Bone health impairment in patients with cerebral palsy

Timeline of diagnosed pain causes in children with severe neurological impairment

Objective

Pain's causes in children with severe cognitive impairment may be challenging to diagnose. This study aimed to investigate if there is a relationship between pain causes and the age of children.

Methods

We conducted a multicenter retrospective study in three Italian Pediatric Units. Eligible subjects were patients from 1 to 18 years with severe neurological impairment. We collected data regarding diagnoses, pain causes and medical or surgical procedures. The timing of pain episodes was categorized into age-related periods: infants and toddlers (0-24 months), preschool children (3-5 years), schoolchildren (6-12 years), and adolescents (13-17 years).

Results

Eighty children with severe neurological impairment were enrolled. The mean age was 11 years (±5.8). Gastroenterological pain was most common in the first years of life (p = 0.004), while orthopaedic and tooth pain was the most typical in schoolchildren and adolescents (p = 0.001 and p = 0.02). Concerning surgical procedures, PEG placement and gastric fundoplication were significantly more common in the first 5 years of age (p = 0.03), and heart surgery was typical of infants (p = 0.04). Orthopaedic surgery was more commonly reported in older children and adolescents (p < 0.001).

Conclusions

Some causes of pain are more frequent in children with severe neurological impairment in defined age-related periods. Specific age-related pain frequencies may help physicians in the diagnostic approach.

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.

Cerebral palsy and bisphosphonates - and what can be learned from other types of secondary osteoporosis in children: A scoping review

AIM

We aimed to improve bone health management of children with cerebral palsy (CP) by reviewing studies investigating bisphosphonate therapy in children with CP and other types of secondary osteoporosis.

METHODS

We included trials on bisphosphonate treatment reporting any direct bone measurement or fracture outcome. All studies of patients with CP were included. We also included all controlled trials of children with secondary bone fragility as well as observational studies with ≥20 participants or at least 3 years of follow-up. Studies were assessed according to PRISMA guidelines using the RoB2-tool and the Newcastle-Ottawa Scale.

RESULTS

We reviewed 1104 studies and found 37 eligible. Some studies were sufficiently homogeneous to include in a meta-analysis, and we found a 1-year effect on lumbar spine bone mineral density (BMD) Z-score of +0.65 after oral and + 1.21 after intravenous bisphosphonates in children with secondary osteoporosis. Further, data on adverse events and post-treatment follow-up were reviewed. Limitations were heterogeneity and small size of the included studies.

CONCLUSION

Meta-analysis consistently showed significant BMD increases with bisphosphonates in children with secondary osteoporosis. Direct evidence of the effect of bisphosphonates on reducing fractures is lacking. We found no reports of long-term adverse events yet longer studies are needed.

Nutritional status and function after high-calorie formula vs. Chinese food intervention in undernourished children with cerebral palsy

Aim

To investigate the efficacy and safety of high-calorie formula vs. Chinese daily food on the nutritional status and motor function of undernourished children with cerebral palsy (CP).

Methods

In this prospective, assessor-blind, and randomized controlled trial, we recruited children (1-10 years) with CP and undernutrition based on the WHO and the American Society for Parenteral and Enteral Nutrition criteria from the National Children's Medical Center. Participants were randomly allocated (1:1) to a high-calorie formula group or a Chinese daily food diet group (control group) for 6 months. Indirect calorimetry was used to estimate energy requirements. We compared the nutritional status and gross motor function of participants in both groups based on weight, height, z-scores (weight-for-age, height-for-age, weight-for-height, and BMI-for-age), and the Gross Motor Function Measure (GMFM), respectively, at baseline, 3-, and 6-months follow-up. In addition, the effective rate of nutritional intervention, and adverse events were simultaneously assessed.

Results

From July 2020 to December 2021, a total of 119 participants were enrolled and randomized, and 110 participants completed the study (with 54 children in the high-calorie formula group and 56 children in the control group). After 6 months of treatment, the weight, height, z-scores (weight-for-height, weight-for-age, and BMI-for-age), and GMFM of both groups were significantly improved (p < 0.05). There were significant differences in changes in weight, weight-for-age z-scores, and GMFM between the two groups (p < 0.05). During the study period, 16 children experienced at least one mild adverse event [9 (16.7%) in the formula group and 7 (12.5%) in the control group].

Conclusion

Nutritional intervention with a high-calorie formula may be an effective and safe option in children with CP for improving undernutrition and gross motor dysfunction.

Clinical trial registration

www.chictr.org.cn, identifier: ChiCTR2000033878.

The Impact of Whole-Body Vibration Training on Bone Minerals and Lean Mass in Children and Adolescents with Motor Disabilities: A Systematic Review and Meta-Analysis

Whole-body vibration training (WBVT) offers a potential auxiliary treatment method for the rehabilitation of motor disabilities to address a reduction in bone minerals and lean mass caused by motor-disability rehabilitation. The aim of this review was to analyze the efficacy of WBVT in muscle-bone rehabilitation. In order to investigate the potential effect of WBVT on children and adolescents with motor disabilities, a meta-analysis was carried out. From January 2006 to June 2021, studies that met certain criteria were searched for in the Scopus, PubMed, Web of Science, and EBSCO databases. An analysis of standardized mean differences was performed using the STATA 15.1 software with a 95% confidence interval (PROSPERO registration number: CRD42021258538). Eight studies were selected that included 179 male and 139 female children and adolescents suffering from motor disabilities. The results of the meta-analysis showed that WBVT significantly improved femur bone-mineral density ((p < 0.01, z = 2.66), standardized mean difference (SMD) (95% CI) = 0.41 (0.11, 0.72)), total body-bone mineral content ((p < 0.01, z = 3.08), SMD (95% CI) = 0.26 (0.10, 0.43)), and lean mass ((p < 0.01, z = 2.63), SMD (95% CI) = 0.22 (0.06, 0.39)). In addition, there was no significant effect of WBVT on lumbar spine bone mineral density in the disabled children and adolescents ((p = 0.21, z = 1.25), SMD (95% CI) = 0.17 (-0.10, 0.43)). WBVT can improve femur bone density, total body bone mineral content, and lean mass in children and adolescents suffering from motor disabilities, while there is no effect on lumbar-spine bone density. WBVT can be used as a potential program to improve bone minerals in children and adolescents with motor disabilities.

Critical periods of bone health across the lifespan for individuals with cerebral palsy: Informing clinical guidelines for fracture prevention and monitoring

BACKGROUND

Skeletal fragility is a major burden for individuals with cerebral palsy (CP), but little is known clinically about when to prevent fractures or monitor bone health for this population. Critical periods of bone health (CPBH) are important windows for intervention to augment bone growth or mitigate bone loss. However, CPBH from the general population may not align with the needs or timing of skeletal fragility for individuals with CP. The objective of this study was to identify discrepancies when evaluating individuals with CP using CPBH across the lifespan from the general population, and propose new CP-specific CPBH.

METHODS

Data from 2016 administrative claims databases were used, including the Optum's De-identified Clinformatics® Data Mart Database and a random 20% sample of the Medicare fee-for-service database from the Centers for Medicare and Medicaid Services. Sex-stratified fracture prevalence was compared between individuals with and without CP across the lifespan starting at 2 years of age using age groups to capture important stages of development and 3-4-year age bands in adulthood (up to >80 years). Sex-specific CPBH from the general population included: rapid bone accrual, peak bone mass, menopause, and elderly.

RESULTS

There were 23,861 individuals with CP and 9,976,161 individuals without CP. CPBH from the general population did not align with the timing of skeletal fragility for CP. For example, fractures were rare and decreased throughout the CPBH of peak bone mass for males without CP, but males with CP had a greater relative fracture risk (2.9-5.6-fold higher) and a substantially increased rate of fracture (CP-slope 14× higher than non-CP-slope). For females with CP, fracture risk was increased by 18-21 years, with additional inflection points (e.g., decade before menopause and again by 57-60 years). For males with CP, fracture risk in mid-life exhibited a pattern similar to elderly males without CP.

CONCLUSIONS

This study identified discrepancies in evaluating fracture risk for individuals with CP if using established CPBH from the general population. We therefore propose new CP- and sex-specific CPBH for fracture monitoring and prevention.

Upper Limb Physical Rehabilitation Using Serious Videogames and Motion Capture Systems: A Systematic Review

The use of videogames and motion capture systems in rehabilitation contributes to the recovery of the patient. This systematic review aimed to explore the works related to these technologies. The PRISMA method (Preferred Reporting Items for Systematic reviews and Meta-Analyses) was used to search the databases Scopus, PubMed, IEEE Xplore, and Web of Science, taking into consideration four aspects: physical rehabilitation, the use of videogames, motion capture technologies, and upper limb rehabilitation. The literature selection was limited to open access works published between 2015 and 2020, obtaining 19 articles that met the inclusion criteria. The works reported the use of inertial measurement units (37%), a Kinect sensor (48%), and other technologies (15%). It was identified that 26% used commercial products, while 74% were developed independently. Another finding was that 47% of the works focus on post-stroke motor recovery. Finally, diverse studies sought to support physical rehabilitation using motion capture systems incorporating inertial units, which offer precision and accessibility at a low cost. There is a clear need to continue generating proposals that confront the challenges of rehabilitation with technologies which offer precision and healthcare coverage, and which, additionally, integrate elements that foster the patient's motivation and participation.