Adults with spastic cerebral palsy have lower bone mass than those with dyskinetic cerebral palsy

Tools for Nutrition Assessment of Adults with Cerebral Palsy: Development of a Gold Standard

PURPOSE OF REVIEW

Cerebral palsy (CP) is a group of disorders caused by non-stabilized cerebral lesions. Individuals with this disorder are at a higher risk of suffering from malnutrition and other related detrimental effects to their quality of life. For this reason, accurate methods of nutritional assessment are vital for people suffering from this condition. While assessment of nutritional status in children with CP has been extensively studied, very few studies have been carried out on adults. These limitations are due to the great anatomical-functional variability characteristic of this syndrome. Difficulties that derive from this variability in adult patients with CP mean that there remains an urgent need for certain standards of nutritional assessment for this population. The objective of this review is to compile the latest trends in nutritional assessment in adults with CP to guide the development of a conceptual framework for future research.

RECENT FINDINGS

With this aim, relevant studies have been identified. The most commonly used technique to evaluate nutritional status is the BMI because of its ease-of-use. However, its well-known limitations fail to adequately estimate the nutritional status in this population, with measurements of patients with CP yielding results that are much less accurate than those that already exist in the general population. Although more studies are needed, kinanthropometry is considered one of the most reliable techniques; nevertheless, the anatomical limitation characteristic of CP plays a limiting factor.

Effect of standing frames used in real life on bone remodeling in non-walking children with cerebral palsy

Children with severe cerebral palsy are prone to low bone mineral density. No clear recommendation exists for an optimal use of standing frame to enhance bone health in this context. Used in real life, this study suggests for the first time that standing practice improved bone mineralization by limiting bone resorption.

INTRODUCTION

To compare the bone health of children with severe cerebral palsy who use a static standing frame in real life to that of children who do not.

METHODS

A total of 24 children with severe cerebral palsy GMFCS IV & V were included in the study and were divided into two groups: 13 were using a passive standing frame and 11 were not. We performed a single center retrospective cross-sectional study comparing the two groups using dual X-ray absorptiometry data and tests on biological samples, including bone remodeling factors.

RESULTS

Total body (less head) bone mineral content was significantly higher in children who used a standing frame for an average of 30 min/day. This was confirmed in the lumbar spine. Although the total body bone mineral density (less head and proximal femur) densitometric data were not significantly higher, a positive trend favored the use of a standing frame in the children. Bone resorptive factors (CTX) were higher in the non-standing-frame group, whereas there was no difference among osteoformation factors. No difference in fracture history was found.

CONCLUSIONS

We show that non-ambulant children with cerebral palsy who use a static standing frame in real life have better bone health, with lower bone resorption, than children who do not. Further studies are needed to determine how standing practice could impact bone mineralization over time in real life and to explore more bone remodeling factors.

Adaptive Cycling: Injuries and Health Concerns

Para-cycling has high rates of acute injuries. The underlying medical conditions of para-athletes predispose these cyclists to injury patterns and sequelae different from those of their able-bodied counterparts. Such injuries include an increased incidence of upper-extremity and soft tissue injuries, along with predisposition for respiratory, skin, genitourinary, and heat-related illnesses. There are no validated sideline assessment tools or return-to-play protocols for sports-related concussion in wheelchair user para-athletes or those with balance deficits. Para-cyclists may be at increased risk for relative energy deficiency in sport due to competitive pressure to maintain certain weights and increased incidence of low bone mineral density.

Bone Mineral Density in Adults With Cerebral Palsy

Low bone mineral density (BMD) is an emerging health issue in adults with cerebral palsy (CP). This cross-sectional study aimed to describe the characteristics of BMD in adults with CP, and to elucidate the risk factors for low BMD in this population. People aged ≥20 years and diagnosed with CP were recruited from February 2014 to November 2014. We assessed BMD using dual-energy X-ray absorptiometry (DXA) for the lumbar spine, femoral neck, and total femur. Moreover, the body composition was assessed using DXA. We included a total of 87 adults with CP (mean age 42.01 years; 52 men). The prevalence of low BMD was 25.3%. Male sex and age were associated with lower BMD. BMD was significantly lower in the non-ambulatory group than that in the ambulatory group for both lumbar spine and femoral neck. The total fat mass demonstrated a positive correlation with the Z-score and BMD for the femur neck and total femur. Body mass index (BMI) and total fat mass were positively correlated with BMD in the lumbar spine, femoral neck, and total femur. However, the Gross Motor Function Classification Scale levels were negatively correlated with BMD at the aforementioned three sites. In conclusion, adults with CP revealed decreased BMD, which was associated with male sex, age, decreased gross motor function, loss of ambulatory function, low BMI, decreased total fat mass, and decreased total fat-free mass.

Collagen-binding peptide reverses bone loss in a mouse model of cerebral palsy based on clinical databases

BACKGROUND

Individuals with cerebral palsy (CP) experience bone loss due to impaired weight bearing. Despite serious complications, there is no standard medication.

OBJECTIVE

To develop a new pharmacological agent, we performed a series of studies. The primary aim was to develop an animal model of CP to use our target medication based on transcriptome analysis of individuals with CP. The secondary aim was to show the therapeutic capability of collagen-binding peptide (CBP) in reversing bone loss in the CP mouse model.

METHODS

A total of 119 people with CP and 13 healthy adults participated in the study and 140 mice were used for the behavioral analysis and discovery of therapeutic effects in the preclinical study. The mouse model of CP was induced by hypoxic-ischemic brain injury. Inclusion and exclusion criteria were established for CBP medication in the CP mouse model with bone loss.

RESULTS

On the basis of clinical outcomes showing insufficient mechanical loading from non-ambulatory function and that underweight mainly affects bone loss in adults with CP, we developed a mouse model of CP with bone loss. Injury severity and body weight mainly affected bone loss in the CP mouse model. Transcriptome analysis showed SPP1 expression downregulated in adults with CP who showed lower bone density than healthy controls. Therefore, a synthesized CBP was administered to the mouse model. Trabecular thickness, total collagen and bone turnover activity increased with CBP treatment as compared with the saline control. Immunohistochemistry showed increased immunoreactivity of runt-related transcription factor 2 and osteocalcin, so the CBP participated in osteoblast differentiation.

CONCLUSIONS

This study can provide a scientific basis for a promising translational approach for developing new anabolic CBP medication to treat bone loss in individuals with CP.

Complicated Muscle-Bone Interactions in Children with Cerebral Palsy

PURPOSE OF REVIEW

The goal of this review is to highlight the deficits in muscle and bone in children with cerebral palsy (CP), discuss the muscle-bone relationship in the CP population, and identify muscle-based intervention strategies that may stimulate an improvement in their bone development.

RECENT FINDINGS

The latest research suggests that muscle and bone are both severely underdeveloped and weak in children with CP, even in ambulatory children with mild forms of the disorder. The small and low-performing muscles and limited participation in physical activity are likely the major contributors to the poor bone development in children with CP. However, the muscle-bone relationship may be complicated by other factors, such as a high degree of fat and collagen infiltration of muscle, atypical muscle activation, and muscle spasticity. Muscle-based interventions, such as resistance training, vibration, and nutritional supplementation, have the potential to improve bone development in children with CP, especially if they are initiated before puberty. Studies are needed to identify the muscle-related factors with the greatest influence on bone development in children with CP. Identifying treatment strategies that capitalize on the relationship between muscle and bone, while also improving balance, coordination, and physical activity participation, is an important step toward increasing bone strength and minimizing fractures in children with CP.

Longitudinal changes in bone density in adolescents and young adults with cerebral palsy: A case for early intervention

CONTEXT

Cerebral palsy (CP) is a motor disorder affecting movement, muscle tone and posture due to damage to the foetal or infant brain. The subsequent lack of ambulation, nutritional deficiencies, anticonvulsant use and hormonal deficiencies have been implicated in the low bone mass associated with this condition.

OBJECTIVE

To assess changes in areal bone mineral density (aBMD) during adolescence and young adulthood in individuals with CP. The effect of ambulation, nutrition, hypogonadism on longitudinal changes in aBMD is also examined.

DESIGN

Retrospective longitudinal study.

SETTING AND PARTICIPANTS

Forty-five subjects with CP who had longitudinal dual-energy X-ray absorptiometry (DXA) scans at a single tertiary hospital between 2006 and 2018.

RESULTS

Mean age at first DXA was 19.4 years (range: 10-36 years), 57.8% were male and 80% were nonambulatory. The mean Z-scores at baseline were <-2.0 at all sites - lumbar spine (LS), femoral neck (FN), total hip (TH) and total body (TB). The median change in aBMD was +1.2%-1.9% per year in all subjects but in those <20 years of age, the median change was 4%-8% per year. Z-scores across all sites remained stable over time. Reduced functional state as measured by the gross motor functional classification scale (GMFCS) had a small negative effect on aBMD over time.

CONCLUSION

In adolescents with CP, low bone mass was evident from the baseline DXA. However, significant bone accrual occurred during the second decade, followed by bone maintenance in young adulthood. Future studies should focus on optimizing bone health from early childhood.

Bone Health in Adaptive Sports Athletes

Adaptive sports athletes represent a growing population within the athletic community worldwide. Given potential cardiometabolic and psychosocial benefits of adaptive sports participation, the impact on bone health and injury risk in adaptive athletes is of increasing clinical interest. Impaired bone health as a result of low energy availability has been well described in able-bodied athletic women and, more recently, men as part of the female athlete triad and Relative Energy Deficiency in Sport (RED-S). However, the applicability of these models to adaptive athletes remains unclear given altered physiology and biomechanics compared with able-bodied counterparts. Thus, a literature review was completed to characterize the influence of adaptive sports participation and associated risk factors for impaired bone health in this unique population. To date, limited investigations demonstrate a consistent, positive effect of sports participation on bone health. Risk factors for impaired bone health include low energy availability and micronutrient deficiency.

Low Energy Availability, Menstrual Dysfunction, and Low Bone Mineral Density in Individuals with a Disability: Implications for the Para Athlete Population

Low energy availability, functional hypothalamic amenorrhea, and low bone mineral density are three interrelated conditions described in athletic women. Although described as the female athlete triad (Triad), males experience similar health concerns. The literature suggests that individuals with a disability may experience altered physiology related to these three conditions when compared with the able-bodied population. The goal of this review is to describe the unique implications of low energy availability, low bone mineral density, and, in females, menstrual dysfunction in individuals with a disability and their potential impact on the para athlete population. A literature review was performed linking search terms related to the three conditions with six disability categories that are most represented in para sport. Few articles were found that directly pertained to athletes, therefore, the review additionally characterizes literature found in a non-athlete population. Review of the available literature in athletes suggests that both male and female athletes with spinal cord injury demonstrate risk factors for low energy availability. Bone mineral density may also show improvements for wheelchair athletes or athletes with hemiplegic cerebral palsy when compared with a disabled non-athlete population. However, the prevalence of the three conditions and implications on the health of para athletes is largely unknown and represents a key gap in the sports medicine literature. As participation in para sport continues to increase, further research is needed to understand the impact of these three interrelated health concerns for athletes with a disability, accompanied by educational initiatives targeting athletes, coaches, and health professionals.

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.

Patients with non-ambulatory cerebral palsy have higher sclerostin levels and lower bone mineral density than patients with ambulatory cerebral palsy

Bone loss is a serious clinical issue in patients with cerebral palsy (CP). Sclerostin has garnered interest as a key mechanosensor in osteocytes, leading to considerations of the therapeutic utilization of anti-sclerostin medications. This study was undertaken to determine associations among mechanical unloading, sclerostin levels, and bone imbalance in patients with CP. A total of 28 patients with CP participated in this cross-sectional study. The following measurements were taken: anthropometrics, clinical diagnosis of CP subtype and ambulatory status, bone mineral density (BMD) z-scores at the lumbar spine and hip, and blood biochemical markers, including sclerostin, parathyroid hormone (PTH), osteocalcin, C-terminal telopeptide, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, creatinine, calcium, and phosphorus. In analysis according to CP subtype, patients with spastic CP showed significantly lower BMD z-scores at the lumbar spine and femur neck regions than patients with dyskinetic CP. In analysis according to ambulatory status, patients with non-ambulatory CP showed significantly lower BMD z-scores at all lumbar spine and femoral sites, lower PTH and creatinine levels, and higher plasma sclerostin levels than patients with ambulatory CP. In regression analysis, ambulatory status was a significant determinant of plasma sclerostin levels. This study is the first to report on sclerostin levels and BMD in patients with CP, based on the hypothesis that patients who lack sufficient weight-bearing activities would show increased sclerostin levels and decreased BMD scores, compared with patients who sustain relatively sufficient physical activity. Therefore, this report may provide clinical insights for clinicians considering ambulatory status, sclerostin levels, and bone loss in patients with CP.

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

PURPOSE

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

Treatment outcomes after insufficiency femoral diaphyseal fractures in nonambulatory children

We retrospectively reviewed the treatment and outcomes of diaphyseal femur fractures in a cohort of nonambulatory children. There were 30 patients (38 fractures) reviewed [average age of 10.1 years (range: 1.8-17.8)]. Fractures were treated with locked plate/screw fixation (n=18), with a complication rate of 24% (9/38). Patients with elastic stable intramedullary nailing experienced the highest complication rate (5/7, 71%) compared with plate/screw fixation (2/18, 11%) (P=0.01) and underwent greater subsequent procedures (n=5, 63%). Surgeons should consider locked plate and screw fixation as their first treatment choice in this challenging patient population.

LEVEL OF EVIDENCE

III, therapeutic study; retrospective comparative study.

Osteoporosis in adults with cerebral palsy: feasibility of DXA screening and risk factors for low bone density

This study aims to describe osteoporosis screening in adults with cerebral palsy (CP) and identify any associated factors. Bone mineral density (BMD) was often lower than expected-for-age in these adults, and present even in young adulthood, particularly at the spine. Low BMD is frequent in adults with CP.

INTRODUCTION

This study aims to describe the feasibility of dual-energy X-Ray absorptiometry (DXA) screening in adults with cerebral palsy (CP) and identify factors associated with low bone mineral density (BMD), including longitudinal changes.

METHODS

A retrospective chart review study of these adults seen at an urban academic rehabilitation clinic and who underwent DXA scan(s). BMD and Z-scores for the lumbar spine, hips, and femoral (neck and total) were recorded. The change in BMD and Z-scores from baseline to follow-up DEXA, Gross Motor Functional Classification System (GMFCS), CP pattern (hemiplegic, diplegic, or quadriplegic), body mass index (BMI), and transfer and ambulation status were assessed.

RESULTS

Forty-two patients (83 % less than age 50 years) had at least one DXA. Seventeen had at least two studies, 15 without pharmacologic interventions between studies. Thirteen fractures in eight subjects were noted, most often lower limb. Fifty percent of spine studies in individuals under 50 had a Z-score of less than -2, while 25 and 30.8 % of these individuals had such scores at the right and left total hip sites, respectively. Need for transfer assistance was associated with lower BMD and Z-scores at all hip sites, but not the lumbar spine. Progressive abnormalities were seen at follow-up DXAs at some sites, however these were not statistically significant.

CONCLUSIONS

Lower than expected-for-age BMD was very frequent in adults with CP with mobility limitations, present at both spine and hip sites. Low BMI and need for transfer assistance had a negative impact on BMD. Although not statistically significant, progression of abnormalities was seen at follow-up for DXAs Z-scores at some sites, which suggests longitudinal studies in this population are needed.