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Whitney DG, Min LC, Hurvitz EA. Age, sex, and multi-morbidity stratified mortality risk estimates for adults with cerebral palsy to inform clinical decision making. Disabil Health J 2024:101683. [PMID: 39153943 DOI: 10.1016/j.dhjo.2024.101683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 08/12/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND While research has provided key insights into mortality rates and risks for individuals with cerebral palsy (CP), clinically useable mortality risk estimates remain unreported for adults with CP, especially by key patient-level factors. OBJECTIVE The objective of this study was to generate clinically useable mortality risk estimates among adults with CP to inform clinical decision making. METHODS This retrospective cohort study, using a fee-for-service Medicare database, identified adults ≥18-years-old with CP from 01/01/2008-12/31/2010 and followed through 12/31/2019 for death. Mortality risk at 1-, 3-, 5-, and 9-year intervals were selected based on common clinical length of time to reasonably benefit from preventive care. Sex-stratified analyses assessed risk estimates by narrow age group (18-25/26-34/35-44/45-54/55-64/65-74/≥75 years old) and multi-morbidity group (Whitney Comorbidity Index score 0-2/3/4-6/≥7). RESULTS Of 24,767 adults with CP, n = 12,962 were men (mean [SD] age = 48.3 [15.0] years) and n = 11,805 were women (age = 49.7 [15.8] years). Loss to follow-up was rare. 1-year risk was similar between men and women (3.4 % vs. 3.3 %), but increased slightly more for men than women through 9-years (30.1 % vs. 28.0 %). As expected, the mortality risk increased with older age and higher WCI scores. The probability of death (and survival) is presented per age and multi-morbidity group for men and women with CP. CONCLUSIONS Mortality risk estimates were reported at clinically relevant intervals by age, sex, and multi-morbidity status. This information can be used to weigh harm-to-benefit ratios of screening and treatment strategies based on mortality expectancy estimates.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.
| | - Lillian C Min
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA; Department of Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA; Veterans Affairs Center for Clinical Management and Research, VA Medical Center, Ann Arbor, MI, USA
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, USA
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Leis AM, Hurvitz EA, Whitney DG. Comorbidity Clusters Among Adults With Cerebral Palsy: A Latent Class Analysis. Am J Prev Med 2024; 66:971-979. [PMID: 38278372 DOI: 10.1016/j.amepre.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Adults with cerebral palsy are at risk for early multimorbidity onset, but little is known about the composition of multimorbidity profiles or how these profiles present across adulthood. The objective of this study was to identify multimorbidity profiles and association with mortality among adults with cerebral palsy. METHODS This retrospective cohort study used a random 20% fee-for-service Medicare database from January 1, 2008 to December 31, 2019 from adults aged ≥18 years with cerebral palsy. Latent class analyses using 4-class models were conducted within each age cohort (young adults aged 18-39 years, middle adulthood aged 40-64 years, and older adults aged ≥65 years) to determine patterns of 30 comorbidities defined using the International Classification of Diseases, Ninth Revision codes, identified from January 1, 2008 to December 31, 2010, and their association with mortality through December 31, 2019 (up to 11 years of follow-up); statistical analysis was performed in 2023. RESULTS Three classes were relatively consistent in the composition of comorbidities across young (n=7,020), middle (n=13,554), and older (n=4,193) cohorts: (1) low morbidity (low proportion of all comorbidities) representing 50.1% (young), 41.4% (middle), and 30.9% (older) of the cohorts; (2) neurologic multimorbidity (e.g., epilepsy, intellectual disabilities) representing 26.0% (young), 26.6% (middle), and 14.7% (older) of the cohorts; and complex multimorbidity (e.g., cardiorespiratory, nutritional, musculoskeletal, neurologic) representing 26.0% (young), 26.6% (middle), and 14.7% (older) of the cohorts. The fourth class varied by young (mental health disorders), middle (hypertension), and older (hypertension and osteoarthritis) age cohorts. Compared with the low morbidity class, other classes had an increased mortality rate for each age cohort (hazard ratio range=1.34-5.58, all p<0.001). CONCLUSIONS Findings provide insight into varied multimorbidity profiles and associations with mortality across the life course for adults with cerebral palsy.
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Affiliation(s)
- Aleda M Leis
- Epidemiology Department, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | - Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan.
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Whitney DG, Hurvitz EA. The age-related association between serum creatinine and cardiorespiratory morbidity and mortality and fractures among adults with cerebral palsy. Adv Med Sci 2023; 68:249-257. [PMID: 37473639 DOI: 10.1016/j.advms.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 05/16/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE Serum creatinine may be an objective biomarker of salient health issues in adults with cerebral palsy (CP). The objective was to assess the age-related association between serum creatinine with 3-year risk of cardiorespiratory morbidity/mortality and fracture among adults with CP. PATIENTS AND METHODS This retrospective cohort study used medical records between Jan. 1, 2012 and Oct. 2, 2022 from adults ≥18 years old with CP. The association between baseline serum creatinine with the 3-year risk of all-cause mortality, respiratory/cardiovascular morbidity/mortality, and fracture was assessed by age and sex using logistic regression. The discriminative ability of serum creatinine alone and in conjunction with other variables was assessed. RESULTS Over the 3-year follow-up, 8.3% of 1368 adults with CP had all-cause mortality, 25.6% had respiratory morbidity/mortality, 12.4% had cardiovascular morbidity/mortality, and 8.9% sustained a fracture. The association between serum creatinine with outcomes was dependent on age. For younger adults, lower creatinine had a higher odds ratio (OR) for all-cause mortality, respiratory morbidity/mortality, and fracture. For 51-60 year olds, higher creatinine had a higher OR for cardiovascular morbidity/mortality. Serum creatinine alone had modest prediction of outcomes, and generally improved prediction when added to models that included sex and co-occurring intellectual disabilities and epilepsy (c-statistic range, 0.54-0.84). CONCLUSIONS Lower serum creatinine may reflect frailty while higher levels may reflect kidney dysfunction, helping to explain the differential associations by age. Serum creatinine may be a useful biomarker as part of risk prediction models for these salient health issues for adults with CP.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, USA
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Whitney DG. 5-year fracture risk among children with cerebral palsy. Pediatr Res 2023; 93:996-1002. [PMID: 35854092 DOI: 10.1038/s41390-022-02207-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Epidemiologic evidence documenting fracture risk as children with cerebral palsy (CP) age throughout growth is lacking to inform on when to implement fracture prevention strategies. The objective was to characterize the 5-year risk of fractures by each year of age among <1-13 year olds with CP and effects by patient-level factors. METHODS This retrospective cohort study used commercial administrative claims from 01/01/2001 to 12/31/2018 from children <1-13 years old with ≥5 years of insurance enrollment. Fractures were examined during the 5-year follow-up. For the CP cohort, the association between 5-year fracture rate and patient-level factors was assessed using Cox regression. RESULTS Children with (n = 5559) vs. without (n = 2.3 million) CP had a higher 5-year fracture risk at the vertebral column, hip, and lower extremities at almost each year of age, but lower 5-year fracture risk at the upper extremities after 6 years old (all P < 0.05). Among children with CP, the 5-year fracture rate was elevated for co-occurring neurological conditions and non-ambulatory status at the vertebral column, hip, and lower extremities (hazard ratio [HR] range, 1.44-2.39), and higher for males at the upper extremities (HR = 1.29) (all P < 0.05). CONCLUSIONS This study provides novel epidemiologic evidence of 5-year fracture risk for each year of age for children with CP. IMPACT This study provides novel epidemiologic evidence of 5-year fracture risk for each year of age across important developmental stages for children with vs. without cerebral palsy (CP). Children with vs. without CP were more likely to fracture at the vertebral column, hip, lower extremities, and humerus and less likely to fracture at the forearm and hands. The age-related 5-year fracture risk was associated with clinically relevant patient-level factors, but in different ways by fracture region. Study findings may be used to enhance clinical detection of at-risk children and strategize when to implement fracture prevention efforts for children with CP.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
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Ryan JM, Albairami F, Hamilton T, Cope N, Amirmudin NA, Manikandan M, Kilbride C, Stevenson VL, Livingstone E, Fortune J. Prevalence and incidence of chronic conditions among adults with cerebral palsy: A systematic review and meta-analysis. Dev Med Child Neurol 2023. [PMID: 36807150 DOI: 10.1111/dmcn.15526] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 02/22/2023]
Abstract
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.
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Affiliation(s)
- Jennifer M Ryan
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fatemah Albairami
- Department of Physical Therapy, Ahmadi Hospital, Kuwait Oil Company, Kuwait.,College of Health, Medicine and Life Sciences, Brunel University, London, UK
| | - Thomas Hamilton
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Nigel Cope
- Physiotherapy Department, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | | | - Manjula Manikandan
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Cherry Kilbride
- College of Health, Medicine and Life Sciences, Brunel University, London, UK
| | - Valerie L Stevenson
- The National Hospital for Neurology and Neurosurgery, UCLH Foundation Trust, London, UK
| | | | - Jennifer Fortune
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
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Whitney DG, Clines GA, Leis AM, Caird MS, Hurvitz EA. Five-year risk of fracture and subsequent fractures among adults with cerebral palsy. Bone Rep 2022; 17:101613. [PMID: 36052289 PMCID: PMC9424353 DOI: 10.1016/j.bonr.2022.101613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background Epidemiologic evidence documenting the incidence of fracture and subsequent fractures among adults with cerebral palsy (CP) is lacking, which could inform fracture prevention efforts. The objective was to characterize the 5-year rate of initial and subsequent fragility fractures among adults with CP. Methods This retrospective cohort study used Medicare claims from 01/01/2008–12/31/2019 from adults ≥18 years old with CP (n = 44,239) and elderly ≥65 years old without CP (n = 2,176,463) as a comparison. The incidence rate (IR), IR ratio (IRR), and site distribution were estimated for the initial and subsequent fragility fractures over 5-years by sex and age. Results The IR of fragility fracture at any site over the 5-year follow-up was similar for 18–30-year-old men with CP (IR = 5.2; 95%CI = 4.4–5.9) and 30–34-year-old women with CP (IR = 6.3; 95%CI = 5.3–7.2) compared to the same sex youngest-old (65–74 years old) without CP (IRR = 1.09 and 0.94, respectively, both P > 0.05), and increased with older age for those with CP. The number of fragility fractures and IR of subsequent fragility fractures was similar for young men and middle-aged women with CP compared to elderly without CP, and increased with older age for those with CP. The proportion of fragility fracture at the tibia/fibula decreased while the vertebral column and multiple simultaneous sites (most involved hip/lower extremities) increased with older age. Conclusion Young and middle-aged adults with CP had similar-to-worse initial and subsequent fragility fracture profiles compared to the general elderly population- a well characterized group for bone fragility. Findings emphasize the need for fracture prevention efforts at younger ages for CP, possibly by ~5 decades younger. Fracture prevention efforts are focused on the elderly and postmenopausal women. Fragility fracture risk is elevated for those with CP across the adult lifespan. For men, the risk for 18–29 year olds (CP) was on par with 65–74 year olds (no CP). For women, risk for 30–34 year olds (CP) was on par with 65–74 year olds (no CP). CP had a higher risk of subsequent fragility fractures that was also premature.
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Affiliation(s)
- Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Corresponding author at: Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower, Ann Arbor, MI, USA.
| | - Gregory A. Clines
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Endocrinology Section, Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Aleda M. Leis
- Epidemiology Department, University of Michigan, Ann Arbor, MI, USA
| | - Michelle S. Caird
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Edward A. Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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Whitney DG. 5-year risk of “adult-onset” chronic diseases during childhood and adolescent transitioning for individuals with cerebral palsy. Prev Med Rep 2022; 29:101933. [PMID: 35928595 PMCID: PMC9344024 DOI: 10.1016/j.pmedr.2022.101933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/18/2022] [Accepted: 07/26/2022] [Indexed: 12/01/2022] Open
Abstract
“Adult-onset” chronic diseases may begin in childhood for individuals with CP. 5-year disease risk was < 64.3-fold higher for < 1–13 year olds with vs without CP. 5-year chronic disease risks were elevated for CP across all developmental stages. Patient factors impacted disease risk variably for children with CP. Findings may inform when to implement prevention efforts and who is more at-risk.
Epidemiologic evidence documenting risk of chronic diseases as children with cerebral palsy age throughout growth is lacking to inform prevention strategies. The objective was to characterize the 5-year risk of chronic diseases that are typically associated with advanced aging among < 1–13 year olds with cerebral palsy and effects by patient-level factors. This retrospective cohort study used nationwide commercial administrative claims from 01/01/2001–12/31/2018 from children < 1–13 years old with ≥ 5 years of mostly continuous insurance enrollment. The 5-year risk of chronic diseases was examined for the entire cohort with and without cerebral palsy and then by baseline age group (<1–2, 3–5, 6–8, 9–11, 12–13 years old), including cardiorespiratory, metabolic, kidney, and liver diseases, cancer, depression, and osteoarthritis. For cerebral palsy, the association between 5-year chronic disease rate and patient-level factors was assessed using Cox regression. Children with (n = 5,559) vs without (n = 2.3 million) cerebral palsy had a higher 5-year risk of all chronic diseases when comparing the entire cohorts (relative risk, 1.19 to 64.26, all P < 0.05) and most chronic diseases when comparing cohorts for each age group. Among children with cerebral palsy, there were effects by gender, co-occurring intellectual disabilities and/or epilepsy, and wheelchair use for some chronic diseases, which can help to identify at-risk children. This study provides novel epidemiologic evidence of 5-year risk of “adult-onset” chronic diseases for children with cerebral palsy during important developmental stages, and associated patient-level factors (to enhance clinical detection). Findings may inform when to implement prevention strategies and who may be more at risk.
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Pizzighello S, Uliana M, Michielotto M, Pellegri A, Vascello MGF, Piccoli S, Martinuzzi M, Martinuzzi A. Psychiatric symptoms in adult patients with cerebral palsy: A cohort study. Front Neurol 2022; 13:998922. [PMID: 36247792 PMCID: PMC9553524 DOI: 10.3389/fneur.2022.998922] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPatients with cerebral palsy (CP) have an increased risk of developing mental health disorders.AimsThis 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 proceduresWe 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 resultsAnxiety 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 implicationsResults 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.
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Affiliation(s)
- Silvia Pizzighello
- Department of Conegliano, Scientific Institute IRCCS E. Medea, Treviso, Italy
- *Correspondence: Silvia Pizzighello
| | - Marianna Uliana
- Department of Conegliano, Scientific Institute IRCCS E. Medea, Treviso, Italy
| | - Martina Michielotto
- Department of Conegliano, Scientific Institute IRCCS E. Medea, Treviso, Italy
| | - Alda Pellegri
- Department of Bosisio Parini, Scientific Institute, IRCCS E. Medea, Lecco, Italy
| | | | - Sara Piccoli
- Department of Mental Health, AULSS 6 Euganea, Padua, Italy
| | - Michela Martinuzzi
- King's College London GKT School of Medical Education, London, United Kingdom
| | - Andrea Martinuzzi
- Department of Conegliano, Scientific Institute IRCCS E. Medea, Treviso, Italy
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Whitney DG, Xu T, Whibley D, Ryan D, Caird MS, Hurvitz EA, Haapala H. Post-Fracture Inpatient and Outpatient Physical/Occupational Therapy and Its Association with Survival among Adults with Cerebral Palsy. J Clin Med 2022; 11:jcm11195561. [PMID: 36233436 PMCID: PMC9570908 DOI: 10.3390/jcm11195561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Physical and/or occupational therapy (PT/OT) may improve post-fracture health and survival among adults with cerebral palsy (CP), but this has not been studied in the inpatient setting. The objective was to quantify the association between acute inpatient and outpatient PT/OT use with 1-year mortality among adults with CP. This was a retrospective cohort study of adults with CP with an incident fragility fracture admitted to an acute care or rehabilitation facility using a random 20% Medicare fee-for-service dataset. Acute care/rehabilitation PT/OT was measured as the average PT/OT cost/day for the length of stay (LOS). Weekly exposure to outpatient PT/OT was examined up to 6 months post-fracture. Cox regression examined the adjusted association between the interaction of acute care/rehabilitation average PT/OT cost/day and LOS with 1-year mortality. A separate Cox model added time-varying outpatient PT/OT. Of 649 adults with CP, average PT/OT cost/day was associated with lower mortality rate for LOS < 17 days (HR range = 0.78−0.93), and increased mortality rate for LOS > 27 days (HR ≥ 1.08) (all, p < 0.05). After acute care/rehabilitation, 44.5% initiated outpatient PT/OT, which was associated with lower mortality rate (HR = 0.52; 95% CI = 0.27−1.01). Post-fracture inpatient and outpatient PT/OT were associated with improved 1-year survival among adults with CP admitted to acute care/rehabilitation facilities.
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Affiliation(s)
- Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
- Correspondence:
| | - Tao Xu
- Kidney Epidemiology and Cost Center, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel Whibley
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Dayna Ryan
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Michelle S. Caird
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Edward A. Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Heidi Haapala
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
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Whitney DG, Xu T, Ryan D, Whibley D, Caird MS, Hurvitz EA, Haapala H. Post-fracture rehabilitation pathways and association with mortality among adults with cerebral palsy. Clin Rehabil 2022; 37:119-131. [PMID: 36039504 PMCID: PMC10150496 DOI: 10.1177/02692155221123544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Rehabilitation may mitigate the high mortality rates and health declines post-fracture for adults with cerebral palsy, but this is understudied. The objectives were to characterize the post-fracture rehabilitation pathways and identify their association with 1-year survival among adults with cerebral palsy. METHODS A retrospective cohort study of adults with cerebral palsy with a fragility fracture with continuous health plan enrollment ≥1-year prior to and ≥1 day after their fracture date was performed using a random 20% Medicare fee-for-service dataset. Participants were categorized as a home discharge or inpatient rehabilitation admission post-fracture. For the home discharge cohort, weekly exposure to outpatient physical/occupational therapy (PT/OT) was examined up to 6-month post-fracture. Cox regression examined the association between time-varying PT/OTuse within 6-month post-fracture and mortality from 30 days to 1-year post-fracture before and after adjusting for confounders (e.g. medical complexity). RESULTS Of 3598 adults with cerebral palsy with an incident fragility fracture, 74% were discharged home without inpatient rehabilitation; they were younger, but more medically complex compared to the 26% admitted to inpatient rehabilitation. Among the home discharge cohort (n = 2662), 43.1% initiated PT/OTwithin 6-month post-fracture, and cumulative PT/OTexposure post-fracture was associated with improved survival; for example, per 3 weeks of PT/OTexposure, the adjusted mortality rate was 40% lower (95% confidence interval (CI) = 0.41-0.89). CONCLUSIONS Most adults with cerebral palsy with a fragility fracture were discharged home rather than to inpatient rehabilitation, and only 43.1% of that group initiated outpatient PT/OTwithin 6 months post-fracture. Receiving outpatient PT/OTwas associated with improved 1-year survival.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, 1259University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, 1259University of Michigan, Ann Arbor, MI, USA
| | - Tao Xu
- Kidney Epidemiology and Cost Center, School of Public Health, 1259University of Michigan, Ann Arbor, MI, USA
| | - Dayna Ryan
- Department of Physical Medicine and Rehabilitation, 1259University of Michigan, Ann Arbor, MI, USA
| | - Daniel Whibley
- Department of Physical Medicine and Rehabilitation, 1259University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, 1259University of Michigan, Ann Arbor, MI, USA
| | - Michelle S Caird
- Department of Orthopaedic Surgery, 1259University of Michigan, Ann Arbor, MI, USA
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, 1259University of Michigan, Ann Arbor, MI, USA
| | - Heidi Haapala
- Department of Physical Medicine and Rehabilitation, 1259University of Michigan, Ann Arbor, MI, USA
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Pingel J, Vandenrijt J, Kampmann ML, Andersen JD. Altered gene expression levels of genes related to muscle function in adults with cerebral palsy. Tissue Cell 2022; 76:101744. [DOI: 10.1016/j.tice.2022.101744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/06/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
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Noten S, Selb M, Troenosemito LAA, Thorpe DE, Rodby‐Bousquet E, van der Slot WMA, Roebroeck ME. ICF Core Sets for the assessment of functioning of adults with cerebral palsy. Dev Med Child Neurol 2022; 64:569-577. [PMID: 34800032 PMCID: PMC9299033 DOI: 10.1111/dmcn.15104] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/17/2021] [Accepted: 09/25/2021] [Indexed: 01/19/2023]
Abstract
AIM To report on the results of the online international consensus process to develop the comprehensive and brief International Classification of Functioning, Disability and Health (ICF) Core Sets for adults with cerebral palsy (CP). METHOD An online iterative decision-making and consensus process involved 25 experts, including clinicians and researchers working with adults with CP, an adult with CP, and the parents of adults with CP from all six regions of the World Health Organization. The most relevant categories were selected from a list of 154 unique second-level candidate categories to develop the ICF Core Sets for adults with CP. This list resulted from evidence gathered during four preparatory studies, that is, a systematic literature review, a qualitative study, an expert survey, and an empirical study. RESULTS The consensus process resulted in the comprehensive ICF Core Set containing 120 second-level ICF categories: 33 body functions; eight body structures; 50 activities and participation; and 29 environmental factors, from which the most essential categories, 33 in total, were selected for the brief ICF Core Set. For body functions, most of the categories were mental functions and neuromusculoskeletal and movement-related functions. Body structures were mostly related to movement. All the chapters of the activities and participation component were represented, with mobility and self-care as the most frequently covered chapters. For environmental factors, most of the categories addressed products and technology and services, systems, and policies. INTERPRETATION The comprehensive and brief ICF Core Sets for adults with CP were created using a new online version of an established ICF Core Set consensus process. These Core Sets complement the age-specific ICF Core Sets for children and young people with CP and will promote standardized data collection worldwide.
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Affiliation(s)
- Suzie Noten
- Department of Rehabilitation MedicineErasmus MC University Medical CenterRotterdamthe Netherlands,Rijndam RehabilitationRotterdamthe Netherlands.
| | - Melissa Selb
- ICF Research BranchNottwilSwitzerland,Swiss Paraplegic ResearchNottwilSwitzerland.
| | - Lorenzo A A Troenosemito
- Department of Rehabilitation MedicineErasmus MC University Medical CenterRotterdamthe Netherlands
| | - Deborah E Thorpe
- Division of Physical TherapySchool of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA.
| | - Elisabet Rodby‐Bousquet
- Centre for Clinical ResearchUppsala University – Region VästmanlandVästeråsSweden,Department of Clinical SciencesOrthopaedicsLund UniversityLundSweden
| | - Wilma M A van der Slot
- Department of Rehabilitation MedicineErasmus MC University Medical CenterRotterdamthe Netherlands,Rijndam RehabilitationRotterdamthe Netherlands.
| | - Marij E Roebroeck
- Department of Rehabilitation MedicineErasmus MC University Medical CenterRotterdamthe Netherlands,Rijndam RehabilitationRotterdamthe Netherlands.
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Whitney DG, Rabideau ML, McKee M, Hurvitz EA. Preventive Care for Adults With Cerebral Palsy and Other Neurodevelopmental Disabilities: Are We Missing the Point? Front Integr Neurosci 2022; 16:866765. [PMID: 35464602 PMCID: PMC9021436 DOI: 10.3389/fnint.2022.866765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/11/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
- *Correspondence: Daniel G. Whitney
| | - Michelle L. Rabideau
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Michael McKee
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Edward A. Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, United States
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14
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Engelborghs S. Adults with cerebral palsy and Alzheimer disease: a missing link? Dev Med Child Neurol 2022; 64:284. [PMID: 34632577 DOI: 10.1111/dmcn.15080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/28/2022]
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15
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Maitre NL, Byrne R, Duncan A, Dusing S, Gaebler-Spira D, Rosenbaum P, Winter S. "High-risk for cerebral palsy" designation: A clinical consensus statement. J Pediatr Rehabil Med 2022; 15:165-174. [PMID: 35275579 DOI: 10.3233/prm-220030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nathalie L Maitre
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | | | - Stacey Dusing
- University of Southern California, Los Angeles, CA, USA
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16
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Whitney DG, Oliverio AL. The Association Between Kidney Disease and Mortality Among Adults With Cerebral Palsy-A Cohort Study: It Is Time to Start Talking About Kidney Health. Front Neurol 2021; 12:732329. [PMID: 34566875 PMCID: PMC8460853 DOI: 10.3389/fneur.2021.732329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/12/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: Recent evidence shows that adults with cerebral palsy (CP) have an increased risk for kidney disease, but nothing is known about how kidney disease integrates with their overall health. To begin understanding the importance of kidney health, the objective was to determine if kidney disease is associated with mortality among adults with CP after accounting for comorbidities common to CP and kidney disease. Methods: Data from 2016 to 2018 from adults ≥18 years with CP were used from a random 20% sample fee-for-service Medicare database. Kidney disease in 2016 was ascertained as chronic kidney disease (CKD) stages 1–4, end stage kidney disease (ESKD), nephritic and nephrotic syndrome, and renal osteodystrophy. A modified version of the Whitney Comorbidity Index (modWCI) was used, which includes 24 comorbidities relevant to CP and kidney disease. Mortality rate ratio (MRR) through the year 2018 was estimated for each kidney disease and Cox regression estimated the hazard ratio (HR) of mortality after adjusting for demographics, co-occurring neurological conditions, and the modWCI. Results: Prevalence of kidney disease was 7.3% among 16,728 adults with CP. MRR was elevated for any kidney disease (MRR = 3.14; 95%CI = 2.76–3.58) and most subtypes (MRR = 2.21–3.56; all p < 0.05). The adjusted HR of mortality remained elevated for any kidney disease (HR = 1.25; 95%CI = 1.09–1.45) and ESKD (HR = 1.38; 95%CI = 1.10–1.74). Discussion: Kidney disease, especially ESKD, is associated with mortality among adults with CP independent of comorbidities that are relevant to CP and kidney disease. Findings suggest that nephrology care should be considered as part of routine clinical care for this population.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Andrea L Oliverio
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.,Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
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Hurvitz EA, Whitney DG, Waldron-Perrine B, Ryan D, Haapala HJ, Schmidt M, Gray C, Peterson MD. Navigating the Pathway to Care in Adults With Cerebral Palsy. Front Neurol 2021; 12:734139. [PMID: 34603186 PMCID: PMC8482767 DOI: 10.3389/fneur.2021.734139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/17/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Edward A. Hurvitz
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Daniel G. Whitney
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brigid Waldron-Perrine
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Dayna Ryan
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Heidi J. Haapala
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mary Schmidt
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Cathryn Gray
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mark D. Peterson
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
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18
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Whitney DG, Hurvitz EA, Caird MS. Critical periods of bone health across the lifespan for individuals with cerebral palsy: Informing clinical guidelines for fracture prevention and monitoring. Bone 2021; 150:116009. [PMID: 34020079 DOI: 10.1016/j.bone.2021.116009] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Michelle S Caird
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
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19
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Hurvitz EA. The long-term view for cerebral palsy research and care. Dev Med Child Neurol 2021; 63:765. [PMID: 33843047 DOI: 10.1111/dmcn.14886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Edward A Hurvitz
- Department of Physical Medicine and Rehabilitation, Michigan Medicine/University of Michigan Health, Ann Arbor, MI, USA
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