of daily assistance than for those in the comparison group (p=0.001).

INTERPRETATION

Adults with CP who had SDR in childhood reported less gross motor decline and fewer daily assistance needs than non-surgically treated peers, suggesting the functional impact of SDR persists long after surgery.

Evidence for increasing physical activity in children with physical disabilities: a systematic review

AIM

To summarize the best evidence of interventions for increasing physical activity in children with physical disabilities.

METHOD

A systematic review was conducted using an electronic search executed in Academic Search Elite, Academic Search Premier, CINAHL, Embase, MEDLINE, PEDro, PsychINFO, and SPORTDiscus up to February 2016. The selection of articles was performed independently by two researchers according to predetermined eligibility criteria. Data extraction, methodological quality, and levels of evidence were independently assessed by two researchers using a data-collection form from the Cochrane Collaboration and according to the guidelines of the American Academy for Cerebral Palsy and Developmental Medicine.

RESULTS

Seven studies were included. Five randomized controlled trials ranged from strong level I to weak level II studies, and two pre-post design studies were classified as level IV. There is level I evidence for no effect of physical training on objectively measured physical activity, conflicting level II evidence for interventions with a behavioural component on the increase of objectively measured physical activity directly after the intervention, and level II evidence for no effect during follow-up. Results are limited to children with cerebral palsy as no other diagnoses were included.

INTERPRETATION

Increasing physical activity in children with physical disabilities is very complex and demands further development and research.

A qualitative evaluation of an aerobic exercise program for young people with cerebral palsy in specialist schools

PURPOSE

To explore the perceived effects of an aerobic exercise program delivered in specialist schools for young people with cerebral palsy with high support needs.

METHODS

In-depth interviews were completed with 8 students with cerebral palsy, 10 parents, 8 teachers and 7 physiotherapists. Interviews were audio-recorded, transcribed verbatim and independently coded by two researchers. Data were analyzed using thematic analysis.

RESULTS

Two themes emerged: one about program impact and the second about influential design features. Exercise was perceived as important, and participants indicated that the program had resulted in positive physical (e.g., improved ease of mobility, fitness and stamina) and psychosocial (e.g., happiness, social experience, challenge) impacts. The school setting, program staff and student attitudes were key features of the program.

CONCLUSIONS

These data converge with those from a randomized controlled trial and attribute physical and psychosocial benefits to a specialist school-based exercise program for young people with cerebral palsy.

An aerobic exercise program for young people with cerebral palsy in specialist schools: A phase I randomized controlled trial

PURPOSE

To evaluate the safety, adherence, and estimates of effect of an aerobic exercise program in specialist schools for young people with cerebral palsy.

METHODS

Nineteen students with cerebral palsy were randomly allocated to an intervention group who completed an aerobic exercise program (27 sessions over nine weeks) or a control group who completed social/art activities over the same time.

RESULTS

There were no serious adverse events and the exercise program was completed with high rates of attendance (77%) and adherence to target heart rate zones (79%). Effect sizes favored the intervention group for measures of cardiovascular performance (sub-maximal treadmill test, effect size d = 0.7; muscle power sprint test, d = 0.9) and participation (Preference for Active-Physical Activities, d = 0.6).

CONCLUSIONS

An aerobic exercise program in specialist schools for young people with cerebral palsy, that may improve measures of cardiovascular performance, can be completed safely, with moderately high levels of adherence.

Health Care Access for Adults With Intellectual and Developmental Disabilities: A Scoping Review

Adults with intellectual and/or developmental disabilities (IDD) often experience health disparities. To address disparities, Healthy People 2020 includes specific disability and health goals focused on improving health care access. The study's purpose was to review the literature exploring health care access for adults with IDD to identify opportunities for occupational therapy research and practice. A scoping review was completed of articles discussing health care access among adults with IDD in the United States. Thirty-seven articles met the inclusion criteria. Results are framed using the ecology of human performance theory identifying person and environmental issues affecting health care access of adults with IDD. Opportunities exist for occupational therapy to improve participation and health of adults with IDD through engaging in research and practice efforts addressing health care access. Occupational therapy could develop interventions to establish skills and abilities and recommend changes to the health care environment.

Coupling Timing of Interventions With Dose to Optimize Plasticity and Participation in Pediatric Neurologic Populations

PURPOSE

The purpose of this article is to propose that coupling of timing of interventions with dosing of interventions optimizes plasticity and participation in pediatric neurologic conditions, specifically cerebral palsy. Dosing includes frequency, intensity, time per session, and type of intervention. Interventions focus on body structures and function and activity and participation, and both are explored. Known parameters for promoting bone, muscle, and brain plasticity and evidence supporting critical periods of growth during development are reviewed. Although parameters for dosing participation are not yet established, emerging evidence suggests that participation at high intensities has the potential for change. Participation interventions may provide an additional avenue to promote change through the life span. Recommendations for research and clinical practice are presented to stimulate discussions and innovations in research and practice.

Multimorbidity in Middle-Aged Adults with Cerebral Palsy

OBJECTIVE

Individuals with cerebral palsy have less lean body mass, greater relative adiposity, and lower fitness and physical activity participation, and yet the prevalence of age-related multimorbidity in this population has yet to be established. The study objective was to examine the prevalence of lifestyle-related chronic conditions and multimorbidity in a sample of middle-aged adults with cerebral palsy.

METHODS

A clinic-based sample of middle-aged adults with cerebral palsy was examined using Electronic Medical Records Search Engine software. Our cohort included 435 individuals aged 40 to 60 years, with an International Classification of Diseases, Clinical Modification, 9th and 10th Revisions Diagnosis Code for cerebral palsy. Prevalence of 12 chronic conditions was evaluated, including existing diagnoses or historical record of osteopenia/osteoporosis, myocardial infarction, stroke, coronary artery disease, impaired glucose tolerance/type 2 diabetes, other cardiovascular conditions, rheumatoid arthritis, osteoarthritis, asthma, emphysema, prehypertension/hypertension, and hyperlipidemia. Multivariate logistic models were used to estimate multimorbidity (ie, ≥2 chronic conditions), adjusting for age, sex, smoking status, obesity, and Gross Motor Function Classification System (GMFCS).

RESULTS

There were 137 unique multimorbidity combinations. Multimorbidity was significantly more prevalent among obese versus nonobese individuals for both GMFCS I-III (75.8% vs 53.6%) and GMFCS IV-V (79.0% vs 64.2%), but was also significantly higher in nonobese individuals with GMFCS IV-V (64.2%) compared with nonobese individuals with GMFCS I-III (53.6%). Both the obesity status (odds ratio, 2.20; 95% confidence interval, 1.32-2.79) and the GMFCS IV-V category (odds ratio, 1.81; 95% confidence interval, 1.32-3.68) were independently associated with multimorbidity.

CONCLUSIONS

Middle-aged adults with cerebral palsy have high estimates of multimorbidity; both obesity and higher GMFCS levels are independently associated with greater risk.

Prevalence of secondary impairments of adults with cerebral palsy according to gross motor function classification system

[Purpose] This study aimed to investigate the prevalence of secondary impairments in adults with cerebral palsy. [Subjects and Methods] The study sample included 52 adults with cerebral palsy who attended a convalescent or rehabilitation center for disabled individuals or a special school for physical disabilities in South Korea. [Results] The univariate analysis showed that the Gross Motor Functional Classification System level was a significant predictor of spondylopathies, general pain, arthropathies, and motor ability loss. The prevalence of these impairments at Gross Motor Functional Classification System level I and II was low compared with the prevalence found at Gross Motor Functional Classification System level III–V. The prevalence of secondary impairments among adults with cerebral palsy at Gross Motor Functional Classification System level III–V was high: loss of motor ability, 42.3%; spondylopathies, 38.4%; general pain, 32.7%; and arthropathies, 28.8%. [Conclusion] In this study, adults with severe cerebral palsy showed a high prevalence of motor ability loss, spondylopathies, arthropathies, and pain. It is necessary to develop intervention programs to prevent secondary impairments in adults with cerebral palsy.

Developing a Clinical Protocol for Habitual Physical Activity Monitoring in Youth With Cerebral Palsy

PURPOSE

The StepWatch (SW) has been used to monitor physical activity (PA) in youth with cerebral palsy; however, there is no standard collection protocol. The goal was to develop such a protocol.

METHODS

Data were examined from patients who wore the SW for 8 to 14 days. The Spearman-Brown prediction formula determined the minimum number of days for reliable PA. Weekdays were compared to weekends and 10- and 60-second collection intervals were examined.

RESULTS

The PA data were collected from 98 youth with cerebral palsy. Results showed 3 days would provide reliable representation of PA, participants took significantly more steps during school days compared with weekends, and there were no differences between collection intervals.

CONCLUSIONS

We recommend setting the SW for 7 days at 10-second collection rate. Data should be analyzed if at least 3 days of data are present. Weekdays and weekend days should be noted, and both included when possible.

Risk of stroke among patients with cerebral palsy: a population-based cohort study

AIM

The aim of the study was to investigate the risk of stroke in patients with cerebral palsy (CP), based on nationwide data in Taiwan.

METHOD

This prospective cohort study was comprised of patients recorded on the Taiwan Longitudinal Health Insurance Database 2005 (LHID2005) who had a diagnosis of CP (n=1975) in records between 1 January 2004 and 31 December 2007. A comparison group (1:5) drawn from the same database was matched for age and sex (n=9875). Each patient was tracked by data until the development of stroke or the end of 2008. Cox proportional-hazards regression analysis was used to evaluate the hazard ratios after adjusting for potential confounding factors.

RESULTS

Patients with CP were more likely to suffer stroke than the comparison population, after adjusting for potential confounding factors (adjusted hazard ratio: 2.17; 95% confidence interval [CI]: 1.74-2.69). The hazard ratio of stroke was 4.78 (95% CI: 3.18-7.17) and 1.57 (95% CI: 1.20-2.05) for patients with CP aged 50 years and under, and over 50 years respectively.

INTERPRETATION

Cerebral palsy is a risk factor or marker for stroke that is independent of traditional stroke risk factors. Further research in this area is warranted.

Comparison of a robotic-assisted gait training program with a program of functional gait training for children with cerebral palsy: design and methods of a two group randomized controlled cross-over trial

Background

Enhancement of functional ambulation is a key goal of rehabilitation for children with cerebral palsy (CP) who experience gross motor impairment. Physiotherapy (PT) approaches often involve overground and treadmill-based gait training to promote motor learning, typically as free walking or with body-weight support. Robotic-assisted gait training (RAGT), using a device such as the Lokomat^®Pro, may permit longer training duration, faster and more variable gait speeds, and support walking pattern guidance more than overground/treadmill training to further capitalize on motor learning principles. Single group pre-/post-test studies have demonstrated an association between RAGT and moderate to large improvements in gross motor skills, gait velocity and endurance. A single published randomized controlled trial (RCT) comparing RAGT to a PT-only intervention showed no difference in gait kinematics. However, gross motor function and walking endurance were not evaluated and conclusions were limited by a large PT group drop-out rate.

Methods/design

In this two-group cross-over RCT, children are randomly allocated to the RAGT or PT arm (each with twice weekly sessions for eight weeks), with cross-over to the other intervention arm following a six-week break. Both interventions are grounded in motor learning principles with incorporation of individualized mobility-based goals. Sessions are fully operationalized through manualized, menu-based protocols and post-session documentation to enhance internal and external validity. Assessments occur pre/post each intervention arm (four time points total) by an independent assessor. The co-primary outcomes are gross motor functional ability (Gross Motor Function Measure (GMFM-66) and 6-minute walk test), with secondary outcome measures assessing: (a) individualized goals; (b) gait variables and daily walking amounts; and (c) functional abilities, participation and quality of life. Investigators and statisticians are blinded to study group allocation in the analyses, and assessors are blinded to treatment group. The primary analysis will be the pre- to post-test differences (change scores) of the GMFM-66 and 6MWT between RAGT and PT groups.

Discussion

This study is the first RCT comparing RAGT to an active gait-related PT intervention in paediatric CP that addresses gait-related gross motor, participation and individualized outcomes, and as such, is expected to provide comprehensive information as to the potential role of RAGT in clinical practice.

Trial registration ClinicalTrials.gov NCT02196298

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-3535-0) contains supplementary material, which is available to authorized users.

Strength Training for Adolescents with cerebral palsy (STAR): study protocol of a randomised controlled trial to determine the feasibility, acceptability and efficacy of resistance training for adolescents with cerebral palsy

INTRODUCTION

Gait is inefficient in children with cerebral palsy, particularly as they transition to adolescence. Gait inefficiency may be associated with declines in gross motor function and participation among adolescents with cerebral palsy. Resistance training may improve gait efficiency through a number of biomechanical and neural mechanisms. The aim of the Strength Training for Adolescents with cerebral palsy (STAR) trial is to evaluate the effect of resistance training on gait efficiency, activity and participation in adolescents with cerebral palsy. We also aim to determine the biomechanical and neural adaptations that occur following resistance training and evaluate the feasibility and acceptability of such an intervention for adolescents with cerebral palsy.

METHODS AND ANALYSIS

60 adolescents (Gross Motor Function Classification System level I-III) will be randomised to a 10-week resistance training group or a usual care control group according to a computer-generated random schedule. The primary outcome is gait efficiency. Secondary outcomes are habitual physical activity, participation, muscle-tendon mechanics and gross motor function. General linear models will be used to evaluate differences in continuous data between the resistance training and usual care groups at 10 and 22 weeks, respectively. A process evaluation will be conducted alongside the intervention. Fidelity of the resistance training programme to trial protocol will be quantified by observations of exercise sessions. Semistructured interviews will be conducted with participants and physiotherapists following the resistance training programme to determine feasibility and acceptability of the programme.

ETHICS AND DISSEMINATION

This trial has ethical approval from Brunel University London's Department of Clinical Sciences' Research Ethics Committee and the National Research Ethics Service (NRES) Committee London-Surrey Borders. The results of the trial will be submitted for publication in academic journals, presented at conferences and distributed to adolescents, families and healthcare professionals through the media with the assistance of the STAR advisory group.

TRIAL REGISTRATION NUMBER

ISRCTN90378161; Pre-results.

Sedentary and Active Time in Toddlers with and without Cerebral Palsy

INTRODUCTION/PURPOSE

To evaluate differences in sedentary time and compare levels of physical activity and sedentary behavior to the Australian physical activity recommendations between toddlers with cerebral palsy (CP) according to functional capacity (Gross Motor Function Classification System [GMFCS]) and age-matched children with typical development (CTD).

METHODS

Children (2.4 ± 0.5 yr old) were split into CTD (n = 20), GMFCS I-II (n = 32), GMFCS III (n = 14), and GMFCS IV-V (n = 12) groups and wore a triaxial ActiGraph® for 3 d. Validated cut points were applied to identify sedentary and active time and the number and duration of sedentary bouts and breaks for each group. Analysis of variance (ANOVA) with post hoc testing, chi-square analysis, and the Fisher exact test were used to compare groups.

RESULTS

No difference between the CTD group (49%) and GMFCS I-II group (52%) was found for sedentary time as a percentage of wear time. The GMFCS III group was more sedentary than both these groups (62%, P < 0.05). The GMFCS IV-V group was more sedentary than all the other groups (74%, P < 0.05). The CTD group and GMFCS I-II group was more likely to spend 180 min or longer in active play on all 3 d than the GMFCS IV-V group (P < 0.05). The GMFCS IV-V group was more likely to have sedentary bouts ≥60 min or longer than all other groups (P < 0.05).

CONCLUSION

Differences in sedentary behavior between the CTD and mildly impaired children with CP (GMFCS I-II) are not evident in the toddler years. Children with moderate-to-severe functional impairment are progressively more sedentary and less likely to meet physical activity guidelines. Further research into the health implications of high levels of sedentary behavior in toddlers is required.

Addressing muscle performance impairments in cerebral palsy: Implications for upper extremity resistance training

STUDY DESIGN

Case study and literature review.

INTRODUCTION

Muscle performance consists of not only strength but also muscle power, rate of force development, and endurance. Therefore, resistance training programs should address not only the force-generating capacity of the muscle but also the ability to produce force quickly.

PURPOSE

To discuss the National Strength and Conditioning Association's resistance training guidelines for youth as specifically related to optimal dosing for muscle strength versus muscle power. Dosing parameters of frequency, volume, intensity, duration, and velocity are discussed independently for strength and power.

METHODS

We describe how resistance training principles can be applied to the upper extremity in CP through a case study. The case describes an individual with spastic CP, who has a severe motor disability and is non-ambulatory, but has been able to perform resistance training focused on speed, power, and strength.

DISCUSSION

Recommendations to optimize the dosing of this individual's resistance training program are made.

Cerebral palsy

Cerebral palsy is the most common cause of childhood-onset, lifelong physical disability in most countries, affecting about 1 in 500 neonates with an estimated prevalence of 17 million people worldwide. Cerebral palsy is not a disease entity in the traditional sense but a clinical description of children who share features of a non-progressive brain injury or lesion acquired during the antenatal, perinatal or early postnatal period. The clinical manifestations of cerebral palsy vary greatly in the type of movement disorder, the degree of functional ability and limitation and the affected parts of the body. There is currently no cure, but progress is being made in both the prevention and the amelioration of the brain injury. For example, administration of magnesium sulfate during premature labour and cooling of high-risk infants can reduce the rate and severity of cerebral palsy. Although the disorder affects individuals throughout their lifetime, most cerebral palsy research efforts and management strategies currently focus on the needs of children. Clinical management of children with cerebral palsy is directed towards maximizing function and participation in activities and minimizing the effects of the factors that can make the condition worse, such as epilepsy, feeding challenges, hip dislocation and scoliosis. These management strategies include enhancing neurological function during early development; managing medical co-morbidities, weakness and hypertonia; using rehabilitation technologies to enhance motor function; and preventing secondary musculoskeletal problems. Meeting the needs of people with cerebral palsy in resource-poor settings is particularly challenging.

Validation of accelerometer cut points in toddlers with and without cerebral palsy

AIM

The purpose of this study was to validate uni- and triaxial ActiGraph cut points for sedentary time in toddlers with cerebral palsy (CP) and typically developing children (TDC).

METHODS

Children (n = 103, 61 boys, mean age = 2 yr, SD = 6 months, range = 1 yr 6 months-3 yr) were divided into calibration (n = 65) and validation (n = 38) samples with separate analyses for TDC (n = 28) and ambulant (Gross Motor Function Classification System I-III, n = 51) and nonambulant (Gross Motor Function Classification System IV-V, n = 25) children with CP. An ActiGraph was worn during a videotaped assessment. Behavior was coded as sedentary or nonsedentary. Receiver operating characteristic-area under the curve analysis determined the classification accuracy of accelerometer data. Predictive validity was determined using the Bland-Altman analysis.

RESULTS

Classification accuracy for uniaxial data was fair for the ambulatory CP and TDC group but poor for the nonambulatory CP group. Triaxial data showed good classification accuracy for all groups. The uniaxial ambulatory CP and TDC cut points significantly overestimated sedentary time (bias = -10.5%, 95% limits of agreement [LoA] = -30.2% to 9.1%; bias = -17.3%, 95% LoA = -44.3% to 8.3%). The triaxial ambulatory and nonambulatory CP and TDC cut points provided accurate group-level measures of sedentary time (bias = -1.5%, 95% LoA = -20% to 16.8%; bias = 2.1%, 95% LoA = -17.3% to 21.5%; bias = -5.1%, 95% LoA = -27.5% to 16.1%).

CONCLUSION

Triaxial accelerometers provide useful group-level measures of sedentary time in children with CP across the spectrum of functional abilities and TDC. Uniaxial cut points are not recommended.

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.

Wide-pulse-high-frequency neuromuscular electrical stimulation in cerebral palsy

OBJECTIVE

The present study assesses whether wide-pulse-high-frequency (WPHF) neuromuscular electrical stimulation (NMES) could result in extra-force production in cerebral palsy (CP) patients as previously observed in healthy individuals.

METHODS

Ten CP and 10 age- and sex-matched control participants underwent plantar flexors NMES. Two to three 10-s WPHF (frequency: 100 Hz, pulse duration: 1 ms) and conventional (CONV, frequency 25 Hz, pulse duration: 50 μs) trains as well as two to three burst-like stimulation trains (2s at 25 Hz, 2s at 100 Hz, 2s at 25 Hz; pulse duration: 1 ms) were evoked. Resting soleus and gastrocnemii maximal H-reflex amplitude (Hmax) was normalized by maximal M-wave amplitude (Mmax) to quantify α-motoneuron modulation.

RESULTS

Similar Hmax/Mmax ratio was found in CP and control participants. Extra-force generation was observed both in CP (+18 ± 74%) and control individuals (+94 ± 124%) during WPHF (p<0.05). Similar extra-forces were found during burst-like stimulations in both groups (+108 ± 110% in CP and +65 ± 85% in controls, p>0.05).

CONCLUSION

Although the mechanisms underlying extra-force production may differ between WPHF and burst-like NMES, similar increases were observed in patients with CP and healthy controls.

SIGNIFICANCE

Development of extra-forces in response to WPHF NMES evoked at low stimulation intensity might open new possibilities in neuromuscular rehabilitation.

Perceived cause, environmental factors, and consequences of falls in adults with cerebral palsy: a preliminary mixed methods study

Objective. Describe perceived cause, environmental influences, and consequences of falls or near-falls in ambulant adults with cerebral palsy (CP). Methods. Adults with CP completed postal surveys and follow-up semistructured interviews. Surveys sought information on demographic data, self-nominated Gross Motor Function Classification Score (GMFCS-E&R), falls, and near-falls. Interviews gathered additional information on falls experiences, near-falls, and physical and psychosocial consequences. Results. Thirty-four adults with CP participated. Thirty-three participants reported at least one fall in the previous year. Twenty-six participants reported near-falls. Most commonly, falls occurred indoors, at home, and whilst engaged in nonhazardous ambulation. Adults with CP experienced adverse falls consequences, lower limb injuries predominant (37%), and descriptions of fear, embarrassment, powerlessness, and isolation. Discussion. Adults with CP may experience injurious falls. Further investigation into the impact of falls on health-related quality of life and effective remediation strategies is warranted to provide comprehensive falls prevention programs for this population.

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.

The continuum of care for individuals with lifelong disabilities: role of the physical therapist

Many individuals with lifelong disabilities (LLDs) of childhood onset are living longer, participating in adult roles, and seeking comprehensive health care services, including physical therapy, with greater frequency than in the past. Individuals with LLDs have the same goals of health and wellness as those without disabilities. Aging with a chronic LLD is not yet well understood; however, impairments such as pain, fatigue, and osteoporosis often present earlier than in adults who are aging typically. People with LLDs, especially those living with developmental disabilities such as cerebral palsy, myelomeningocele, Down syndrome, and intellectual disabilities, frequently have complex and multiple body system impairments and functional limitations that can: (1) be the cause of numerous and varied secondary conditions, (2) limit overall earning power, (3) diminish insurance coverage, and (4) create unique challenges for accessing health care. Collaboration between adult and pediatric practitioners is encouraged to facilitate smooth transitions to health practitioners, including physical therapists. A collaborative client-centered emphasis to support the transition to adult-oriented facilities and promote strategies to increase accessibility should become standard parts of examination, goal setting, and intervention. This perspective article identifies barriers individuals with selected LLDs experience in accessing health care, including physical therapy. Strategies are suggested, including establishment of niche practices, physical accessibility improvement, and inclusion of more specific curriculum content in professional (entry-level) doctorate physical therapy schools.

Abdominal obesity is an independent predictor of serum 25-hydroxyvitamin D deficiency in adults with cerebral palsy

Background

Individuals with cerebral palsy (CP) are at risk for nutritional insufficiency. The purpose of the study was to examine the vitamin D status of adults with CP, and to evaluate the association between vitamin D and functional level, age, race, and anthropometric indicators of adiposity.

Methods

Serum vitamin D levels, BMI, waist circumference (WC), and functional level (measured by Gross Motor Function Classification System (GMFCS)) were examined in 112 adults with CP. Vitamin D status was assessed by serum 25-hydroxyvitamin D level (25(OH)D). The influence of motor impairment and adiposity on 25(OH)D were assessed using general linear modeling and logistic regression, with age, sex, race, and season as covariates.

Results

Mean vitamin D was 28.1 ± 16.0 ng/ml. Only 45% of subjects had optimal levels of 25(OH)D, 21% were insufficient and 34% were deficient. Overweight or obesity was prevalent (52%), as was abdominal obesity in men (23.5% at 102 cm cutoff) and women (31.1% at 88 cm cutoff). There was a robust association between the indicator of visceral adiposity (WC) and 25(OH)D level (p <0.001), even after controlling for age, sex, race, season, and GMFCS. According to sex-specific WC cutoffs, the odds of being deficient in vitamin D increase by a factor of 3.5 (95% CI 1.12-11.0) for abdominal obesity. GMFCS was not associated with 25(OH)D.

Conclusions

Adults with CP are at risk for low vitamin D levels and overweight/obesity. Waist circumference is a strong independent predictor for low vitamin D levels.

Inactive and sedentary lifestyles amongst ambulatory adolescents and young adults with cerebral palsy

Background

To assess physical behaviour, including physical activity and sedentary behaviour, of ambulatory adolescents and young adults with cerebral palsy (CP). We compared participant physical behaviour to that of able-bodied persons and assessed differences related to Gross Motor Functioning Classification System (GMFCS) level and CP distribution (unilateral/bilateral).

Methods

In 48 ambulatory persons aged 16 to 24 years with spastic CP and in 32 able-bodied controls, physical behaviour was objectively determined with an accelerometer-based activity monitor. Total duration, intensity and type of physical activity were assessed and sedentary time was determined (lying and sitting). Furthermore, distribution of walking bouts and sitting bouts was specified.

Results

Adolescents and young adults with CP spent 8.6% of 24 hours physically active and 79.5% sedentary, corresponding with respectively 123 minutes and 1147 minutes per 24 hours. Compared to able-bodied controls, persons with CP participated 48 minutes less in physical activities (p < 0.01) and spent 80 minutes more sedentary per 24 hours (p < 0.01). Physical behaviour was not different between persons with GMFCS level I and II and only number of short sitting bouts were significantly more prevalent in persons with bilateral CP compared to unilateral CP (p < 0.05).

Conclusions

Ambulatory adolescents and young adults with CP are less physically active and spend more time sedentary compared to able-bodied persons, suggesting that this group may be at increased risk for health problems related to less favourable physical behaviour.

Trial registration

Nederlands trial register: NTR1785

Obesity misclassification and the metabolic syndrome in adults with functional mobility impairments: Nutrition Examination Survey 2003-2006

OBJECTIVES

The purpose of this study was to estimate the degree of obesity misclassification between body mass index (BMI) and body fat percentage in adults with functional mobility impairment, and to determine cardiometabolic risk profiles.

METHODS

Data from the combined 2003-2006 National Health and Nutrition Examination Survey (NHANES) were incorporated. The representative sample included 852 individuals, aged 20-85years, reporting at least one major physical limitation related to mobility or lower body function, and 4724 individuals reporting no impairments. Body mass index, percent body fat (%BF) as determined by dual energy X-ray absorptiometry (DXA), objectively measured sedentary behavior and activity, and markers of cardiometabolic risk were compared between adults with and without functional mobility impairments. Among functional mobility impaired individuals, sensitivity, specificity, and receiver operating characteristic curves were used to evaluate the performance of BMI as a continuous variable, as well as various BMI thresholds to detect obesity defined by sex-specific %BF cutoffs.

RESULTS

Adults with functional mobility impairments were older, had larger waist circumferences (WC), had greater prevalence of obesity according to BMI and %BF, were more sedentary, had less physical activity, and had higher overall cardiometabolic risk. The standard BMI cutoff for obesity had excellent specificity in both men (100%) and women (98.4%) with functional mobility impairment, but sensitivity was poor (<55%). Whereas approximately 36% and 43% of impaired men and women fell into the obese BMI category, over 80% of men and women were obese according to %BF. Individuals with high %BF who were misclassified as not obese, according to BMI, had a significantly higher prevalence of the metabolic syndrome (17.6%) compared to subjects with normal BMI and low %BF (2.1%).

CONCLUSIONS

Obesity misclassification and cardiometabolic risk are prevalent among individuals with functional mobility impairments, and thus diagnostic screening for obesity should be modified to account for %BF and/or waist circumference. Behavioral interventions to decrease sedentary behavior, increase activity, and reduce abdominal obesity are warranted.

A path model for evaluating dosing parameters for children with cerebral palsy

Dosing of pediatric rehabilitation services for children with cerebral palsy (CP) has been identified as a national priority. Establishing dosing parameters for pediatric physical therapy interventions is critical for informing clinical decision making, health policy, and guidelines for reimbursement. The purpose of this perspective article is to describe a path model for evaluating dosing parameters of interventions for children with CP. The model is intended for dose-related and effectiveness studies of pediatric physical therapy interventions. The premise of the model is: Intervention type (focus on body structures, activity, or the environment) acts on a child first through the family, then through the dose (frequency, intensity, time), to yield structural and behavioral changes. As a result, these changes are linked to improvements in functional independence. Community factors affect dose as well as functional independence (performance and capacity), influencing the relationships between type of intervention and intervention responses. The constructs of family characteristics; child characteristics (eg, age, level of severity, comorbidities, readiness to change, preferences); plastic changes in bone, muscle, and brain; motor skill acquisition; and community access warrant consideration from researchers who are designing intervention studies. Multiple knowledge gaps are identified, and a framework is provided for conceptualizing dosing parameters for children with CP.