Greater Adipose Tissue Distribution and Diminished Spinal Musculoskeletal Density in Adults With Cerebral Palsy

Motor function and gait decline in individuals with cerebral palsy during adulthood: a narrative review of potential physiological determinants

Cerebral palsy (CP) is the most common childhood-onset disability. The evolution of gait according to severity is well known amongst children and thought to peak between 8 and 12 years of age among those walking without assistive devices. However, among adults, clinical experience as well as scientific studies report, through clinical assessments, questionnaires and interviews, increasing walking difficulties leading to an increased dependency of assistive devices in everyday ambulation. For many individuals with CP, this change will occur around 30-40 years, with the risk of losing mobility increasing with age. This narrative review aims to first provide objective evidence of motor function and gait decline in adults with CP when ageing, and then to offer mechanistic hypotheses to explain those alterations. Many studies have compared individuals with CP to the typically developing population, yet the evolution with ageing has largely been understudied. Comorbid diagnoses comprise one of the potential determinants of motor function and gait decline with ageing in people with CP, with the first manifestations happening at an early age and worsening with ageing. Similarly, ageing appears to cause alterations to the neuromuscular and cardiovascular systems at an earlier age than their typically developing (TD) peers. Future studies should, however, try to better understand how the physiological particularities of CP change with ageing that could pave the way for better strategies for maintaining function and quality of life in people with CP.

Feasibility and reliability of measured glomerular filtration rate with [I125]-iothalamate among young adults with mild-to-moderate cerebral palsy

Objective

Despite the need, measuring glomerular filtration rate (mGFR) is not routinely performed for adults with cerebral palsy (CP), possibly due to unknown feasibility given the secondary complications of CP. This study aimed to assess the feasibility and reliability of mGFR and explore factors associated with eGFR-mGFR discordance among young adults with mild-to-moderate CP.

Methods

This single-center, cross-sectional study included 18- to 40-year-olds with CP gross motor function classification system (GMFCS) I-III. The participants were excluded if they were pregnant/lactating, had cognitive impairments, or had contraindications to mGFR. A routine clinical protocol for mGFR and eGFR was used. mGFR feasibility was assessed based on the number of participants who completed testing. mGFR reliability was assessed using the coefficient of variation (CV) across the four 30 min intervals. The association between age, sex, and GMFCS and the percentage of eGFR-mGFR discordance was assessed.

Results

Of the 19 participants enrolled, 18 completed the testing [mean age (SD), 29.9 (7.4) years, n = 10 female participants, n = 10/3/5 for GMFCS I/II/III] and most (n = 15) of the participants had an mGFR >90 mL/min; 14 participants (77.8%) had a CV <20%, 2 had a CV between 20 and 25%, and 2 had a CV >50%. eGFR overestimated mGFR by a median (interquartile range) of approximately 17.5% (2-38%); the full range of mis-estimation was -20.5 to 174.3%. Increasing age and GMFCS levels exhibited notable, but weak-to-modest, associations with a larger eGFR-mGFR discordance.

Discussion

Obtaining mGFR was feasible and reasonably reliable within this small sample. eGFR overestimated mGFR by a notable amount, which may be associated with patient-level factors.

Impaired sliding between the lower esophageal sphincter and crural diaphragm (esophageal hiatus) in patients with achalasia esophagus

Swallow-related axial shortening of the esophagus results in the formation of phrenic ampulla in normal subjects; whether it is the case in achalasia esophagus is not known. The goal is to study axial shortening of the esophagus and relative movement between the lower esophageal sphincter (LES) and crural diaphragm (CD) in normal subjects and patients with achalasia. A novel method, isoimpedance contour excursion at the lower edger of LES, as a marker of axial esophageal shortening was validated using X-ray fluoroscopy (n = 5) and used to study axial shortening and separation between the LES and CD during peristalsis in normal subjects (n = 15) and patients with achalasia type 2 esophagus (n = 15). Abdominal CT scan images were used to determine the nature of tissue in the esophageal hiatus of control (n = 15) and achalasia patients (n = 15). Swallow-induced peristalsis resulted in an axial excursion of isoimpedance contours, which was quantitatively similar to the metal clip anchored to the LES on X-ray fluoroscopy (2.3 ± 1.4 vs. 2.1 ± 1.4 cm with deep inspiration and 2.7 ± 0.6 cm vs. 2.7 ± 0.6 cm with swallow-induced peristalsis). Esophageal axial shortening with swallows in patients with achalasia was significantly smaller than normal (1.64 ± 0.5 cm vs. 3.59 ± 0.4 cm, P < 0.001). Gray-level matrix analysis of CT images suggests more "fibrous" and less fat in the hiatus of patients with achalasia. Lack of sliding between the LES and CD explains the low prevalence of hiatus hernia, and low compliance of the LES in achalasia esophagus, which likely plays a role in the pathogenesis of achalasia.NEW & NOTEWORTHY Swallow-related axial shortening of the esophagus is reduced, and there is no separation between the lower esophageal sphincter and crural diaphragm (CD) with swallowing in patients with achalasia esophagus. Fat in the hiatal opening of the esophagus appears to be replaced with fibrous tissue in patients with achalasia, resulting in tight anchoring between the LES and CD. The above findings explain low prevalence of hiatus hernia and the low compliance of the LES in achalasia esophagus.

Motor deficits are associated with increased glial cell activation in the hypothalamus and cerebellum of young rats subjected to cerebral palsy

Cerebral palsy (CP) is a syndrome characterized by a wide range of sensory and motor damage, associated with behavioral and cognitive deficits. The aim of the present study was to investigate the potential of a model of CP using a combination of perinatal anoxia and sensorimotor restriction of hind paws to replicate motor, behavioral and neural deficits. A total of 30 of male Wistar rats were divided into Control (C, n = 15), and CP (CP, n = 15) groups. The potential of the CP model was assessed by evaluating food intake, the behavioral satiety sequence, performance on the CatWalk and parallel bars, muscle strength, and locomotor activity. The weight of the encephalon, soleus, and extensor digitorum longus (EDL) muscles, and the activation of glial cells (microglia and astrocytes) were also measured. The CP animals showed delayed satiety, impaired locomotion on the CatWalk and open field test, reduced muscle strength, and reduced motor coordination. CP also reduced the weight of the soleus and muscles, brain weight, liver weight, and quantity of fat in various parts of the body. There was also found to be an increase in astrocyte and microglia activation in the cerebellum and hypothalamus (arcuate nucleus, ARC) of animals subjected to CP.

The association between isometric strength and cognitive function in adults with cerebral palsy

Background

The literature supports quantifying the maximum force/tension generated by one's forearm muscles such as the hand grip strength (HGS) to screen for physical and cognitive frailty in older adults. Thus, we postulate that individuals with cerebral palsy (CP), who are at higher risk for premature aging, could benefit from tools that objectively measure muscle strength as a functional biomarker to detect frailty and cognitive decline. This study assesses the clinical relevancy of the former and quantifies isometric muscle strength to determine its association with cognitive function in adults with CP.

Methods

Ambulatory adults with CP were identified from a patient registry and were enrolled into this study. Peak rate of force development (RFD) and maximum voluntary isometric contraction of the quadriceps were measured using a commercial isokinetic machine, while HGS was collected with a clinical dynamometer. Dominant and non-dominant side were identified. Standardized cognitive assessments, including the Wechsler Memory and Adult Intelligence Scales IV, Short Test of Mental Status, and the Patient-Reported Outcomes Measurement Information System (PROMIS®) were used to evaluate cognitive function.

Results

A total of 57 participants (32 females; mean age 24.3 [SD 5.3]; GMFCS levels I-IV) were included in the analysis. Although dominant and non-dominant RFD and HGS measures were associated with cognitive function, non-dominant peak RFD showed the strongest associations with cognitive function.

Conclusion

RFD capacity may reflect age-related neural and physical health and could be a better health indicator than HGS in the CP population.

Relationship of anthropometric measurements and percent body fat mass to cardiovascular disease risk factors in adults with cerebral palsy

INTRODUCTION

Adults with cerebral palsy (CP) face high morbidity from cardiovascular disease (CVD). Of concern, classic screening parameters are inconsistent in identifying CVD risk in this population. Dual-energy x-ray absorptiometry (DEXA), which provides direct measurements of fat mass (FM), may be an alternative screening method.

OBJECTIVE

To evaluate whether FM measurement with DEXA is feasible in screening adults with CP and compare FM and anthropometric measures to CVD risk factors.

DESIGN

Cross-sectional study.

SETTING

Outpatient rehabilitation hospital.

PARTICIPANTS

Forty-seven adults with CP.

MAIN OUTCOME MEASURES

Weight, height, waist circumference (WC), and hip circumference (HC) were measured; waist-to-hip ratio (WHR) and body mass index (BMI) were calculated. Blood pressure (BP), FM by DEXA, hemoglobin A1c (HbA1c), and lipid measurements were obtained. Logistic regression models investigated odds ratios (ORs) and 95% confidence intervals (CIs) between anthropometric measurements/FM and CVD risk factors; correlations were assessed using Pearson correlation coefficients.

RESULTS

Elevated BP or hypertension diagnosis was present in 47.8%; HbA1c ≥5.7% in 22.2%; and high-density lipoprotein (HDL) level below optimal for 33.3%. DEXA FM was obtained in 29 of 47 participants, as surgical metal and positioning limited many studies. Excess FM was noted in 75.9% versus 41.3% overweight/obese by BMI. WC correlated with HbA1c (r = 0.46, p = .002), HDL (r = -0.36, p = .018), and triglyceride (TG) levels (r = 0.30, p = .045); however at-risk WC values were associated only with odds of elevated HbA1c (OR 8.53, 95% CI 1.46-50.05; p = .018). HC correlated with HbA1c levels (r = 0.38, p = .011) and systolic BPs (r = 0.35, p = .019); similarly, ORs for elevated HC were weakly associated with elevated HbA1c and BPs (OR 1.08, 95% CI 1.01-1.16; p = .024 and OR 1.07, 95% CI 1.01-1.14; p = .024, respectively). WHR correlated with TGs; however few TG levels were elevated. FM measures were not associated with at-risk lab values or BPs.

CONCLUSIONS

DEXA FM measurements may not be feasible for CVD screening in many adults with CP. Although CVD risk factors are frequently present, anthropometric measurements commonly used for general population screening may not translate well to adults with CP.

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.

Body Fat Distribution in Children and Adolescents With Cerebral Palsy

To evaluate the body fat distribution in children with cerebral palsy (CP). The present study focusses on a monocentric retrospective analysis of body fat distribution from children diagnosed with CP. The children participated in a rehabilitation program. Reference centiles were calculated based on data from the National Health and Nutrition Examination Survey (NHANES, 1999-2004). Z-scores for trunk-to-leg fat ratio were calculated. Further, fat mass index (FMI) was evaluated based on percentiles that have already been published. 237 males and 194 females with CP were considered (mean age: 11 years and 11 months [SD 3 years]). These were compared to 1059 males and 796 females from the NHANES (mean age: 14 years and 7 months [SD 3 years and 4 months]). The z-scores for trunk-to-leg fat ratio showed the following values: mean -0.47 (SD 1.50) for males, -0.49 (SD 1.11), for females, -0.48 (SD 1.34) for all. The z-scores for FMI showed the following values: mean -0.29 (SD 0.70) for males, -0.88 (SD 2.0) for females, -0.55 (SD 1.46) for all. The results showed rather a gynoid fat distribution and a lower FMI in children with CP than in the reference population (NHANES 1999-2004).

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.

Perirenalfat thickness is associated with bone turnover markers and bone mineral density in postmenopausal women with type 2 diabetes mellitus

OBJECTIVES

Emerging evidence demonstrated that perirenal fat may modulate bone metabolism through several pathological pathways. This study was aimed to assess the associations between perirenal fat thickness (PrFT) and bone turnover markers (BTMs) and bone mineral density (BMD) in postmenopausal women with type 2 diabetes mellitus (T2DM) and further explore the correlation between PrFT and osteoporosis.

METHODS

In this cross-sectional study, a total of 626 participants with complete data were enrolled in this study. Demographic and anthropometric information was collected. Biochemical parameters and BTMs were determined. PrFT and BMD were measured by computed tomography and dual-energy x-ray absorptiometry, respectively. Correlation analysis and regression models were used to assess the associations between PrFT and BTMs and BMD. The multiple binomial logistic regression model was used to estimate the independent variables of PrFT for osteoporosis.

RESULTS

Overall, the prevalence of osteoporosis was 38.7%. PrFT was negatively correlated with β-cross-linked C-telopeptide of type I collagen (β-CTX) (r = -0.216,< 0.001), L1-L4 BMD (r = -0.351, < 0.001), and T-score (r = -0.396, < 0.001). PrFT also remained significantly correlated with β-CTX (β = -0.291, P< 0.001), L1-L4 BMD (β = -0.109, P= 0.027), and L1-L4 T-score (β = -0.149, P= 0.001) after adjustment for other confounding factors. Furthermore, PrFT was also independently associated with osteoporosis after adjustment for other confounding factors; the OR (95% CI) was 1.13 (1.04-1.23). PrFT also seems to have a relatively good identifying value for osteoporosis. The area under the curve (AUC) value of PrFT in identifying osteoporosis was 0.766 (95% CI: 0.705-0.826, P < 0.001). The optimal cutoff value of PrFT was 15.2 mm (sensitivity: 72.5%, specificity: 79.8%).

CONCLUSIONS

PrFT was significantly associated with β-CTX, BMD, and osteoporosis. These findings indicate that perirenal fat may play an important role in bone metabolism.

CLINICAL TRIAL REGISTRATION

http://www.chictr.org.cn/, identifier (ChiCTR2100052032).

Body Fat Distribution and Associated Risk of Cardiovascular Disease in Adults With Cerebral Palsy

Objective: Fat distribution has increasingly been acknowledged as a more significant health parameter than general obesity, in terms of the risk of cardiovascular disease (CVD). We aimed to investigate the regional fat distribution pattern and general body fat characteristics of adults with cerebral palsy (CP), and we explored the risk of CVD in this population. Methods: People aged ≥20 years who were diagnosed with CP were recruited between February 2014 and November 2014. The subjects underwent a structured interview, laboratory studies, and physical examination. The amount and distribution of fat were determined directly by dual-energy X-ray absorptiometry. Laboratory analysis was performed to measure total cholesterol and triglyceride, high-density lipoprotein (HDL), low-density lipoprotein, and fasting plasma glucose levels. The Framingham risk score (FRS) was used to present the 10-year risk for having CVD, and predictors such as sex, age, total cholesterol, HDL, systolic blood pressure, treatment for hypertension, and smoking status were used to calculate the FRS. Results: Ninety-nine adults (58 men, mean age 41.77 ± 8.95 years) with CP were included. The participants consisted of all five levels of the Gross Motor Function Classification System. The mean body mass index (BMI) was 22.52 ± 4.58 kg/m². According to BMI criteria, 54.9% were overweight and 27.3% were obese. The fat mass index criteria revealed 10.1% excess fat and 7.6% obesity. In univariable regression analysis, age, the timing of physical function deterioration, and android fat percentage were associated with the FRS (p <0.001, p <0.001, and p = 0.007, respectively). In multiple regression analysis, the FRS was associated with age and android fat percentage, based on the following formula: " FRS= - 18 . 549 + 0 . 410  ∗  Age + 0 . 577  ∗  Android percent fat  ( % )   ( R 2 =0 . 528 ) ' '                                                                                                                                          ( p < 0.001 ) . Conclusions: Body fat distribution in the android area is significantly associated with future CVD risk in adults with CP.

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.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

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.

Pain phenotypes among adults living with cerebral palsy and spina bifida

ABSTRACT

Chronic pain is the most commonly reported physical symptomology of cerebral palsy (CP) and spina bifida (SB) throughout the lifespan, and yet, pain is perhaps the least understood comorbidity in these populations. The objective of this study was to compare the prevalence and types of pain diagnosed among adults living with and without CP or SB. In this retrospective cohort study, we analyzed data from a nationwide commercial insurance claims database. Beneficiaries were included if they had an International Classification of Diseases, Ninth revision, Clinical Modification diagnosis code for CP or SB (n = 22,648). Adults without CP or SB were also included as controls (n = 931,623). Pain phenotypes (nociceptive, nociplastic, and neuropathic pain) and pain multimorbidity (≥2 conditions) were compared. We found that adults living with CP or SB had a higher prevalence of any pain disorders (55.9% vs 35.2%), nociceptive pain (44.0% vs 26.7%), nociplastic pain (26.1% vs 11.9%), neuropathic pain (9.6% vs 5.6%), and pain multimorbidity (21.1% vs 8.4%), as compared to adults without CP or SB, and differences were to a clinically meaningful extent. Adjusted odds ratios of nociceptive pain (odds ratio [OR]: 2.20; 95% confidence interval [CI]: 2.15-2.24), nociplastic pain (OR: 2.47; 95% CI: 2.41-2.53), neuropathic pain (OR: 2.71; 95% CI: 2.54-2.89), and other pain (OR: 3.92; 95% CI: 3.67-4.19) were significantly higher for adults living with CP or SB. In conclusion, adults with CP or SB have a significantly higher prevalence and odds of common peripheral, central, and neuropathic pain disorders and pain multimorbidity, as compared to adults without CP or SB.

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.

Blood pressure in adults with cerebral palsy: a systematic review and meta-analysis of individual participant data

Objectives:

This systematic review and meta-analysis was designed to determine the overall mean blood pressure and prevalence of hypertension among a representative sample of adults living with cerebral palsy by combining individual participant data. Additional objectives included estimating variations between subgroups and investigating potential risk factors for hypertension.

Methods:

Potential datasets were identified by literature searches for studies published between January 2000 and November 2017 and by experts in the field. Samples of adults with cerebral palsy (n ≥ 10, age ≥ 18 years) were included if blood pressure data, cerebral palsy-related factors (e.g. cerebral palsy subtype), and sociodemographic variables (e.g. age, sex) were available. Hypertension was defined as at least 140/90 mmHg and/or use of antihypertensive medication.

Results:

We included data from 11 international cohorts representing 444 adults with cerebral palsy [median (IQR) age of the sample was 29.0 (23.0–38.0); 51% men; 89% spastic type; Gross Motor Function Classification System levels I–V]. Overall mean SBP was 124.9 mmHg [95% confidence interval (CI) 121.7–128.1] and overall mean DBP was 79.9 mmHg (95% CI 77.2–82.5). Overall prevalence of hypertension was 28.7% (95% CI 18.8–39.8%). Subgroup analysis indicated higher blood pressure levels or higher prevalence of hypertension in adults with cerebral palsy above 40 years of age, men, those with spastic cerebral palsy or those who lived in Africa. BMI, resting heart rate and alcohol consumption were risk factors that were associated with blood pressure or hypertension.

Conclusion:

Our findings underscore the importance of clinical screening for blood pressure in individuals with cerebral palsy beginning in young adulthood.

Psychological morbidity among adults with cerebral palsy and spina bifida

BACKGROUND

Very little is known about the risk of developing psychological morbidities among adults living with cerebral palsy (CP) or spina bifida (SB). The objective of this study was to compare the incidence of and adjusted hazards for psychological morbidities among adults with and without CP or SB.

METHODS

Privately insured beneficiaries were included if they had an International Classification of Diseases, Ninth revision, Clinical Modification diagnostic code for CP or SB (n = 15 302). Adults without CP or SB were also included (n = 1 935 480). Incidence estimates of common psychological morbidities were compared at 4-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident psychological morbidities.

RESULTS

Adults living with CP or SB had a higher 4-year incidence of any psychological morbidity (38.8% v. 24.2%) 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 any psychological morbidity [hazard ratio (HR): 1.60; 95% CI 1.55-1.65], and all but one psychological disorder (alcohol-related disorders), and ranged from HR: 1.32 (1.23, 1.42) for substance disorders, to HR: 4.12 (3.24, 5.25) for impulse control disorders.

CONCLUSIONS

Adults with CP or SB have a significantly higher incidence of and risk for common psychological 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 the risk of disease onset/progression in these higher-risk populations.

Cerebral Palsy: Sport and Exercise Considerations

ABSTRACT

Cerebral palsy (CP) is a group of debilitating motor disorders that carries a wide array of clinical presentations ranging from isolated physical or cognitive impairment to global loss of function. Despite the prevalence of CP, recommendations and benefits of physical activity/exercise have historically not been clearly defined. The research on the subject has several limitations, including small sample size, power, standardized measures/outcomes, and poor classification regarding severity of the disease. Nonetheless, the general consensus and new research shows that individuals with CP who participate in sports and exercise regimens, even at reduced frequency and intensity, exhibit improvements in health care benefits, including cardiorespiratory endurance, gross motor function, gait stability, and reduction in pain. These regimens can be prescribed safely and individualized by health care providers to improve morbidity and mortality in patients suffering from CP.

Cardiometabolic Morbidity in Adults With Cerebral Palsy and Spina Bifida

PURPOSE

The purpose of this study was to compare the incidence of, and adjusted hazards for, cardiometabolic morbidities 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 (ICD-9-CM) diagnostic code for cerebral palsy or spina bifida (n = 15,302). Adults without cerebral palsy or spina bifida were also included (n = 1,935,480). Incidence estimates of common cardiometabolic morbidities were compared at 4 years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios (HRs) for incident cardiometabolic morbidities.

RESULTS

Adults living with cerebral palsy or spina bifida had a higher 4-year incidence of any cardiometabolic morbidity (41.5% vs 30.6%) as compared to adults without cerebral palsy or spina bifida, and differences were to a clinically meaningful extent. Fully adjusted survival models demonstrated that adults with cerebral palsy or spina bifida had a greater hazard for any cardiometabolic morbidity (HR: 1.52; 95% confidence interval [CI]: 1.47, 1.57), and all but 1 cardiometabolic disorder (nonalcoholic fatty liver disease) and ranged from HR: 1.20 (1.15, 1.25) for hypercholesterolemia to HR: 1.86 (1.74, 1.98) for heart failure.

CONCLUSIONS

Adults with cerebral palsy or spina bifida have a significantly higher incidence of, and risk for, common cardiometabolic morbidities, as compared to 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 cardiometabolic disease onset and progression in these higher-risk populations.

Greater Visceral Fat but No Difference in Measures of Total Body Fat in Ambulatory Children With Spastic Cerebral Palsy Compared to Typically Developing Children

BACKGROUND

Individuals with cerebral palsy (CP) are at increased risk for obesity and obesity-related complications. Studies of total body fat in those with CP are inconsistent and studies of abdominal fat are lacking in children with CP. The objective of this study was to determine if ambulatory children with spastic CP have greater central adiposity compared to typically developing children.

METHODOLOGY

Eighteen ambulatory children with spastic CP (n = 5 girls; 8.6 ± 2.9 yr) and 18 age-, sex-, and race-matched typically developing children (controls; 8.9 ± 2.1 yr) participated in this cross-sectional study. Children with CP were classified as I or II using the Gross Motor Function Classification System. Dual-energy X-ray absorptiometry assessed body composition, including total body, trunk and abdominal fat mass, fat-free mass, fat mass index (FMI), and fat-free mass index (FFMI).

RESULTS

There were no group differences in fat mass, fat-free mass, FMI, and FFMI in the total body, fat mass, fat-free mass, and FFMI in the trunk, or fat mass, visceral fat mass, and subcutaneous fat mass in the abdomen (p > 0.05). Compared to controls, children with CP had higher trunk FMI, abdominal FMI, and visceral FMI (p < 0.05). Although marginally insignificant (p = 0.088), children with CP had higher subcutaneous FMI.

CONCLUSIONS

Ambulatory children with spastic CP have elevated central adiposity, especially in the visceral region, despite no differences in measures of total body fat. How this relates to cardiometabolic disease progression in those with CP requires further investigation.

Resistance Training for Older Adults: Position Statement From the National Strength and Conditioning Association

Fragala, MS, Cadore, EL, Dorgo, S, Izquierdo, M, Kraemer, WJ, Peterson, MD, and Ryan, ED. Resistance training for older adults: position statement from the national strength and conditioning association. J Strength Cond Res 33(8): 2019-2052, 2019-Aging, even in the absence of chronic disease, is associated with a variety of biological changes that can contribute to decreases in skeletal muscle mass, strength, and function. Such losses decrease physiologic resilience and increase vulnerability to catastrophic events. As such, strategies for both prevention and treatment are necessary for the health and well-being of older adults. The purpose of this Position Statement is to provide an overview of the current and relevant literature and provide evidence-based recommendations for resistance training for older adults. As presented in this Position Statement, current research has demonstrated that countering muscle disuse through resistance training is a powerful intervention to combat the loss of muscle strength and muscle mass, physiological vulnerability, and their debilitating consequences on physical functioning, mobility, independence, chronic disease management, psychological well-being, quality of life, and healthy life expectancy. This Position Statement provides evidence to support recommendations for successful resistance training in older adults related to 4 parts: (a) program design variables, (b) physiological adaptations, (c) functional benefits, and (d) considerations for frailty, sarcopenia, and other chronic conditions. The goal of this Position Statement is to a) help foster a more unified and holistic approach to resistance training for older adults, b) promote the health and functional benefits of resistance training for older adults, and c) prevent or minimize fears and other barriers to implementation of resistance training programs for older adults.

Noncommunicable disease among adults with cerebral palsy: A matched cohort study

OBJECTIVE

To compare the incidence of noncommunicable diseases between adults with and without cerebral palsy (CP).

METHODS

A cohort study was conducted using primary care data from the Clinical Practice Research Datalink. Cox models, stratified by matched set and adjusted for potential confounders, were fitted to compare the risk of any noncommunicable disease, cancer, cardiovascular disease, type 2 diabetes mellitus, and respiratory disease between adults with and without CP.

RESULTS

The analysis included 1,705 adults with CP and 5,115 age-, sex-, and general practice-matched adults without CP. There was evidence from adjusted analyses that adults with CP had 75% increased risk of developing any noncommunicable disease compared to adults without CP (hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.58-1.94). Specifically, they had increased risk of cardiovascular disease (HR 1.76, 95% CI 1.48-2.11) and respiratory disease (HR 2.61, 95% CI 2.14-3.19). There was no evidence of increased risk of cancer or type 2 diabetes mellitus.

CONCLUSIONS

Adults with CP had increased risk of noncommunicable disease, specifically cardiovascular and respiratory disease. These findings highlight the need for clinical vigilance regarding identification of noncommunicable disease in people with CP and further research into the etiology and management of noncommunicable disease in this population.

Bone Marrow Fat Physiology in Relation to Skeletal Metabolism and Cardiometabolic Disease Risk in Children With Cerebral Palsy

Individuals with cerebral palsy exhibit neuromuscular complications and low physical activity levels. Adults with cerebral palsy exhibit a high prevalence of chronic diseases, which is associated with musculoskeletal deficits. Children with cerebral palsy have poor musculoskeletal accretion accompanied by excess bone marrow fat, which may lead to weaker bones. Mechanistic studies to determine the role of bone marrow fat on skeletal growth and maintenance and how it relates to systemic energy metabolism among individuals with cerebral palsy are lacking. In this review, we highlight the skeletal status in children with cerebral palsy and analyze the existing literature on the interactions among bone marrow fat, skeletal health, and cardiometabolic disease risk in the general population. Clinically vital questions are proposed, including the following: (1) Is the bone marrow fat in children with cerebral palsy metabolically distinct from typically developing children in terms of its lipid and inflammatory composition? (2) Does the bone marrow fat suppress skeletal acquisition? (3) Or, does it accelerate chronic disease development in children with cerebral palsy? (4) If so, what are the mechanisms? In conclusion, although inadequate mechanical loading may initiate poor skeletal development, subsequent expansion of bone marrow fat may further impede skeletal acquisition and increase cardiometabolic disease risk in those with cerebral palsy.

Emerging Issues in Cerebral Palsy Associated With Aging: A Physiatrist Perspective

The population of adults diagnosed with cerebral palsy (CP) is increasing along with the survival rate of children born with the disability. Adults with CP need health services for the continued monitoring and management of their condition. Moreover, the development of additional health problems in adulthood increases the need for ongoing access to health services. Adults with CP manifest a higher rate of chronic health conditions and eventual decline in strength and functional reserve, deterioration in physical activity, increased risk of musculoskeletal complications, and gradual changes in swallowing ability. They are also reported to exhibit difficulty engaging socially and have a low health-related quality of life (QOL). However, there are a large number of adults with CP who cannot access medical services adequately and are therefore not effectively treated. To overcome these apparent challenges, we need to fully comprehend the healthcare needs of adults with CP to develop adult-focused health services. Further research is needed regarding the impact of physical activity, nutrition, sarcopenia, myeloradiculopathy, and swallowing function on QOL.

Gross Motor Function Classification System Specific Growth Charts-Utility as a Risk Stratification Tool for Surgical Site Infection Following Spine Surgery

BACKGROUND

There is currently minimal evidence that preoperative malnutrition increases surgical site infection (SSI) risk in children with cerebral palsy (CP) undergoing spinal deformity surgery. Growth charts specifically for patients with CP have been created to aid in the clinical interpretation of body mass index (BMI) as a marker of nutritional status, but to our knowledge these charts have never been used to risk stratify patients before orthopaedic surgery. We hypothesize that patients with CP who have BMI-for-age below the 10th percentile (BMI≤10) on CP-specific growth charts are at increased risk of surgical site infection following spinal deformity surgery compared with patients with BMI-for-age above the 10th percentile (BMI>10).

METHODS

Single-center, retrospective review comparing the rate of SSI in patients with CP stratified by BMI-for-age percentiles on CP-specific growth charts who underwent spinal deformity surgery. Odds ratios with 95% confidence intervals and Pearson χ tests were used to analyze the association of the measured nutritional indicators with SSI.

RESULTS

In total, 65 patients, who underwent 74 procedures, had complete follow-up data and were included in this analysis. Ten patients (15.4%) were GMFCS I-III and 55 (84.6%) were GMFCS IV-V; 39 (60%) were orally fed and 26 (40%) were tube-fed. The rate of SSI in this patient population was 13.5% with 10 SSIs reported within 90 days of surgery. There was a significant association between patients with a BMI below the 10th percentile on GMFCS-stratified growth charts and the development of SSI (OR, 13.6; 95% CI, 2.4-75.4; P=0.005). All SSIs occurred in patients that were GMFCS IV-V. There was no association between height, weight, feeding method, or pelvic instrumentation and development of SSI.

CONCLUSIONS

CP-specific growth charts are useful tools for identifying patients at increased risk for SSI following spinal instrumentation procedures, whereas standard CDC growth charts are much less sensitive. There is a strong association between preoperative BMI percentile on GMFCS-stratified growth charts and SSI following spinal deformity surgery.

LEVEL OF EVIDENCE

Level III-Retrospective Study.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

WHAT THIS PAPER ADDS

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

Trabecular bone score in adults with cerebral palsy

CONTEXT

Bone fragility in cerebral palsy (CP) is secondary to a complex interplay of functional, hormonal, and nutritional factors that affect bone remodelling. A greater understanding of bone microarchitectural changes seen in CP should assist therapeutic decision making.

OBJECTIVE

To examine the relationship between trabecular bone score (TBS), BMD and fractures in adults with CP; the influence of clinical factors and body composition on bone microarchitecture were explored.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

43 adults (25 male) with CP of median age 25 years (interquartile range 21.4-33.9) who had evaluable dual-energy X-ray absorptiometry imaging of the lumbar spine from a single tertiary hospital between 2005-March 2018.

RESULTS

24/43 (55.8%) of patients had TBS values indicating intermediate or high risk of fracture (<1.31). TBS correlated with areal BMD at the lumbar spine, femoral neck and total body. TBS was significantly associated with arm and leg lean mass, with adjustment for age, gender and height (adjusted R² = 0.18, p = 0.042 for arm lean mass; adjusted R² = 0.19, p = 0.036 for leg lean mass). There was no difference in TBS when patients were grouped by fracture status, anticonvulsant use, gonadal status or use of PEG feeding. TBS was lower in non-ambulatory patients compared with ambulatory patients (1.28 vs 1.37, p = 0.019).

CONCLUSIONS

Abnormal bone microarchitecture, as measured by TBS, was seen in >50% of young adults with CP. TBS correlated with both areal BMD and appendicular lean mass. Maintaining muscle function is likely to be important for bone health in young adults with CP and needs to be confirmed in further studies.

Determinants of muscle preservation in individuals with cerebral palsy across the lifespan: a narrative review of the literature

In individuals with cerebral palsy (CP), smaller muscle and atrophy are present at young age. Many people with CP also experience a decline in gross motor function as they age, which might be explained by the loss of muscle mass. The clinical observation of muscle wasting has prompted a comparison with sarcopenia in older adults, and the term accelerated musculoskeletal ageing is often used to describe the hallmark phenotype of CP through the lifespan. However, there has been very little research emphasis on the natural history of ageing with CP and even less with respect to the determinants or prevention of muscle loss with CP. Considering the burgeoning interest in the science of muscle preservation, this paper aims to (i) describe the characteristics of accelerated musculoskeletal ageing in people with CP, (ii) describe the pathophysiology of sarcopenia and parallels with CP, and (iii) discuss possible therapeutic approaches, based on established approaches for sarcopenia.

Low bone mineral density in ambulatory persons with cerebral palsy? A systematic review

Purpose: Non-ambulatory persons with cerebral palsy are prone to low bone mineral density. In ambulatory persons with cerebral palsy, bone mineral density deficits are expected to be small or absent, but a consensus conclusion is lacking. In this systematic review bone mineral density in ambulatory persons with cerebral palsy (Gross Motor Function Classification Scales I-III) was studied. Materials and methods: Medline, Embase, and Web of Science were searched. According to international guidelines, low bone mineral density was defined as Z-score ≤ -2.0. In addition, we focused on Z-score ≤ -1.0 because this may indicate a tendency towards low bone mineral density. Results: We included 16 studies, comprising 465 patients aged 1-65 years. Moderate and conflicting evidence for low bone mineral density (Z-score ≤ -2.0) was found for several body parts (total proximal femur, total body, distal femur, lumbar spine) in children with Gross Motor Function Classification Scales II and III. We found no evidence for low bone mineral density in children with Gross Motor Function Classification Scale I or adults, although there was a tendency towards low bone mineral density (Z-score ≤ -1.0) for several body parts. Conclusions: Although more high-quality research is needed, results indicate that deficits in bone mineral density are not restricted to non-ambulatory people with cerebral palsy. Implications for Rehabilitation Although more high-quality research is needed, including adults and fracture risk assessment, the current study indicates that deficits in bone mineral density are not restricted to non-ambulatory people with CP. Health care professionals should be aware that optimal nutrition, supplements on indication, and an active lifestyle, preferably with weight-bearing activities, are important in ambulatory people with CP, also from a bone quality point-of-view. If indicated, medication and fall prevention training should be prescribed.

Cerebral palsy

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

Opportunistic Use of CT Imaging for Osteoporosis Screening and Bone Density Assessment: A Qualitative Systematic Review

BACKGROUND

The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literature.

METHODS

A systematic review of the MEDLINE database was performed in February 2016 using the PubMed interface. The inclusion criteria were English language, studies performed using living human subjects, studies pertaining to orthopaedics, use of conventional diagnostic CT scans, studies that measured cancellous bone, and studies that reported Hounsfield unit (HU) measurements directly rather than a computed bone mineral density.

RESULTS

Thirty-seven studies that reported on a total of 9,109 patients were included. Of these, 10 studies correlated HU measurements of trabecular bone with DXA-based bone assessment. Reported correlation coefficients ranged between 0.399 and 0.891, and 5 of the studies reported appropriate threshold HU levels for diagnosing osteoporosis or osteopenia.

CONCLUSIONS

Direct HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation. There is a lack of exchangeability among different machines that limits its broad applicability. Future research efforts should focus on identifying thresholds at specific anatomic regions in high-risk patients in order to have the greatest impact on patients. However, using diagnostic CT to infer region-specific osteoporosis could be extraordinarily valuable to orthopaedic surgeons and primary care physicians, and merits further research.

Multimorbidity in Middle-Aged Adults with Cerebral Palsy

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Differences in Body Composition According to Gross Motor Function in Children With Cerebral Palsy

OBJECTIVE

To assess differences in body composition according to gross motor function in children with cerebral palsy (CP) compared with healthy controls.

DESIGN

Retrospective case-control study.

SETTING

Tertiary referral center for CP.

PARTICIPANTS

Participants (N=146) comprised consecutive patients with CP (n=100; mean age, 11.5±4.2y) who were admitted for orthopedic surgery between May 2014 and March 2016 and typically developing children (TDC, n=46; control group).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Bioelectrical impedance analysis (BIA) was used to assess body composition, including body fat, soft lean mass (SLM), fat-free mass (FFM), skeletal muscle mass (SMM), body cell mass (BCM), bone mineral content (BMC), and basal metabolic rate. Body composition measures were compared according to Gross Motor Function Classification System (GMFCS) level, as well as between children with CP and TDC.

RESULTS

Children with CP with GMFCS levels IV and V had a lower height, weight, and body mass index than those with GMFCS levels I to III. Children with CP with GMFCS levels IV and V had a significantly lower SLM, SLM index, FFM, FFM index, SMM, SMM index, BCM, BCM index, BMC, and BMC index than those with GMFCS levels I to III and TDC. GMFCS level significantly affected SLM and BMC.

CONCLUSIONS

Body composition analysis using BIA showed that nonambulatory children with CP had significantly lower FFM, SLM, SMM, BCM, and BMC than ambulatory children with CP and TDC. However, further study is required to allow the use of BIA as a valid nutritional assessment tool in patients with CP.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

Relative abdominal adiposity is associated with chronic low back pain: a preliminary explorative study

Background

Although previous research suggests a relationship between chronic low back pain (cLBP) and adiposity, this relationship is poorly understood. No research has explored the relationship between abdominal-specific subcutaneous and visceral adiposity with pain and disability in cLBP individuals. The aim of this study therefore was to examine the relationship of regional and total body adiposity to pain and disability in cLBP individuals.

Methods

A preliminary explorative study design of seventy (n = 70) adult men and women with cLBP was employed. Anthropometric and adiposity measures were collected, including body mass index, waist-to-hip ratio, total body adiposity and specific ultrasound-based abdominal adiposity measurements. Self-reported pain and disability were measured using a Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) questionnaires respectively. Relationships between anthropometric and adiposity measures with pain and disability were assessed using correlation and regression analyses.

Results

Significant correlations between abdominal to lumbar adiposity ratio (A-L) variables and the waist-to-hip ratio with self-reported pain were observed. A-L variables were found to predict pain, with 9.1–30.5 % of the variance in pain across the three analysis models explained by these variables. No relationships between anthropometric or adiposity variables to self-reported disability were identified.

Conclusions

The findings of this study indicated that regional distribution of adiposity via the A-L is associated with cLBP, providing a rationale for future research on adiposity and cLBP.

Exercise and physical activity recommendations for people with cerebral palsy

Physical activity and its promotion, as well as the avoidance of sedentary behaviour, play important roles in health promotion and prevention of lifestyle-related diseases. Guidelines for young people and adults with typical development are available from the World Health Organisation and American College of Sports Medicine. However, detailed recommendations for physical activity and sedentary behaviour have not been established for children, adolescents, and adults with cerebral palsy (CP). This paper presents the first CP-specific physical activity and exercise recommendations. The recommendations are based on (1) a comprehensive review and analysis of the literature, (2) expert opinion, and (3) extensive clinical experience. The evidence supporting these recommendations is based on randomized controlled trials and observational studies involving children, adolescents, and adults with CP, and buttressed by the previous guidelines for the general population. These recommendations may be used to guide healthcare providers on exercise and daily physical activity prescription for individuals with CP.