Risk of Depression and Anxiety in Adults With Cerebral Palsy

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

BACKGROUND

Chronic pain is common among adults with cerebral palsy (CP) and an area of priority for research and treatment.

OBJECTIVE

Describe the pain experience and its functional and quality of life impact among adults with CP with chronic pain in the community.

METHODS

Cross-sectional analysis of adult patient-reported outcomes collected by the Cerebral Palsy Research Network Community Registry.

RESULTS

Among all participants in the Community Registry, n = 205 reported having chronic pain, and 73 % of those (n = 149) completed the Chronic Pain Survey Bundle (75 % female; mean age 43 years (SD 14 years); 94 % White; 91 % non-Hispanic). Back and weight-bearing joints of lower extremities were most frequently reported as painful. There were no differences in average pain severity scores between varying GMFCS levels (H = 6.25, p = 0.18) and age groups (H = 3.20, p = 0.36). Several nonpharmacologic interventions were most frequently reported as beneficial. Participants with moderate to severe average pain scores (5-10) had higher levels of pain interference (p < 0.01) and depression (p < 0.01), and lower levels of satisfaction with social roles (p < 0.01) and lower extremity function (p < 0.01). Pain interference was significantly positively correlated with depression, and negatively correlated with upper and lower extremity function and satisfaction with social roles.

CONCLUSIONS

Chronic pain is experienced by adults with CP of varying ages and functional levels and is associated with several adverse quality of life and functional outcomes. Improved understanding of chronic pain in this population will facilitate the development and study of treatment interventions optimizing health, function, participation, and quality of life.

Enhanced EEG power density during painful stretching in individuals with cerebral palsy

BACKGROUND

Pain perception mechanisms in cerebral palsy remain largely unclear.

AIMS

This study investigates brain activity in adults with cerebral palsy during painful and non-painful stretching to elucidate their pain processing characteristics.

METHODS AND PROCEDURES

Twenty adults with cerebral palsy and 20 controls underwent EEG in three conditions: rest, non-painful stretching, and painful stretching. Time-frequency power density of theta, alpha, and beta waves in somatosensory and frontal cortices was analyzed, alongside baseline pressure pain thresholds.

OUTCOMES AND RESULTS

Cerebral palsy individuals exhibited higher theta, alpha, and beta power density in both cortices during painful stretching compared to rest, and lower during non-painful stretching. Controls showed higher power density during non-painful stretching but lower during painful stretching. Cerebral palsy individuals had higher pain sensitivity, with those more sensitive experiencing greater alpha power density.

CONCLUSIONS AND IMPLICATIONS

These findings confirm alterations in the cerebral processing of pain in individuals with cerebral palsy. This knowledge could enhance future approaches to the diagnosis and treatment of pain in this vulnerable population.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A co-designed mixed methods study on community-based gym exercise for non-ambulant adults with childhood onset disability

PURPOSE

Explore community-based gym exercise for non-ambulant adults with childhood-onset disability.

MATERIALS AND METHODS

Non-ambulant adults with childhood-onset disability participated in four, weekly gym sessions co-facilitated by physiotherapists and exercise professionals. Practicalities of participating in the sessions were recorded via uptake and attrition, weekly surveys, and focus groups. Perspectives of those who designed/delivered the study were gathered via weekly debrief meetings. Quantitative data were analysed descriptively, qualitative data were analysed thematically.

RESULTS

Ten non-ambulant adults with childhood-onset disability participated; 70% completed all exercise sessions. Focus groups identified three themes. "I wouldn't be able to exercise…there's no option for a community-based setting" described the lack of opportunities for exercise in gyms. "You don't realise the benefit of coming here" highlighted benefits of exercise. "We can do better" had two sub-themes: problem solving and ingredients for community-based gym exercise. Weekly feedback and debrief meetings identified practicalities related to equipment, exercises, and collaborative working between facilitators.

CONCLUSIONS

Whilst there is an interest in community-based gym exercise for non-ambulant adults with childhood-onset disability, there remains a lack of inclusive gyms. Co-design of inclusive gym guidelines and condition-specific physical activity referral scheme may enhance opportunities for participation in gym exercise for adults with childhood-onset disability.

Experiences of young adults with cerebral palsy in pediatric care transitioning to adult care

AIM

To increase understanding regarding the experiences and values of young adults with cerebral palsy (CP), and their caregivers, regarding pediatric rehabilitation-related care, including perceived barriers and potential facilitators to transition to adult care.

METHOD

This was a qualitative descriptive study that used 20 semi-structured interviews (13 caregivers and seven patient-caregiver dyads).

RESULTS

We identified four major themes: (1) the value and security of long-term relationships; (2) feeling 'rudderless' navigating the logistics of transition; (3) differences in pediatric versus adult models of care; and (4) perceived lack of provider expertise and comfort in adult care settings. Young adults with CP who had not yet transitioned to adult rehabilitation care and their caregivers placed high value on provider relationships and expertise, advanced planning, communication, and coordination of care.

INTERPRETATION

Identified barriers and potential facilitators to the transition to adult rehabilitation care reflected the uncertainty that accompanies leaving an established healthcare relationship. Challenges related to the logistics of this transition, differences in models of care, and perceived lack of provider comfort and expertise in adult care settings were also noted. Our findings could be used to develop and study patient-centered and family-centered transition processes for individuals with CP to promote age-appropriate and developmentally appropriate lifespan care.

Satisfaction with health care services in young people with cerebral palsy in the transition period: results from a European multicenter study

Background

Young people with chronic health conditions and disabilities rely on the healthcare system to maintain their best possible health. The appropriate delivery and utilization of healthcare services are key to improve their autonomy, self-efficacy and employment outcomes. The research question of our study is directed toward investigating if poor availability and accessibility of healthcare services in general, as identified by unmet needs in healthcare, are associated with dissatisfaction with healthcare.

Methods

Within a European multicenter observational study, 357 young adults with cerebral palsy aged 19-28 were included. We assessed special healthcare needs, utilization of healthcare services, and satisfaction with healthcare applying the short-form of the YHC-SUN-SF, environmental and social variables (EAEQ) as well as indicators for severity of condition and functionality (e.g., GMFCS) of these participants based on a self-, assisted self- or proxy-reports. We used correlation analyses to explore associations between satisfaction with healthcare and respective indicators related to availability and accessibility of healthcare services as well as severity of the condition. In addition, we included reference values for satisfaction with heath care from young adults with various chronic conditions assessed within population-based surveys from some of the European countries included in the study.

Results

We identified several unmet healthcare needs, especially for widely used and established services (e.g., physical therapy). Satisfaction with healthcare (YHC-SUN-SF general and subscale scores) was moderate to high and almost consistently better for the sample of young adults with cerebral palsy as compared to reference values for young adults with various chronic conditions assessed within general population surveys). Correlation coefficients between satisfaction with healthcare and utilization of services and (unmet) healthcare needs were low, also with different indicators for severity of the condition or functionality.

Conclusion

Young adults with cerebral palsy reports of unmet healthcare needs varied largely but showed substantial deficits in some aspects. This seems to have no impact on the satisfaction with healthcare those patients currently receive. We conclude that these are two different constructs and somewhat independent indicators to evaluate the quality of healthcare. Clinicians and other practitioners should consider this distinction when monitoring patient needs in their daily practice.

Pain coping and catastrophizing in youth with and without cerebral palsy

OBJECTIVES

The aim of this study is to compare the use of pain coping strategies and pain catastrophizing in youth with and without cerebral palsy (CP), and to examine how these two groups differ with respect to the associations between pain coping, catastrophizing, and measures of psychological function and sleep disturbance.

METHODS

Twenty-seven individuals with CP and 49 healthy controls aged 15-22 were included in this cross-sectional observational study. Pain was assessed using a semi-structured interviews and participants completed measures of pain coping, pain catastrophizing, psychological function, and sleep.

RESULTS

Youth with CP used information seeking and problem solving (p = 0.003, Cohen's d (d) = -0.80) and sought social support (p = 0.044, d = -0.51) less often, and used internalizing as a coping strategy more often (p = 0.045, d = 0.59) than healthy controls. The use of information seeking and problem solving correlated more strongly with measures of depression (p = 0.023, Cohen's f (f) = 0.08) and sleep disturbance (p = 0.022, f = 0.08), while behavioral distraction correlated more strongly with measures of anxiety (p = 0.006, f = 0.11) and sleep disturbance (p = 0.017, f = 0.09) in youth with CP, compared to healthy controls.

CONCLUSIONS

The study findings raise the possibility that youth with CP may benefit more in terms of psychological function and sleep quality from coping training interventions that focus on behavioral distraction, information seeking, and problem solving. Research to test these ideas in additional samples of youth with CP is warranted.

Measuring grip strength in adolescents and adults with cerebral palsy in a clinic setting: Feasibility, reliability, and clinical associations

AIM

To determine the feasibility and reliability of measuring grip strength and its association with anthropometrics and diseases among adolescents and adults (≥16 years old) with cerebral palsy (CP).

METHOD

In this cross-sectional study, individuals with CP, classified in Gross Motor Function Classification System (GMFCS)/Manual Ability Classification System (MACS) levels I to V, were recruited to measure grip strength, anthropometrics, and self-reported current/history of disease during a routine clinical visit. Feasibility was determined as the proportion recruited/consented/completed testing. Test-retest reliability of three maximal effort trials per side was assessed. Linear regression determined associations of grip strength with anthropometrics after adjusting for age, sex, and GMFCS. The predictive ability of GMFCS alone, grip strength alone, GMFCS + grip strength, and GMFCS × grip strength for diseases was compared.

RESULTS

Of 114 individuals approached, 112 participated and 111 successfully completed all tasks. There was good to excellent reliability of test-retest grip strength between trials for dominant and non-dominant sides for the entire cohort and when stratified by each GMFCS and MACS level (intraclass correlation coefficient range 0.83-0.97). Sex, GMFCS, MACS, body mass, and waist circumference were associated with grip strength (p < 0.05), but not hip circumference, waist:hip ratio, or triceps skinfold thickness. Modeling grip strength with GMFCS had a higher predictive value for relevant diseases than GMFCS alone.

INTERPRETATION

Grip strength is a feasible and reliable measurement for CP, and is associated with some demographics and anthropometric measures. Grip strength, in addition to the GMFCS, enhanced prediction of disease outcomes.

WHAT THIS PAPER ADDS

Measurement of hand grip strength is clinically feasible for adolescents/adults with cerebral palsy. Grip strength has good to excellent test-retest reliability across Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) levels. Grip strength is associated with sex, weight, waist circumference, GMFCS, and especially MACS. Grip strength, in addition to GMFCS, shows promise for enhancing disease prediction in this cohort.

Evaluation of a Modified Mindfulness-Based Stress Reduction Intervention for Adults with Cerebral Palsy and Anxiety and/or Emotion Regulation Difficulties-A Randomised Control Trial

Mindfulness-Based Stress Reduction (MBSR) has not yet been evaluated for people with cerebral palsy (CP). The aims of this randomised control trial were to investigate whether a modified telehealth MBSR program could improve mindfulness and reduce depression, anxiety, and emotion regulation difficulties among adults with CP with elevated anxiety and/or emotional regulation difficulties. Participants (n = 31) with elevated anxiety and/or emotion regulation difficulties and no/mild intellectual impairment were randomised to a modified telehealth MBSR program (90 min weekly, 9 weeks) group or a wait-list group. Measurements were collected prior to (T1), after (T2), and 8 weeks post-intervention (T3). The primary outcome was the mean between-group difference in the change in Cognitive and Affective Mindfulness Scale-R (CAMS-R) scores in T1-T2. The secondary outcomes included mean within-group differences over time for the CAMS-R total scores, Depression Anxiety and Stress Scale-21 subscales, and Difficulties in Emotion Regulation Scale (DERS) total t-score. We found no statistically significant between-group difference in mean change in mindfulness scores for T1-T2 (primary outcome). Secondary outcomes: The MBSR intervention group had improved CAMS-R scores with respect to T1-T2 and T1-T3; improved mean scores for Depression and Stress subscales for T1-T2; and improved DERS t-scores for T1-T2 and T1-T3. In conclusion, this study found no significant between-group difference for the primary outcome of mindfulness. The MBSR program was successfully modified for adults with CP and was effective in improving depression, stress, and emotion regulation. ACTRN12621000960853.

Nationwide trends in the prevalence and incidence of depressive disorders and their correlates among adults with disabilities in Korea from 2006 to 2017

BACKGROUND

Evidence suggests that people with disabilities are more likely to suffer from depression. Previous studies have focused on depressive disorders in specific disability types or age groups using small-scale cross-sectional samples. We investigated longitudinal trends in the prevalence and incidence of depressive disorders according to disability types and severity levels in the entire Korean adult population.

METHODS

The age-standardised prevalence and incidence of depressive disorders were investigated using National Health Insurance claims data from 2006 to 2017. The odds of depressive disorders by type and severity were examined using logistic regression after adjusting for sociodemographic characteristics and comorbidities based on merged 2006 to 2017 data.

RESULTS

Both the incidence and prevalence of depressive disorders were higher among the disabled than the non-disabled, with the prevalence gap being larger than the incidence gap. In regression analyses, adjusting for sociodemographic characteristics and comorbidities considerably reduced the odds ratios, particularly for incidence. The severity of disabilities was inversely associated with the incidence of depressive disorders. Brain injury and disabilities in major internal organs were associated with lower odds of developing depressive disorders than in non-disabled individuals.

CONCLUSIONS

A significant proportion of depressive disorders in disabled individuals are caused by financial hardships or comorbidities rather than disabilities themselves. We must pay special attention to those who cannot access healthcare services due to severe disabilities and those whose depressive disorders are misdiagnosed as intellectual disabilities. More research is required to elucidate the causal mechanisms underlying depressive disorders in people with various types and severities of disabilities.

Adults with Cerebral Palsy: Navigating the Complexities of Aging

The goal of this narrative review is to highlight the healthcare challenges faced by adults with cerebral palsy, including the management of long-term motor deficits, difficulty finding clinicians with expertise in these long-term impairments, and scarcity of rehabilitation options. Additionally, this narrative review seeks to examine potential methods for maintaining functional independence, promoting social integration, and community participation. Although the brain lesion that causes the movement disorder is non-progressive, the neurodevelopmental disorder worsens from secondary complications of existing sensory, motor, and cognitive impairments. Therefore, maintaining the continuum of care across one's lifespan is of utmost importance. Advancements in healthcare services over the past decade have resulted in lower mortality rates and increased the average life expectancy of people with cerebral palsy. However, once they transition from adolescence to adulthood, limited federal and community resources, and health care professionals' lack of expertise present significant obstacles to achieving quality healthcare and long-term benefits. This paper highlights the common impairments seen in adults with cerebral palsy. Additionally, it underscores the critical role of long-term healthcare and management to prevent functional decline and enhance quality of life across physical, cognitive, and social domains.

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

Introduction

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

Materials and methods

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

Results

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

Conclusions

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

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

Physical activity of a sufficient amount and intensity is essential to health and the prevention of a sedentary lifestyle in all children as they transition into adolescence and adulthood. While fostering a fit lifestyle in all children can be challenging, it may be even more so for those with cerebral palsy (CP). Evidence suggests that bone and muscle health can improve with targeted exercise programs for children with CP. Yet, it is not clear how musculoskeletal improvements are sustained into adulthood. In this perspective, we introduce key ingredients and guidelines to promote bone and muscle health in ambulatory children with CP (GMFCS I-III), which could lay the foundation for sustained fitness and musculoskeletal health as they transition from childhood to adolescence and adulthood. First, one must consider crucial characteristics of the skeletal and muscular systems as well as key factors to augment bone and muscle integrity. Second, to build a better foundation, we must consider critical time periods and essential ingredients for programming. Finally, to foster the sustainability of a fit lifestyle, we must encourage commitment and self-initiated action while ensuring the attainment of skill acquisition and function. Thus, the overall objective of this perspective paper is to guide exercise programming and community implementation to truly alter lifelong fitness in persons with CP.

Lifelong Fitness in Ambulatory Children and Adolescents with Cerebral Palsy II: Influencing the Trajectory

Physical activity of at least moderate intensity in all children contributes to higher levels of physical and psychological health. While essential, children with cerebral palsy (CP) often lack the physical capacity, resources, and knowledge to engage in physical activity at a sufficient intensity to optimize health and well-being. Low levels of physical activity place them at risk for declining fitness and health, contributing to a sedentary lifestyle. From this perspective, we describe a framework to foster a lifelong trajectory of fitness in ambulatory children with CP (GMFCS I-III) as they progress into adolescence and adulthood, implemented in conjunction with a training program to augment bone and muscle health. First, we recommend that altering the fitness trajectory of children with CP will require the use of methods to drive behavioral change prior to adolescence. Second, to promote behavior change, we suggest embedding lifestyle intervention into fitness programming while including meaningful activities and peer socialization to foster self-directed habit formation. If the inclusion of lifestyle intervention to drive behavior change is embedded into fitness programs and found to be effective, it may guide the delivery of targeted programming and community implementation. Participation in comprehensive programming could alter the long-term trajectory of musculoskeletal health while fostering strong self-efficacy in persons with CP.

Serotonin syndrome from combination hydrocodone and cyclobenzaprine in a patient with cerebral palsy

Aim: Serotonin syndrome (SS) is a life-threatening syndrome that occurs with the use of serotonergic drugs, most commonly due to two or more agents. Cerebral palsy is associated with mood disorders, and more commonly pain, with a prevalence of up to 50-80%. Case presentation: A 58-year-old female with cerebral palsy, metastatic malignancy and mood disorder who presented to the emergency department with acute-on-chronic pain, and signs of SS. She was initiated on iv. dilaudid, titrated off oral medications and scheduled for a left-sided sacroiliac joint injection. Results: It was suspected that due to additional doses of hydrocodone and cyclobenzaprine, she developed moderate-SS. Conclusion: Physicians need to be cognizant of comorbidities and uncommon pain medications that can predispose patients to SS.

Mental health problems among transition-aged youth with physical disabilities: an initial evaluation

Aim

Decreased participation and complex transitions into adulthood among youth with disabilities may impede their well-being. To advance knowledge on the co-occurrence of mental health problems and physical disability, this brief report describes the frequency of mental health problems, measured by the Behavior Assessment System of Children (BASC-3), among transition-aged youth (14-25 years) with physical disabilities and examines the association between mental health problems and sex, age, and number of functional issues.

Methods

Thirty-three participants completed a demographic questionnaire and the BASC-3. Frequency of BASC-3 scales falling within 3 categories: "within norms", "at risk", and "clinically significant" were described. Crosstabs and Chi-square tests were used to examine the association between BASC-3 scales and sex, age (< and ≥ 20), and number of functional issues (< and ≥ 6).

Results

Overall, "somatization", "self-esteem", "depression" and "sense of inadequacy" were the most common subscales being at risk. Participants with a higher number of functional issues (≥6) were more likely to fall within "at risk" or "clinically significant" categories across 20 (out of 22) BASC-3 scales, and female participants tended to fall more within "at risk" or "clinically significant" categories for 8 of BASC-3 scales. Younger participants (<20) were ranked in the "at risk" or "clinically significant" categories for 7 scales.

Conclusions

Findings lend further support for the occurrence of mental health problems emerging in youth with physical disabilities and highlight initial trends especially across functional levels. Further investigation of such co-occurrences and the factors that affect their development is needed.

Coping with the COVID-19 pandemic by Paralympic athletes preparing for elite sport events: A longitudinal study

INTRODUCTION

This study investigates the impact of the COVID-19 pandemic on mental health, coping styles and their relationship, and training opportunities in elite athletes with disabilities (AwD) preparing for national and international sport events during a ten-month observation period.

METHODS

The study covered four time points in 3-month intervals, one retrospective, and three times during the 10 months of the pandemic period with diversified numbers of average new infections per day: A-pre-pandemic, B-third wave of the pandemic (mean = 15 681), C-decrease of the pandemic (mean = 102), and D-fourth wave of the pandemic (mean = 22 591). Main outcome measures included the Coping Inventory for Stressful Situations and the Hospital Anxiety and Depression Scale.

RESULTS

The models regarding changes in anxiety (F_(3,72)  = 22.43; p < 0.001; partial η2 = 0.48) and depression (F_(3,72)  = 23.82; p < 0.001; partial η²  = 0.50) over the four time points of examination were significant. The pattern of relationship between coping styles and mood changes during COVID-19 pandemic periods, that is, a sudden increase in anxiety during dynamic growth of infections (waves of a pandemic) and a steady increase in depression over the course of the pandemic was not found. The difference in planned and actual training decreased significantly over time (p < 0.001).

CONCLUSIONS

During the transitionary times of the COVID-19 pandemic, both mental health and training opportunities of AwD were at increased risk. Individual coping styles used by AwD were insufficient resources to cope with the extreme stress caused by the COVID-19 pandemic. Their mental health should be monitored in pandemics and similar situations to ensure appropriate and timely organizational and psychological intervention.

Understanding physiotherapy and physiotherapy services: exploring the perspectives of adults living with cerebral palsy

PURPOSE

To understand physiotherapy and physiotherapy services from the perspectives of adults with cerebral palsy (CP).

METHODS

Twenty-two adults with CP (15 women, 7 men), from across the UK, aged between 23 and 51 years, Gross Motor Function Classification System I-V, were interviewed about their experiences of physiotherapy and physiotherapy services. Participants were recruited through advertisements placed with relevant national organisations. The interviews were transcribed and analysed according to principles of Reflective Lifeworld Research. A second analysis examined the findings in relation to Donabedian's structure-process-outcome framework for healthcare quality.

RESULTS

Specialist services for adults with CP were described as scarce, unknowable, complex and disconnected through the life course. Specific problems included; structural dimensions such as access to and organisation of services, signposting to services and access to expert advice; process dimensions including a lack of attention to patients' perspectives, needs, priorities, experience and expertise; and outcome dimensions for example the negative impact of physiotherapy service configurations on health, well-being and quality of life.

CONCLUSION

Study findings support grassroots calls to radically improve and increase physiotherapy services for adults with CP. Accessible and widely available specialist services, information and advice across the life course would do much to address unmet need. Implications for RehabilitationAdults with CP found it difficult to identify and access specialised physiotherapy services and to obtain information and advice to help them best manage their condition.Adults with CP need physiotherapy services throughout the different phases of their lives, to meet their present needs, and to anticipate and, where possible, to prevent future needs.Participants highly valued person-centred physiotherapy and we recommend this approach is adopted as the foundational philosophy guiding physiotherapy services and interventions for adults with CP.More specialist physiotherapy services are urgently needed to meet the needs of adults with CP in the UK.

Emotion Regulation Is Associated with Anxiety, Depression and Stress in Adults with Cerebral Palsy

Emotion regulation difficulties are associated with many neurological conditions and negatively impact daily function. Yet little is known about emotion regulation in adults with cerebral palsy (CP). Our aim was to investigate emotion regulation in adults with CP and its relationship with condition-related and/or socio-demographic factors. In a cross-sectional study of adults with CP, participants completed a survey containing the Difficulties in Emotion Regulation Scale (DERS), Depression Anxiety and Stress Scale-21 (DASS-21), and socio-demographic and condition-related questions. Descriptive statistics, chi-squared and Mann–Whitney tests were performed. Of the 42 adults with CP (x31.5 years, SD13.5) that were tested, 38 had within normal limits DERS total scores; however, a significantly higher proportion of participants experienced elevated scores (i.e., more difficulties with emotion regulation) than would be expected in the general population across five of the six DERs subdomains. Moderate–extremely severe depression and anxiety symptoms were reported by 33% and 60% of participants, respectively. The DERS total scores for participants with elevated depression, anxiety, and stress scores were significantly higher than the DERS totals score for those without elevated depression, anxiety, and stress scores. DERS and DASS-21 scores did not differ significantly by condition-related nor socio-demographic characteristics. In conclusion, emotion regulation difficulties were associated with elevated symptoms of depression and anxiety, which were overrepresented in the adults with CP participating in this study.

Prevalence and incidence of chronic conditions among adults with cerebral palsy: A systematic review and meta-analysis

AIM

To assess the prevalence and incidence of chronic conditions among adults with cerebral palsy (CP) and compare them to the prevalence and incidence among adults without CP.

METHOD

We searched MEDLINE and Embase for studies reporting the prevalence or incidence of one or more chronic conditions among adults with CP. Two independent reviewers screened titles, abstracts, and full-text articles. Two independent reviewers extracted data relating to prevalence and incidence and appraised study quality. We performed random-effects meta-analyses to pool prevalence and incidence.

RESULTS

We identified 69 studies; 65 reported the prevalence of 53 conditions and 13 reported the incidence of 21 conditions. At least 20% of adults had the following conditions: depression (21%); anxiety (21%); mood affective disorders (23%); asthma (24%); hypertension (26%); epilepsy (28%); urinary incontinence (32%); malnutrition (38%); and scoliosis (46%). Adults with CP were more likely to have type 2 diabetes, anxiety, bipolar disorder, depression, schizophrenia, hypertension, ischaemic heart disease, stroke, cerebrovascular disease, asthma, liver disease, osteoarthritis, osteoporosis, underweight, and chronic kidney disease than adults without CP.

INTERPRETATION

These data from 18 countries, which provide an international perspective, may be used to promote awareness, identify targets for intervention, and inform the development of appropriate supports for adults with CP.

Transition to adult services experienced by young people with cerebral palsy: A cross-sectional study

AIM

To assess if young people with cerebral palsy experience and health professionals provide practices that may improve transition from child to adult health services.

METHOD

Seventy-five young people (31 females, 44 males; mean age 18 years 5 months [standard deviation 2 years 2 months]) and/or parents and 108 health professionals completed a questionnaire describing their experience or the provision of nine transition practices.

RESULTS

The percentage of young people reporting each practice was: appropriate parent involvement (90%); promotion of health self-efficacy (37%); named worker who supports the transition process (36%); self-management support for physical health (36%); self-management support for mental health (17%); information about the transition process (24%); meeting the adult team (16%); and life skills training (16%). Post-discharge, 10% of young people reported that their general practitioner (GP) received a discharge letter. The percentage of health professionals reporting each practice was: promotion of health self-efficacy (73.2%); self-management support (73.2%); information (69%); consulting the parent and young person about parent involvement (63% and 66%); discharge letter to a GP (55%); life skills training (36%); named worker (35%); meeting the adult team (30%); and senior manager (20%).

INTERPRETATION

Many young people did not experience practices that may improve the experience and outcomes of transition. Young people should be involved in the development and delivery of transition to ensure it meets their needs.

WHAT THIS PAPER ADDS

Many young people with cerebral palsy (CP) do not receive support that may improve the experience of transition. Appropriate protocols and training for health professionals may improve the provision of transition and reduce inconsistency in care between and within organizations. Young people and their families should be involved in service design, delivery, and evaluation related to the transition to ensure it meets their needs.

Differences in suicide risk correlates and history of suicide ideation and attempts as a function of disability type

BACKGROUND

Disability status is associated with correlates of suicide risk (perceived burdensomeness, thwarted belongingness, negative future disposition, felt stigma, suicidal ideation, and suicide attempts).

AIMS

This study aimed to examine whether suicide-related correlates differ significantly as a function of disability type.

METHODS

Individuals with mobility and vision disabilities (N = 102) completed semistructured interviews and online-based questionnaires. Analysis of variance/analysis of covaiance and Fisher's exact tests were conducted to examine whether mean levels of suicide-related correlates differed significantly between individuals with blindness/low vision (n = 63) versus mobility-related (n = 39) disabilities.

RESULTS

No significant between-group differences were observed for most outcomes; however, individuals with vision disabilities reported higher mean levels of felt stigma and positive future disposition than those with mobility-related disabilities.

LIMITATIONS

The limited representation of disabilities among participants precludes generalization to individuals with other forms of disability and the cross-sectional design prevents inference about causality.

CONCLUSIONS

Interventions targeting cognitive processes that underlie suicide risk may be applicable to people with mobility and vision disabilities.

MENTAL HEALTH, QUALITY OF LIFE, SPIRITUAL DRYNESS AND ACEDIA SYMPTOMS IN PATIENTS SUFFERING FROM CHRONIC DISEASES

OBJECTIVE

The aim of the present study is to examine mental health, quality of life, acedia and spiritual dryness in patients suffering from chronic diseases.

PATIENTS AND METHODS

Materials and method: Data were collected by special design instrument for the needs of the present study. Descriptive statistics and inferential statistics were applied and the analysis was carried out with IBM SPSS 26 and JASP 0.14.01.

RESULTS

Results: From the total of 210 participants, 106 (50.4%) were male, the mean age was 62.9 years, and the majority of them were diagnosed with type 2 diabetes. 50 (23.8%) of the participants suffer from anxiety and 39 (18.6%) from depression. In addition, 17.1% experience phases of spiritual dryness frequently or regularly. Physical quality of life component, was associated with the following variables: live from faith, psychological wellbeing, type of disease and age. This model can predict 31.1% of the variance. In terms of psychological wellbeing, the variables living arrangement, awe/gratitude, anxiety, and spiritual dryness can interpret 41.5% of the variance. When it comes to depression, we found that wellbeing, awe/gratitude are predictors of depressive symptoms, explaining at least 14.1% of the variance. Finally, anxiety can be predicted by wellbeing, awe/gratitude, and the type of the disease, interpreting 17.2% of the variance.

CONCLUSION

Conclusions: Patients suffering from chronic diseases are experiencing spiritual dryness and acedia symptoms, and those aspects can be associated with various domains of health and wellbeing.

Effects of MgSO4 Alone or Associated with 4-PBA on Behavior and White Matter Integrity in a Mouse Model of Cerebral Palsy: A Sex- and Time-Dependent Study

Cerebral palsy (CP) is defined as permanent disorders of movement and posture. Prematurity and hypoxia-ischemia (HI) are risk factors of CP, and boys display a greater vulnerability to develop CP. Magnesium sulfate (MgSO₄) is administered to mothers at risk of preterm delivery as a neuroprotective agent. However, its effectiveness is only partial at long term. To prolong MgSO₄ effects, it was combined with 4-phenylbutyrate (4-PBA). A mouse model of neonatal HI, generating lesions similar to those reported in preterms, was realized. At short term, at the behavioral and cellular levels, and in both sexes, the MgSO₄/4-PBA association did not alter the total prevention induced by MgSO₄ alone. At long term, the association extended the MgSO₄ preventive effects on HI-induced motor and cognitive deficits. This might be sustained by the promotion of oligodendrocyte precursor differentiation after HI at short term, which led to improvement of white matter integrity at long term. Interestingly, at long term, at a behavioral level, sex-dependent responses to HI were observed. This might partly be explained by early sex-dependent pathological processes that occur after HI. Indeed, at short term, apoptosis through mitochondrial pathways seemed to be activated in females but not in males, and only the MgSO₄/4-PBA association seemed to counter this apoptotic process.

Incidence of anxiety and depression in children and young people with life-limiting conditions

BACKGROUND

The aim of this study was to investigate the incidence of anxiety and depression in children and young people with life-limiting conditions.

METHODS

A comparative cohort study was conducted, using primary and secondary care data from the Clinical Practice Research Datalink (CPRD) in England. Anxiety and depression codes were identified using diagnostic, symptom and prescription codes. Incidence rates of anxiety and depression were compared across condition groups using Poisson regression, adjusting for sex, age, ethnicity, and deprivation status.

RESULTS

A total of 25,313 children and young people were included in the study: 5527 with life-limiting conditions, 6729 with chronic conditions, and 13,057 with no long-term conditions. The incidence of anxiety (IRR_adj: 1.39, 95% CI: 1.09-1.77) and depression (IRR_adj: 1.41, 95% CI: 1.08-1.83) was significantly higher in children and young people with life-limiting conditions, compared to children and young people with no long-term conditions.

CONCLUSIONS

The higher incidence of anxiety and depression observed among children and young people with life-limiting conditions highlights the need for psychological support in this population, including further efforts to prevent, identify, and treat anxiety and depression.

IMPACT

The analysis of primary and secondary healthcare data from England revealed that the incidence of anxiety and depression was higher among children and young people with life-limiting conditions, compared to those with no long-term conditions. This is the first study to investigate the incidence of anxiety and depression in children and young people with a wide range of life-limiting conditions. The higher incidence of anxiety and depression observed in children and young people with life-limiting conditions highlights the need for psychological support aiming to prevent, identify, and treat anxiety and depression in this population group.

Underlying Causes of Death among Adults with Cerebral Palsy

Background: Adults with cerebral palsy (CP) represent a growing population whose healthcare needs are poorly understood. The purpose of this study was to examine trends in the underlying causes of death (UCOD) among adults with CP in the United States. Methods: A national cohort was created from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (WONDER) database from 1999 to 2019. The UCOD was determined using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10 code G80x, Infantile CP) based on death certificate adjudication. Crude and age-adjusted mortality rates (AAMRs), as well as 95% confidence intervals (CIs) were calculated for adults with CP. Results: There were 25,138 deaths where CP was listed as the UCOD between 1999–2019. There was a steady increase in the UCOD attributable to CP in both crude mortality rates and AAMRs, with the highest rates occurring in 2019. The highest co-occurring secondary causes of death were other diseases of the nervous system (e.g., epilepsy), diseases of the respiratory system (e.g., pneumonia), symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (e.g., dysphagia), and diseases of the circulatory system (e.g., cardiovascular disease). Conclusions: Listing the UCOD as CP should be accompanied by other mechanisms leading to mortality in this population.

Psychiatric symptoms in adult patients with cerebral palsy: A cohort study

Background

Patients with cerebral palsy (CP) have an increased risk of developing mental health disorders.

Aims

This paper is aimed to investigate the occurrence of psychiatric symptoms in adults with CP and to explore the relation between clinical and psychosocial variables.

Methods and procedures

We included 199 adults with a diagnosis of CP. The chi-square and the Mann-Whitney U tests were used to compare clinical and psychosocial variables, the level of perceived disability, and the type of observed parental style in patients with and without psychiatric symptoms. Logistic regression analysis was used to identify variables that could predict the occurrence of mental health disorders.

Outcome and results

Anxiety and psychosis were the most represented disorders. Age, living status, assumption of drugs, motor, manual, and global impairment were significantly different between patients with and without psychiatric symptoms. Similarly, a different parental style was observed between the two groups. Logistic regression indicated that living status, prescribed drugs, parental style, and the perceived disability in getting along with others predicted the occurrence of psychiatric symptoms.

Conclusions and implications

Results suggest that patients with and without psychiatric symptoms have different clinical and psychosocial characteristics. Some variables should be considered as potentially affecting the mental health of patients with CP.

Increased Sensitivity to Serotonin Syndrome in Cerebral Palsy

Serotonin syndrome is characterized by symptoms of neuromuscular and autonomic excitation and altered mental status. It is most often drug induced with antidepressants being the main precipitants. However, other classes have been implicated as well including antipsychotics, antiemetic and pain medications, and lithium. The syndrome is typically induced by the combination of two or more serotonergic agents; however, there have been instances of serotonin syndrome occurring while a patient is on a single medication. The literature is limited regarding the study of risk factors associated with the production of serotonin syndrome while on only monotherapy or otherwise atypically causative agents. One such risk factor may be underlying neuromuscular pathology. This study is the first case series to our knowledge reporting two separate cases of serotonin syndrome being induced in patients with cerebral palsy as an underlying common factor.

Musculoskeletal Morbidity Among Adults Living With Spina Bifida and Cerebral Palsy

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Unmet Health Needs among Young Adults with Cerebral Palsy in Ireland: A Cross-Sectional Study

Data describing the unmet health needs of young adults with cerebral palsy (CP) may support the development of appropriate health services. This study aimed to describe unmet health needs among young adults with CP in Ireland and examine if these differed between young adults who were and were not yet discharged from children’s services. In this cross-sectional study, young adults with CP aged 16–22 years completed a questionnaire assessing unmet health needs. Logistic regression was used to examine the association between discharge status and unmet health needs. Seventy-five young adults (mean age 18.4 yr; 41% female; 60% in GMFCS levels I-III) were included in the study. Forty (53%) had been discharged from children’s services. Unmet health need, as a proportion of those with needs, was highest for speech (0.64), followed by epilepsy (0.50) and equipment, mobility, control of movement and bone or joint problems (0.39 or 0.38). After adjusting for ambulatory status, unmet health needs did not differ according to discharge status. The proportion of young adults with unmet health needs highlights the importance of taking a life-course approach to CP and providing appropriate services to people with CP regardless of age.

Opioid prescription patterns among adults with cerebral palsy and spina bifida

Background

Pain is the most common symptom of cerebral palsy and spina bifida (CP/SB). The objective of this study was to compare the opioid prescription patterns for differing pain types and overlapping pain among adults living with and without CP/SB.

Methods

Privately-insured beneficiaries were included if they had CP/SB (n = 22,647). Adults without CP/SB were also included as controls (n = 931,528). Oral morphine equivalents (OMEs) were calculated. A multivariable logistic regression was used to analyze the association between CP/SB and OMEs, across the three pain categories: (1) no pain, (2) isolated pain, and (3) pain multimorbidity.

Results

Adults living with CP/SB had a higher OME prescription pattern per year than adults without CP or SB (8,981.0 ± 5,183.0 vs. 4,549.1 ± 2,988.0), and for no pain (4,010.8 ± 828.1 vs. 1,623.53 ± 47.5), isolated pain (7,179.9 ± 378.8 vs. 3,531.0 ± 131.0), and pain multimorbidity (15,752.4 ± 1,395.5 vs. 8,492.9 ± 398.0) (all p < 0.001), and differences were to a clinically meaningful extent. Adjusted odds ratios (OR) for prescribed OMEs were higher for adults with CP/SB vs. control and (1) no pain (OR: 1.51; 95%CI: 1.46, 1.56), (2) isolated pain (OR: 1.48; 95%CI: 1.44, 1.52), and (3) pain multimorbidity (OR: 1.79; 95%CI: 1.72, 1.86).

Conclusions

Adults with CP/SB obtain significantly higher prescription of OMEs than adults without CP/SB.

'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.

Public and Patient Involvement in Doctoral Research During the COVID-19 Pandemic: Reflections on the Process, Challenges, Impact and Experiences From the Perspectives of Adults With Cerebral Palsy and the Doctoral Researcher

Introduction

Cerebral palsy (CP) is a lifelong condition, where people may experience complications as they age. Including the views of people with CP through Public and Patient Involvement (PPI) ensures that research into the condition is relevant and meaningful in addressing their concerns. However, there is a lack of evidence on incorporating the voices of adults with CP in the doctoral research process. Therefore, this paper aims to provide an overview of how adults with CP were involved in a doctoral research process during the pandemic.

Methods

This paper describes the PPI process and its impact at various stages of the doctoral research process and reflects on the experiences from the perspective of the doctoral researcher and adults with CP using the INVOLVE Values and Principles framework. Five adults with CP were consulted throughout the doctoral research programme. The data for this paper is a combination of reflection notes, email exchanges, meeting minutes and informal discussions with the PPI team on their experiences of being involved in the PPI process. The content of this paper is informed by GRIPP 2 checklist.

Results

The doctoral researcher and adult reflections highlighted the value of collaboration and the positive impact on research at each stage of the doctoral research process. Although meetings were adapted due to the pandemic, the values of PPI were adhered to throughout the doctoral research.

Conclusion

Involving adults with CP positively impacted the doctoral research process. It is recommended to consider individual access needs to ensure meetings and information are accessible for disabled adults. Our reflective findings and recommendations may help other researchers who plan to involve adults with CP in doctoral research.

Medication use during pregnancy among women with congenital physical disabilities

BACKGROUND

Medication use during pregnancy is common, with up to 90% of pregnant women taking at least one medication. Women with congenital physical disabilities often report co-occurring conditions during pregnancy that may warrant pharmaceutical treatment, however, research is limited. We aim to describe medication use during pregnancy including: pain, psychotropic, and antibacterial medication, among women with and without congenital physical disabilities.

METHODS

We used data from the Slone Birth Defects Study (1976-2015), a case-control study that collected information on pre-pregnancy health conditions and exposures among participating mothers. Women with congenital physical disabilities (n = 132) included women with spina bifida, cerebral palsy, muscular dystrophy, limb deficiencies, and other skeletal/connective tissue conditions and were matched by interview year and study site to women without congenital physical disabilities (n = 528). Proportions and difference in proportions for each medication were compared between groups. Simple proportions were also calculated for duration and multiple medication use variables.

RESULTS

Women with congenital physical disabilities more frequently reported use of pain (acetaminophen and opioids), psychotropic (antidepressants), and antibacterial medications during pregnancy. Women with congenital physical disabilities used pain and psychotropic medications for longer, frequent durations, and more frequently reported haven taken multiple medications during pregnancy.

CONCLUSION

Women with congenital physical disabilities report higher medication use during pregnancy compared to women without physical disabilities. Patterns may be attributable to co-occurring conditions or increased risk of pregnancy complications in this population. Further research is needed to describe the patterns of medication use for clinical decisions regarding treatment of pregnant women with disabilities.

Correlates of Mental Health in Adolescents and Young Adults with Cerebral Palsy: A Cross-Sectional Analysis of the MyStory Project

Background: It is important to gain a better understanding of mental health issues in adolescents and young adults (AYA) with cerebral palsy (CP). In this cross-sectional study, we explore if demographics, social and clinical questionnaire scores, and cortisol levels in hair samples from AYA with CP are associated with higher scores on anxiety and/or depression questionnaires. Methods: Data from a community-based sample of 63 AYA with CP (30 females; ages 16 to 30 (median age of 25)) were analyzed. Forty-one (65%) participants (20 females) provided a hair sample. Outcomes were assessed using bivariate linear regression analyses and hierarchical regression analyses. Results: Clinical depressive and anxiety symptoms were present in 33% and 31% of participants, respectively. Family functioning, B = 9.62 (95%CI: 5.49–13.74), fatigue, B = 0.15 (95%CI: 0.05–0.25), and pain, B = 1.53 (95%CI: 0.48–2.58) were statistically significant predictors of depressive symptoms. Fatigue, B = 0.24 (95%CI: 0.12–0.35) and pain, B = 1.63 (95%CI: 0.33–2.94) were statistically significant predictors of anxiety. Cortisol levels from hair samples were not found to be associated with depressive symptoms or anxiety. Conclusions: A high prevalence of mental health problems and co-occurring physical problems was found in AYA with CP. Integrating mental support into regular care for AYA with CP is recommended.

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

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

Risk of early- and late-onset Alzheimer disease and related dementia in adults with cerebral palsy

AIM

To examine the risk of Alzheimer disease and related dementia (ADRD) among adults with cerebral palsy (CP).

METHOD

Using administrative insurance claims data for 2007 to 2017 in the USA, we identified adults (45y or older) with a diagnosis of CP (n=5176). Adults without a diagnosis of CP were included as a typically developing comparison group (n=1 119 131). Using age, sex, ethnicity, other demographic variables, and a set of chronic morbidities, we propensity-matched individuals with and without CP (n=5038). Cox survival models were used to estimate ADRD risk within a 3-year follow up.

RESULTS

The unadjusted incidence of ADRD was 9 and 2.4 times higher among cohorts of adults 45 to 64 years (1.8%) and 65 years and older (4.8%) with CP than the respective unmatched individuals without CP (0.2% and 2.0% among 45-64y and 65y or older respectively). Fully adjusted survival models indicated that adults with CP had a greater hazard for ADRD (among 45-64y: unmatched hazard ratio 7.48 [95% confidence interval {CI} 6.05-9.25], matched hazard ratio 4.73 [95% CI 2.72-8.29]; among 65y or older: unmatched hazard ratio 2.21 [95% CI 1.95-2.51], matched hazard ratio 1.73 [1.39-2.15]).

INTERPRETATION

Clinical guidelines for early screening of cognitive function among individuals with CP need updating, and preventative and/or therapeutic services should be used to reduce the risk of ADRD.

Pain in Adults With Cerebral Palsy After Single-Event Multilevel Surgery

OBJECTIVE

The aim of the investigation was to assess the contribution of pain to functional, social, and health-related quality-of-life outcomes in adults with cerebral palsy.

DESIGN

This monocentric, prospective study included long-term data for ambulant adults with cerebral palsy and at levels I-III in the Gross Motor Function Classification System who had received orthopedic multilevel surgery in adulthood and in whom preoperative and postoperative three-dimensional gait analysis was conducted, including the Gait Profile Score. A questionnaire including the Visual Analog Scale, Oswestry Disability Index, and European Quality of Life 5 Dimensions 3 Level was analyzed.

RESULTS

Twenty-four adults at a mean age of 38.0 yrs were included. Sixteen patients (66.7%) indicated that they experienced pain and 10 patients (41.7%) had pain for more than 6 mos. Overall, 13 patients (54%) experienced both pain and anxiety. There was no correlation of the Gait Profile Score with pain, Gross Motor Function Classification System, and Oswestry Disability Index. The Oswestry Disability Index showed a positive correlation with the Gross Motor Function Classification System (r = 0.39, P = 0.05) and pain (r = 0.57, P = 0.004).

CONCLUSIONS

Pain and anxiety represent relevant comorbidities in adults with cerebral palsy. The occurrence of pain correlates with the Oswestry Disability Index and is higher than in children with cerebral palsy.

Anxiety in Angelman Syndrome

Angelman Syndrome (AS) is a neurodevelopmental disorder most commonly caused by the impaired expression of the maternal UBE3A gene on chromosome 15. Though anxiety has been identified as a frequently present characteristic in AS, there are limited studies examining anxiety in this population. Studies of anxiety in other neurodevelopmental disorders have found disorder specific symptoms of anxiety and age specific displays of anxiety symptoms. However, there is a consistent challenge in identifying anxiety in people with neurodevelopmental disorders given the lack of measurement instruments specifically designed for this population. Given the limited information about AS and anxiety, the aims of the current project were to (a) examine symptoms of anxiety in children with AS and (b) determine the correlates of anxiety in children with AS. Participants included 42 adult caregivers of youth with AS in the AS Natural History study who completed the Developmental Behavior Checklist (DBC). The results found that 26% of the sample demonstrated elevated symptoms of anxiety and established a relationship between elevated anxiety in youth with AS and higher levels of irritability, hyperactivity, self-absorbed behaviors, and disruptive/antisocial behaviors. Findings from this research provide a foundation for tailoring evidence-based assessments and treatments for youth with AS and anxiety.

Combined effect of hydrotherapy and transcranial direct-current stimulation on children with cerebral palsy: A protocol for a randomized controlled trial

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disorder caused by a brain injury resulting in poor coordination and motor control deficits, which is one of the most common physical disabilities in children. CP brings a heavy burden on families and society and becomes a significant public health issue. In recent years, hydrotherapy, and transcranial direct current stimulation (tDCS) as a physical therapy for CP is developing rapidly. When hydrotherapy and tDCS are used to treat separately, it has positive therapeutic effect in children with CP. The development of new therapies in combination with physical rehabilitation approaches is critical to optimize functional outcomes. tDCS has attracted interest in this context, because of significant functional improvements have been demonstrated in individuals with brain injuries after a short period of cerebral stimulation. Since the onset of this work, tDCS has been used in combination with constraint-induced therapy, virtual reality therapy to potentiate the treatment effect. Up to now, there are no studies on the effect of a combined application of hydrotherapy and tDCS in children with CP. We will conduct a 2-arm parallel clinical trial to investigate the effect of a combined application of tDCS and hydrotherapy.

METHODS AND ANALYSIS

This study is an outcome assessor and data analyst-blinded, randomized, controlled superiority trial during the period from October 2021 to December 2023. CP patients meeting the inclusion criteria will be allocated in a 1:1 ratio into the treatment group (hydrotherapy plus tDCS), or the control group (treatment as usual). All participants will receive 30 sessions of treatment over 10 weeks. The primary outcomes will be the difference in the Gross Motor Function Assessment and Pediatric Balance Scale during rest and activity. The secondary outcomes will be the difference in adverse effects between the control and treatment groups.

CONCLUSIONS

This study aims to estimate the efficacy of a combined application of tDCS and hydrotherapy in patients with CP.

TRIAL REGISTRATION

This study protocol was registered in Chinese ClinicalTrials.gov, ID: ChiCTR2100047946.

Birth outcomes among women with congenital neuromuscular disabilities

BACKGROUND

Women with disabilities are at an increased risk for adverse birth outcomes; however, research among women with congenital neuromuscular disabilities (CNMD) is limited.

OBJECTIVE

To describe characteristics and compare birth outcomes among mothers with and without cNMD.

METHODS

Data were from the Slone Birth Defects Study (case-control, conducted from 1976 to 2015), which collected information on demographic, reproductive, and lifestyle characteristics. cNMD included spina bifida, cerebral palsy, muscular dystrophy, contractures, or arthrogryposis and were identified by participant report. Those with cNMD were matched to participants without cNMD by interview year and study site. We use modified Poisson regression to estimate relative risks (RR) for low birthweight, macrosomia, preterm birth, and small/large-for-gestational age (SGA/LGA). Given the case-control design and overrepresentation of infants with congenital anomalies, data were weighted to reflect a 3% national prevalence of infants with congenital anomalies.

RESULTS

Mothers with cNMD (n = 125) were more likely to be white, nulliparous, have a cesarean section, have an unplanned pregnancy, report a pre-pregnancy BMI ≥25 kg/m², smoke during pregnancy, and report genitourinary infections. Mothers with cNMD had infants with shorter gestational length (mean difference: -7.44 days, 95% CI: -13.94, -0.95) compared to mothers without cNMD. cNMD was associated with higher risk of preterm birth (RR = 3.98, 95% CI: 1.33, 11.95) and SGA (RR = 2.14, 95% CI: 0.74, 6.15).

CONCLUSION

Mothers with cNMD were more likely to deliver preterm and have an SGA infant. These findings highlight disparities faced by mothers with cNMD and stress the need to provide optimal perinatal and reproductive care.

Health Conditions in Adults With Cerebral Palsy: The Association With CP Subtype and Severity of Impairments

Aim: To determine the prevalence of common health conditions in adults with cerebral palsy (CP) and to identify associations with the CP subtype or the severity of impairments.

Methods: A population-based, cross-sectional study of 153 adults with CP born from 1959 to 1978 (87 males, 66 females; median age 48 years 3 months, range 37–58 years; 41% with unilateral spastic, 36% bilateral spastic, 19% dyskinetic, and 4% with ataxic CP). Data was gathered through interviews, physical assessments, and medical record reviews.

Results: The most common health conditions in adults with CP were pain 65%, upper gastrointestinal disorders 33%, dysphagia 29%, epilepsy 29%, and depression 27%. Cerebral palsy subtype was significantly associated with the presence of pain (p = 0.029), gastrointestinal (p < 0.001), and respiratory disorders (p = 0.006). A more severe physical impairment was associated with a higher prevalence of gastrointestinal disorders (p < 0.001), respiratory disorders (p < 0.001), and pressure ulcers (p < 0.001). Intellectual disability was associated with a higher prevalence of gastrointestinal disorders (p < 0.001), pneumonia (p = 0.001) epilepsy (p = 0.001), and pressure ulcers (p < 0.001), but with a lower prevalence of pain (p < 0.004) and hypertension (p = 0.043).

Conclusion: The prevalence of several common health conditions is related to the CP subtype and severity of impairments, indicating that CP plays a role in the development of these health conditions. Follow-up of adults with CP needs to include not only impairments, but general health as well. Increased attention directed toward signs of gastrointestinal and respiratory disorders in individuals with either dyskinetic CP, gross motor function classification system (GMFCS) levels IV–V, or intellectual disability, is recommended.

Shared Physiologic Pathways Among Comorbidities for Adults With Cerebral Palsy

Objective: Aging with cerebral palsy is accompanied by a declining health and function status across neurological and non-neurological systems. There is a need to understand the shared pathophysiology among comorbidities for adults with cerebral palsy, to inform clinical assessment and guidelines for interventions to improve healthful aging. To begin defining multimorbidity, this study identified the most common comorbidity combinations and their association with mortality among a representative sample of adults with cerebral palsy.

Methods: Data from 2016 to 2018 were used from a random 20% sample from the fee-for-service Medicare database. Adults ≥18 years with cerebral palsy and 25 neurological and non-neurological comorbidities were obtained from 2016. Principal component (PC) analysis identified the most common comorbidity combinations, defined as individual PCs. Cox regression estimated the hazard ratio (HR) of 2-year mortality including all PCs and demographics in a single model. To facilitate comparisons, PC scores were transformed into quintiles (reference: lowest quintile).

Results: Among the 16,728 adults with cerebral palsy, the most common comorbidity combinations (PCs) in order were: cardiorespiratory diseases, dysphagia, and fluid/electrolyte disorders; metabolic disorders (e.g., diabetes, renal disease, hypertension); neurologic-related disorders (e.g., dementia, cerebrovascular disease); gastrointestinal issues; and orthopedic-related disorders. During the 2-year follow-up, 1,486 (8.9%) died. In the adjusted model, most PCs were associated with an elevated mortality rate, especially the first PC (5th quintile HR = 3.91; 95%CI = 3.29–4.65).

Discussion: This study identified the most common comorbidity combinations for adults with cerebral palsy, many of them were deadly, which may inform on the underlying pathophysiology or shared characteristics of multimorbidity for this population.

Psychological, Cardiometabolic, and Musculoskeletal Morbidity and Multimorbidity Among Adults With Cerebral Palsy and Spina Bifida: A Retrospective Cross-sectional Study

BACKGROUND

Individuals living with cerebral palsy or spina bifida are at heightened risk for a number of chronic health conditions, such as secondary comorbidities, that may develop or be influenced by the disability, the presence of impairment, and/or the process of aging. However, very little is known about the prevalence and/or risk of developing secondary comorbidities among individuals living with cerebral palsy or spina bifida throughout adulthood. The objective of this study was to compare the prevalence of psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity among adults with and without cerebral palsy or spina bifida.

METHODS

Privately insured beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for cerebral palsy or spina bifida (n = 29,841). Adults without cerebral palsy or spina bifida were also included (n = 5,384,849). Prevalence estimates of common psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity (≥2 conditions) were compared.

RESULTS

Adults living with cerebral palsy or spina bifida had a higher prevalence of all psychological disorders and psychological multimorbidity (14.6% vs. 5.4%), all cardiometabolic disorders and cardiometabolic multimorbidity (22.4% vs. 15.0%), and all musculoskeletal disorders and musculoskeletal multimorbidity (12.2% vs. 5.4%), as compared with adults without cerebral palsy or spina bifida, and differences were to a clinically meaningful extent.

CONCLUSIONS

Adults with cerebral palsy or spina bifida have a significantly higher prevalence of common psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity, as compared with adults without cerebral palsy or spina bifida. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of disease onset/progression in these higher risk populations.

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CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) List the main categories of morbidity that present with higher risk in adults with cerebral palsy and spina bifida; (2) Discuss the potential impact of multimorbidity on 'early aging' in adults living with cerebral palsy and spina bifida; and (3) Describe challenges that adults with cerebral palsy and spina bifida have in obtaining appropriate health care to address prevention and treatment of multimorbidity.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Skeletal Muscle Mitochondrial Physiology in Children With Cerebral Palsy: Considerations for Healthy Aging

Skeletal muscle contractile proteins require a constant supply of energy to produce force needed for movement. Energy (ATP) is primarily produced by mitochondrial organelles, located within and around muscle fibers, by oxidative phosphorylation that couples electron flux through the electron transport chain to create a proton gradient across the inner mitochondrial membrane that is in turn used by the ATP synthase. Mitochondrial networks increase in size by biogenesis to increase mitochondrial abundance and activity in response to endurance exercise, while their function and content reduce with constant inactivity, such as during muscle atrophy. During healthy aging, there is an overall decline in mitochondrial activity and abundance, increase in mitochondrial DNA mutations, potential increase in oxidative stress, and reduction in overall muscular capacity. Many of these alterations can be attenuated by consistent endurance exercise. Children with cerebral palsy (CP) have significantly increased energetics of movement, reduced endurance capacity, and increased perceived effort. Recent work in leg muscles in ambulatory children with CP show a marked reduction in mitochondrial function. Arm muscles show that mitochondrial protein content and mitochondria DNA copy number are lower, suggesting a reduction in mitochondrial abundance, along with a reduction in markers for mitochondrial biogenesis. Gene expression networks are reduced for glycolytic and mitochondrial pathways and share similarities with gene networks with aging and chronic inactivity. Given the importance of mitochondria for energy production and changes with aging, future work needs to assess changes in mitochondria across the lifespan in people with CP and the effect of exercise on promoting metabolic health.

Unmet healthcare needs in adults with childhood-onset neurodisabilities: a protocol for a systematic review

Background

Many adults with childhood-onset neurodisabilities, such as those with intellectual disability or cerebral palsy, report difficulties accessing the healthcare that they require when they are no longer eligible for paediatric services. Compared to the general population, this population is at greater risk of developing many ageing-related diseases and has higher rates of preventable deaths and premature mortality. Addressing unmet healthcare needs is essential to ensuring equitable access in a quality healthcare system. The aim of this systematic review is to synthesise the current available evidence related to unmet healthcare needs in adults with a range of childhood-onset neurodisabilities.

Methods

A systematic review of quantitative research studies of adults with a range of diagnoses that fall under the neurodisability umbrella and outcomes related to unmet healthcare needs will be undertaken. The Conducting Systematic Reviews and Meta-Analyses of Observational Studies (COSMOS-E) guidelines will be adhered to. Searches of key databases will be undertaken, and a two-phase screening process carried out by pairs of independent reviewers to select studies that meet the inclusion criteria. Data will be extracted using a purposefully designed form. Risk of bias will be assessed using the Joanna Briggs Institute Critical Appraisal Tools. If it is possible to pool prevalence data, a meta-analysis will be undertaken. Where pooling of data is not possible, a structured synthesis approach will be used, and results will be presented in tables and summarised narratively.

Conclusions

In recent years, there has been increased emphasis placed on promoting positive ageing and improving the healthcare experiences throughout the lifespan for people with neurodisabilities. Findings of this systematic review can inform decision-making related to healthcare for this vulnerable population and has the potential to contribute to reducing preventable deaths and premature mortality and promoting positive and healthy ageing for this group.

Differential DNA methylation and transcriptional signatures characterize impairment of muscle stem cells in pediatric human muscle contractures after brain injury

Limb contractures are a debilitating and progressive consequence of a wide range of upper motor neuron injuries that affect skeletal muscle function. One type of perinatal brain injury causes cerebral palsy (CP), which affects a child's ability to move and is often painful. While several rehabilitation therapies are used to treat contractures, their long-term effectiveness is marginal since such therapies do not change muscle biological properties. Therefore, new therapies based on a biological understanding of contracture development are needed. Here, we show that myoblast progenitors from contractured muscle in children with CP are hyperproliferative. This phenotype is associated with DNA hypermethylation and specific gene expression patterns that favor cell proliferation over quiescence. Treatment of CP myoblasts with 5-azacytidine, a DNA hypomethylating agent, reduced this epigenetic imprint to TD levels, promoting exit from mitosis and molecular mechanisms of cellular quiescence. Together with previous studies demonstrating reduction in myoblast differentiation, this suggests a mechanism of contracture formation that is due to epigenetic modifications that alter the myogenic program of muscle-generating stem cells. We suggest that normalization of DNA methylation levels could rescue myogenesis and promote regulated muscle growth in muscle contracture and thus may represent a new nonsurgical approach to treating this devastating neuromuscular condition.

Navigating the Pathway to Care in Adults With Cerebral Palsy

As individuals with cerebral palsy (CP) age, they face unique challenges which complicate their ability to access and receive appropriate health care. These problems exist at the level of the health care system, the clinician, and the individual. At the system level, there is an inadequate number of professionals who are informed of and interested in the care of adults with CP. Pediatric clinicians prefer treating children, and adult caregivers are not knowledgeable about and may feel less competent about CP. Pediatric care does not translate well to the adult population, and information about best practices for adults is just starting to develop. Differences in the physiologic development of individuals with CP render well-established clinical protocols for risk screening of chronic diseases less effective. Moreover, lack of supportive resources decreases a caregiver's sense of self-efficacy in treating this population. The patient's ability to navigate these barriers is complicated by the high prevalence of comorbid cognitive impairment and mental health issues including anxiety, depression, and other psychiatric disorders; a bidirectional relationship between challenges in navigating care/needs and comorbid mental health conditions appears likely. Many patients have additional barriers related to social determinants of health, such as access to transportation, accessible health care facilities, and other personal and environmental factors that may impede health maintenance and wellness. Increasing and disseminating knowledge, harnessing the power of new technologies such as telemedicine, and addressing mental health issues are some of the methods that are available to help adults with CP navigate this road.

More than 25 years after selective dorsal rhizotomy: physical status, quality of life, and levels of anxiety and depression in adults with cerebral palsy

OBJECTIVE

The primary purpose of selective dorsal rhizotomy (SDR) is to ameliorate spasticity in the lower extremities of children with cerebral palsy (CP). In correctly selected patients, this neurosurgical procedure has been shown to have a beneficial effect on many aspects of the child's life. However, given the challenges faced by adults with CP, it would be valuable to document the status of this population compared to their peers later in adulthood. Therefore, the aim of this study was to determine the physical status, mental health, and health-related quality of life (HRQoL) of adults with CP who underwent SDR at least 25 years ago, compared to matched typically developing (TD) individuals. The second aim was to investigate relationships between physical status and the other outcome measures.

METHODS

Adults with CP were recruited from a database of children who had undergone SDR performed using the technique introduced by Professor Warwick Peacock at Red Cross War Memorial Children's Hospital in Cape Town, South Africa, between 1981 and 1991. These individuals were matched for age, sex, body mass index, and socioeconomic status to a TD adult cohort from a similar background. The parameters assessed were lower-extremity muscle tone, passive range of motion, muscle strength, selectivity, functional mobility and dynamic balance (Timed Up and Go [TUG] test), HRQoL (SF-36), and anxiety and depression levels.

RESULTS

Twenty-six adults with CP who had a median age of 35.8 years (interquartile range 34.2-41.4 years) (female/male: n = 10/16; Gross Motor Function Classification System level I/II/III: n = 13/10/3), were compared to 26 TD adults. Muscle tone was similar, whereas passive range of motion, muscle strength, selectivity, TUG, and SF-36 physical functioning (concept and summary) scores differed between the cohorts. Other SF-36 parameters, anxiety levels, and depression levels were not different. Strong correlations were found between the muscle strength and TUG scores.

CONCLUSIONS

Normalized lower-extremity muscle tone was sustained 25-35 years after SDR. Whereas the lower scores for physical assessments are in line with findings in other CP populations, remarkably, relatively good mental health and HRQoL scores were reported in this CP group despite their physical limitations. The strong correlation between muscle strength and TUG suggests that strength training after SDR may have value in improving functional mobility and balance.