Age trajectories of musculoskeletal morbidities 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.

Anxiety, depression, and support needs of the mothers of children with cerebral palsy and determining their opinions: Mixed methods study

PURPOSE

This study aimed to determine the level of anxiety, depression, support needs and opinions of mothers of children with cerebral palsy.

DESIGN AND METHODS

The study used a descriptive qualitative design. The population of the study consisted of children with cerebral palsy who were educated in special education centers in a province of Eastern Turkey. All participants who volunteered for the study were accepted and the study was completed with 126 mothers.

RESULTS

Caregiver mothers with male cerebral palsy patients had higher carer support needs and anxiety total mean scores. The mean scores of depression and anxiety of the mothers who were older were statistically higher. This study found that mothers of children with diseases other than cerebral palsy had statistically higher mean depression scores. The mothers of child with cerebral palsy who had a high gross motor classification score had higher mean carer support needs, depression, and anxiety total scores.

CONCLUSIONS

According to the study, depression and trait anxiety were linked to greater maternal support needs. Qualitative interviews revealed that mothers experienced issues such as stigmatization and withdrawal from social activities as a result of their children's illness.

PRACTICE IMPLICATIONS

This study shows the relationship of need for support of mothers of children with cerebral palsy and mental problems such as depression and trait anxiety. Pediatric nurses should provide emotional support to mothers and guide them towards support groups and training programs.

Ankle fracture open reduction and internal fixation in patients with cerebral palsy

AIM

To examine patients with cerebral palsy (CP) undergoing open reduction and internal fixation (ORIF) for ankle fractures.

METHOD

This was a retrospective study of adult patients undergoing ankle fracture ORIF for closed, isolated ankle fractures identified in between 2010 and 2021 in the Q1 PearlDiver M151 database. Patients with CP were identified with International Classification of Diseases (ICD)-9 and ICD-10 codes, and were matched to those without 1:10 on age, sex, and Elixhauser comorbidity index (ECI). Ninety-day adverse events were assessed with multivariable logistic regression.

RESULTS

A total of 148 993 patients with isolated ankle fracture ORIF were identified, of whom 407 (0.27%) had CP. After matching, 3863 without CP were compared to 389 with CP. Patients with CP were at increased odds of: 90-day urinary tract infection (odds ratios [OR] 6.26), pneumonia (OR 3.50), minor adverse events (OR 3.46), sepsis (OR 3.30), any adverse events (OR 3.04), emergency department visits (OR 2.28), serious adverse events (OR 1.77), and prolonged length of stay more than 4 days (OR 22.44) (p < 0.001 for all).

INTERPRETATION

Patients with CP undergoing ORIF for isolated, closed ankle fractures are at increased odds of several 90-day adverse events and prolonged length of stay compared to matched patients without CP.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

WHAT THIS PAPER ADDS

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

Adults with Cerebral Palsy: Navigating the Complexities of Aging

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

Five-year risk of fracture and subsequent fractures among adults with cerebral palsy

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.

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.

The effects of Bobath therapy on children with cerebral palsy: a systematic review

Background/Aims

Despite its broad application in paediatric care, the effectiveness of therapy based on the Bobath concept has not been systematically researched. The aim of this review was to explore whether there is scientific evidence regarding the validity of the Bobath concept as an effective therapy for children with cerebral palsy.

Methods

A search was conducted between March and December 2020, of research databases (Cochrane, PEDro, PubMed, Web of Science), selecting randomised controlled trials published since 2015, which compared Bobath therapy with other therapies in terms of their effect on the gross motor functions of children with cerebral palsy.

Results

Applying the eligibility criteria, four randomised controlled trials were selected, three of which found Bobath therapy to be more effective than other therapies as a therapeutic method, while one found no difference between Bobath therapy and another therapy. No study that met the inclusion criteria found Bobath therapy to be less effective than another therapy.

Conclusions

The principal limitation of this review has been the small number of randomised controlled trials found and so the results must be interpreted with caution. Nonetheless, studies showed that therapy based on Bobath therapy improves the gross motor function of children with cerebral palsy.

The effect of an ankle-foot orthosis on tibiofemoral motion during step-up and step-down in healthy adults

BACKGROUND

Solid ankle-foot orthoses (SAFOs) are frequently prescribed in conditions such as cerebral palsy and stroke. Although gait is improved in the short term, long-term effects of limiting ankle and foot motion during functional activities on joints such as the knee have not been investigated. Our study purpose was to compare tibiofemoral (TF) motion in shoe and SAFO conditions in healthy adults to inform future studies in clinical populations.

METHODS

A custom-made device using electromagnetic sensors was used to collect three-dimensional TF rotation data while 29 healthy adult participants (female participants = 19, age = 24.4 ± 4.5 years) performed step-up/step-down in shoe and SAFO conditions.

RESULTS

In the SAFO condition during step-up, extent of motion was greater in frontal and transverse planes and less in the sagittal plane. Discrete values at 0%-10% of the cycle in sagittal, 50%-100% in frontal, and 40%-100% in transverse planes were statistically different, producing more abduction and external rotation. In the SAFO condition during step-down, extent of motion was significantly greater in the frontal and transverse planes. Discrete values were statistically different in 40%-60% of the cycle in sagittal, 0%-30% and 70%-90% in frontal, and 0%-30% and 70%-90% in transverse planes, producing more abduction and external rotation in the first half of the cycle and more adduction and internal rotation in the second half of the cycle.

CONCLUSIONS

An SAFO affects triplanar TF kinematics in healthy adults during step-up/step-down. Future investigations into ankle-foot orthosis prescription and TF motion in clinical populations will facilitate optimal ankle-foot orthosis prescription and knee function in the long term.

Shared Physiologic Pathways Among Comorbidities for Adults With Cerebral Palsy

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

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

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

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

Polypharmacy is a risk factor for mortality, severe chronic kidney disease, and liver disease among privately insured adults with cerebral palsy

BACKGROUND: Adults with cerebral palsy (CP) have an increased risk for polypharmacy, premature mortality, and early development of several morbidities, including conditions associated with excess medication exposure, such as chronic kidney disease (CKD) and liver disease. To date, very little is known about the consequence of polypharmacy for adults with CP. OBJECTIVE: To determine if polypharmacy is associated with an increased risk for mortality, severe CKD, and liver disease among adults with CP, before and after adjusting for comorbid neurodevelopmental disabilities (NDDs) and multimorbidity. METHODS: This is an exploratory treatment effectiveness study. Data from the Optum Clinformatics Data Mart were used for this retrospective cohort study. Adults aged 18 years or older with a diagnosis of CP and without severe CKD (stages IV+) and liver disease were identified from the calendar year 2013 and were subsequently followed from January 1, 2014, to death, severe CKD, liver disease, loss to follow-up, or end of study period (December 31, 2017). Diagnosis codes were used to identify NDDs (intellectual disabilities, epilepsy, autism spectrum disorders, spina bifida) and 24 relevant morbidities at baseline (i.e., calendar year 2013). Polypharmacy was defined as ≥ 5 medications and hyperpolypharmacy was defined as ≥ 10 medications at baseline. Cox regression models were developed to examine the association (as HR and 95% CI) between polypharmacy and hyperpolypharmacy with mortality, severe CKD, and liver disease separately, before and after adjusting for covariates (demographics, NDDs, multimorbidity). Exploratory analyses examined the mediating effect of incident severe CKD or liver disease on the association between the exposure (polypharmacy or hyperpolypharmacy) on outcomes. RESULTS: Of the 9,238 adults with CP, 58.5% had polypharmacy and 29.5% had hyperpolypharmacy. The fully adjusted HR for mortality was 2.14 (95% CI = 1.59-2.89) for polypharmacy and 1.65 (95% CI = 1.31-2.09) for hyperpolypharmacy. The fully adjusted HR for severe CKD was 1.66 (95% CI = 1.17-2.36) for polypharmacy and 1.67 (95% CI = 1.27-2.19) for hyperpolypharmacy. The fully adjusted HR for liver disease was 1.57 (95% CI = 1.27-1.94) for polypharmacy and 1.72 (95% CI = 1.42-2.08) for hyperpolypharmacy. Incident liver disease mediated 5.37% (polypharmacy) and 7.54% (hyperpolypharmacy) of the association between the exposure with incident severe CKD for nonelderly (aged < 65 years), while incident severe CKD mediated 7.05% (polypharmacy) and 6.64% (hyperpolypharmacy) of the association between the exposure with incident liver disease for elderly (aged ≥ 65 years). CONCLUSIONS: Polypharmacy and hyperpolypharmacy are robust risk factors for risk of mortality, severe CKD, and liver disease among privately insured adults with CP. While incidence of severe CKD and liver disease had negligible effects on the association between polypharmacy with mortality, there is evidence that they mediate a considerable portion of one another and require further examination. DISCLOSURES: During the work for this study, Whitney was supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund and American Academy for Cerebral Palsy and Developmental Medicine. The funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The authors have no conflicts of interest to report.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What Happens to Our Neuromuscular Patients in Adulthood: Pathway to Independence and Maximal Function

BACKGROUND

Children with neuromuscular disorders regularly seek care from pediatric orthopaedic surgeons. These conditions can have a significant impact on the growth and development of children and their function and well-being as adults. Questions exist about the long-term outcomes of musculoskeletal interventions performed during childhood.

METHODS

A search of recent literature pertaining to the musculoskeletal and functional consequences of cerebral palsy, spina bifida, Duchenne muscular dystrophy, and spinal muscle atrophy was performed. Information from those articles was combined with the experience of the authors and their institutions.

RESULTS

Neuromuscular conditions can result in limb and spine deformities that lead to impaired physical function. Orthopaedic interventions during childhood can improve function and well-being and can be durable into adulthood. Unfortunately, many individuals with these conditions transition to adult health care that lacks the informed, collaborative multidisciplinary care they received as children. This can lead to unmet health care needs and a shortage of long-term natural history and outcome studies that would inform the care of children today.

CONCLUSIONS

Adults with childhood-onset neuromuscular conditions need, and deserve, dedicated health care systems that include the best aspects of the care they received as children. Pediatric orthopaedic surgeons have a role in promoting the development of such systems and a responsibility to learn from their adult patients.

LEVEL OF EVIDENCE

Expert Opinion.

Timecourse of Morbidity Onset Among Adults Living With Cerebral Palsy

INTRODUCTION

Despite the greater risk of an array of morbidities, little is known about when morbidities occur for adults with cerebral palsy. The objective of this study is to determine the timecourse of morbidity risk/development for adults with cerebral palsy and the effect by patient-level factors.

METHODS

Cross-sectional data from 2016 were used from a random 20% sample from the fee-for-service Medicare database. Diagnosis codes identified adults aged ≥18 years with cerebral palsy and 16 clinically relevant morbidities. Qualitative and quantitative approaches identified the age where each morbidity became exceedingly prevalent. The effect of the timecourse by sex, race, and co-occurring intellectual disabilities and epilepsy was examined. Data were sequestered and analyzed in 2020.

RESULTS

Among 16,818 adults with cerebral palsy, the prevalence of most morbidities was already high among those aged 18-30 years, and all morbidities increased with age except liver disease and anxiety. Hypertension and diabetes exhibited a positive linear trend with age. Of the morbidities that did not exhibit a linear trend, the qualitative and quantitative approaches were consistent considering that the cardiorespiratory diseases, osteoarthritis, renal disease, and dementia became exceedingly more prevalent at age >50 years, whereas the threshold was >60 years for depression, cancer, and metastatic cancer. There were interactions with sex, race, and co-occurring intellectual disabilities and epilepsy for some of the morbidities.

CONCLUSIONS

Morbidity prevalence is already elevated early in adulthood among individuals living with cerebral palsy, with an abrupt increase by age 50 years. Preventive efforts should be adopted early in the lifespan and not later than age 50 years for adults with cerebral palsy.

Whitney Comorbidity Index to monitor health status for adults with cerebral palsy: validation and thresholds to assist clinical decision making

AIM

To validate the Whitney Comorbidity Index (WCI), which was recently developed to monitor disease status for adults with cerebral palsy (CP), and to identify WCI scores associated with an increased mortality risk using a representative sample of adults with CP.

METHOD

Data from 2016 to 2018 were used from a random 20% sample from the fee-for-service Medicare database for this retrospective cohort study. The WCI was examined as unweighted (WCI_unw ) and weighted (WCI_w ) among adults at least 18 years old with CP. Cox regression models were developed with mortality as the outcome after adjusting for demographics. A concordance statistic (C-statistic) of at least 0.70 was considered as showing sufficient validity. The hazard ratio of mortality for each WCI score was estimated. Secondary analyses were performed for subgroups with co-occurring epilepsy and/or intellectual disabilities.

RESULTS

For the entire group (n=16 728) and subgroups, the WCI showed sufficient validity (C-statistic 0.73-0.81). For the entire group, the mortality rate was elevated for a score of 1 compared with 0 from the WCI_unw (hazard ratio 3.06; 95% confidence interval [CI] 1.52-6.17) and WCI_w (hazard ratio 4.08; 95% CI 1.69-9.85), and became larger with each WCI score. Results were similar for the subgroups.

INTERPRETATION

The WCI is a valid marker for health/disease status for adults with CP. Several WCI score thresholds were identified to assist in clinical decision making for preventive medicine and intervention implementation. What this paper adds The Whitney Comorbidity Index (WCI) is valid among 16 728 adults with CP. The WCI is valid for those with co-occurring epilepsy and/or intellectual disabilities. Thresholds of the WCI score were identified to assist clinical decision making.

Fracture characteristics by age, sex, and ambulatory status among individuals with cerebral palsy: a descriptive study

PURPOSE

To evaluate clinically relevant fracture characteristics by age, sex, and ambulatory status among individuals with cerebral palsy.

METHODS

Fracture location, energy of fracture, and activities that lead to a fracture were assessed among a clinic-based sample of children (0-17 years; n = 57) and adults (18-70 years; n = 58) with cerebral palsy that sustained a fracture by sex and gross motor function classification system (GMFCS) I-III vs. IV/V.

RESULTS

Proportion of fractures that were low-energy was 67-99% for children and 69-84% for adults. ∼2/3rds of fractures were at the lower extremities, with the distal femur being the most common site for children (44%) and the foot/ankle for adults (40%); however, there were age, sex, and ambulatory effects, such that 43% of adults GMFCS IV/V and 32% of women had a distal femur fracture. GMFCS I-III were more likely to fracture from functionally complex activities, while GMFCS IV/V were more likely to fracture from wheelchair/transfers/limb-stuck and incidental findings.

CONCLUSIONS

The majority of fractures were low-energy and occurred in the lower extremities, with effects by age, sex, and GMFCS. Activities that led to a fracture also differed by age and GMFCS, which can be used to design fracture prevention interventions in addition to bolstering skeletal mass and architecture.Implications for rehabilitationSkeletal fragility is a major problem for individuals with cerebral palsy (CP) across the lifespan leading to an increased risk of fragility fractures.Rehabilitation is a prime clinical intervention to prevent fractures from occurring and improving post-fracture healing and function; yet, effective rehabilitation interventions require knowledge of fracture characteristics, such as where fractures are occurring and the activities that lead to the fracture event specific to individuals with CP.Using a clinic-based sample of 0-70 year olds with CP, we describe salient fracture characteristics based on age, sex, and ambulatory status to enhance translation into clinical and rehabilitation practice.

Musculoskeletal diagnoses, comorbidities, and physical and occupational therapy use among older adults with and without cerebral palsy

BACKGROUND

Musculoskeletal (MSK) disorder in adults with cerebral palsy (CP) is higher than in the general population. Evidence lacks about physical therapy (PT) and occupational therapy (OT) service utilization among older adults (65> years) living with CP.

OBJECTIVE

We compared the presence of comorbidities and patterns of PT and OT use among older adults with and without CP seeking care for MSK disorders.

METHODS

A 20% national sample of Medicare claims data (2011-2014) identified community-living older adults with (n = 8796) and without CP (n = 5,613,384) with one or more ambulatory claims for MSK diagnoses. The sample matched one CP case to two non-CP cases per year on MSK diagnoses, age, sex, race, dual eligibility, and census region. Exposure variable was the presence/absence of a CP diagnosis. Outcomes were use of PT and OT services identified via CPT and revenue center codes, and the presence/absence of Elixhauser comorbidities.

RESULTS

In older adults with MSK diagnoses, less than a third regularly utilized PT and/or OT services, and adults with CP utilized significantly less PT than adults without CP, and for some MSK diagnoses had fewer visits than their matched peers. Older adults with CP were at greater risk for secondary conditions that influence morbidity, mortality, and quality of life compared to their age-matched peers without CP.

CONCLUSIONS

Older adults with CP and MSK diagnoses had a greater prevalence of numerous comorbidities and lower use of PT services relative to their non-CP peers.

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.

Development of a new comorbidity index for adults with cerebral palsy and comparative assessment with common comorbidity indices

AIM

To develop a new comorbidity index for adults with cerebral palsy (CP), the Whitney Comorbidity Index (WCI), which includes relevant comorbidities for this population and better predicts mortality than the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI).

METHOD

Data from the Optum Clinformatics Data Mart was used for this retrospective cohort study. Diagnosis codes were used to identify adults aged 18 years or older with CP (n=1511 females, n=1511 males; mean [SD; range] age=48y [19y 2mo; 18-89y]) and all comorbidities in the year 2014. The WCI was developed based on the comorbidities of the CCI and ECI and other relevant comorbidities associated with 2-year mortality using Cox regression and competing risk analysis. The WCI was examined as unweighted (WCI_unw ) and weighted (WCI_w ). The model fit and discrimination (C-statistic) of each index was assessed using Cox regression.

RESULTS

Twenty-seven comorbidities were included in the WCI; seven new comorbidities that were not part of the CCI or ECI were added. The WCI_unw and WCI_w showed a better model fit and discrimination for 1- and 2-year mortality compared to the CCI and ECI. The WCI_unw and WCI_w were strong predictors for 1- and 2-year mortality (C-statistic [95% confidence interval] ranging from 0.81 [0.76-0.85] to 0.88 [0.82-0.94]).

INTERPRETATION

The new WCI, designed to include clinically relevant comorbidities, provides a better model fit and discrimination of mortality for adults with CP.

WHAT THIS PAPER ADDS

Common comorbidity indices exclude relevant comorbidities for adults with cerebral palsy (CP). A new comorbidity index for adults with CP was created by harmonizing clinical theory and data-driven methods. The Whitney Comorbidity Index better predicted 1- and 2-year mortality than other commonly used comorbidity indices.

The Effect of Osteoporosis Medication on Risk Attenuation of Non-Trauma Fracture Among Adults with Cerebral Palsy: A Propensity Score-Matched Observational Study

Purpose

The efficacy of osteoporosis medication on reducing the risk of non-trauma fracture (NTFx) among adults with cerebral palsy (CP) has not been comprehensively investigated. There are many logistical and biological factors that may reduce this efficacy, and therefore requires attention. The purpose of this propensity score-matched, observational cohort study was to determine if osteoporosis medication was associated with NTFx risk attenuation among adults with CP and compared to adults without CP.

Materials and Methods

Data from 07/01/2011 to 09/30/2015 were extracted from Optum Clinformatics^® Data Mart. Claims identified adults (≥18 years), CP, osteoporosis medication, pre-index NTFx (6-months), and post-index NTFx (12-months). CP without osteoporosis medication (CP_Meds-) and without CP with Meds (non-CP_Meds+; reflects "background" population) served as controls and were matched (6:1 ratio) to adults with CP with Meds (CP_Meds+; n=306). The Meds groups were further stratified by the initiation of their medication as new users or consistent users. Changes in the prevalence of NTFx from pre- to post-index periods were examined with risk ratios (RR) and the change was compared among groups using the ratio of the RR (RRR) via difference-in-difference analysis.

Results

New users with CP had: a larger risk attenuation of any NTFx compared to CP_Meds- (RRR=0.39; 95% CI=0.22-0.71), which was consistent for vertebral column/hip and lower extremities; a larger risk attenuation for NTFx of the lower extremities compared to consistent users with CP (RRR=0.22; 95% CI=0.05-0.93); and a similar risk attenuation of any NTFx compared to new users without CP (RRR=0.81; 95% CI=0.45-1.43), which was consistent for vertebral column/hip and lower extremities.

Conclusion

The findings suggest that osteoporosis medication is associated with clinically meaningful risk attenuation of NTFx, especially for new users with CP.

Risk of dementia in adults with cerebral palsy: a matched cohort study using general practice data

OBJECTIVES

Determine the risk of incident dementia in adults with cerebral palsy (CP) compared with age, sex and general practice (GP) matched controls.

DESIGN

Retrospective cohort study.

SETTING

UK GPs linked into the Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

CPRD data were used to identify adults aged 18 or older with a diagnosis of CP. Each adult with CP was matched to three controls who were matched for age, sex and GP. In total, 1703 adults with CP and 5109 matched controls were included in the analysis. The mean baseline age of participants was 33.30 years (SD: 15.48 years) and 46.8% of the sample were female.

PRIMARY OUTCOME

New diagnosis of dementia during the follow-up period (earliest date of 1987 to latest date of 2015).

RESULTS

During the follow-up, 72 people were identified with a new diagnosis of dementia. The overall proportion of people with and without CP who developed dementia was similar (CP: n=19, 1.1%; matched controls n=54, 10.0%). The unadjusted HR suggested that people with CP had an increased hazard of being diagnosed with dementia when compared with matched controls (HR 2.69, 95% CI 1.44 to 5.00). This association was attenuated when CP comorbidities (sensory impairment, intellectual disability and epilepsy) were accounted for (HR 1.92, 95% CI 0.92 to 4.02).

CONCLUSIONS

There was no difference in the proportion of people with CP and matched controls who were diagnosed with dementia during the follow-up. Furthermore, while there was evidence for an increased hazard of dementia among people with CP, the fact that this association was attenuated after controlling for comorbidities indicates that this association may be explained by comorbidities rather than being a direct result of CP. Findings should be interpreted with caution due to the low number of incident cases of dementia.

Designing Exercise to Improve Bone Health Among Individuals With Cerebral Palsy

PURPOSE

Individuals with cerebral palsy (CP), ambulatory or not, have less bone strength and density than their peers. Aging individuals with CP are at a higher risk for nontraumatic fractures, progressive deformity, pain, and spinal stenosis. Critical periods for skeletal formation are during prepuberty and adolescence. Applying mechanostat theory to exercise design for individuals with CP may be beneficial.

METHODS

Principles of mechanostat theory, particularly the osteogenic index, is applied to guide the design of exercise programs based on varying levels of physical capacity.

RESULTS

Recommendations are made for optimizing dosing of a variety of interventions for improving bone health among individuals with CP based on mechanostat theory with specific type, number of repetitions, and frequency.

CONCLUSIONS

Researchers and clinicians are called to action to consider the role of exercise throughout the lifespan for all individuals with CP, regardless of level of severity.

Nontrauma fracture increases risk for respiratory disease among adults with cerebral palsy

Individuals with cerebral palsy (CP) manifest skeletal fragility problems early in life and are vulnerable to nontrauma fracture (NTFx), which may exacerbate the risk of respiratory disease (RD)- the main cause of premature mortality for this population. The purpose of this study was to determine if adults with CP had a greater 12-month risk of RD post-NTFx compared to adults without CP. Data from 2011 to 2017 were leveraged from Optum Clinformatics Data Mart; a claims database from a single private payer in the United States diagnostic codes were used to identify adults (≥18 years) with and without CP, NTFx, incident RD, and pre-NTFx cardiometabolic diseases. Cox proportional hazards regression models were used to compare 12-month RD incidence following NTFx with adjustment for sociodemographics and cardiometabolic diseases. Mean age (SD) at baseline was 57.5 (18.4) for adults with CP (n = 646) and 61.8 (19.7) for adults without CP (n = 321,482). During the follow-up, 172 adults with CP (26.6%) and 73 937 adults without CP (23.0%) developed RD. Adults with CP had higher 12-month post-NTFx RD incidence compared to adults without CP (hazard ratio [HR] = 1.20; 95% confidence interval [CI] = 1.03-1.37). When stratified by the RD subtype, adults with CP had a higher incidence of pneumonia (HR = 2.15; 95% CI = 1.56-2.95), interstitial/pleura disease (HR = 2.13; 95% CI = 1.53-2.96), and other RD (eg, respiratory failure; HR = 2.33; 95% CI = 1.82-2.98), but not acute respiratory infection (HR = 0.93; 95% CI = 0.75-1.15) or chronic obstructive pulmonary disease (HR = 1.15; 95% CI = 0.86-1.53). Among privately insured adults with CP, NTFx is associated with greater risk of RD among adults with vs without CP.

The respiratory disease burden of non-traumatic fractures for adults with cerebral palsy

Background

Individuals with cerebral palsy (CP) are vulnerable to non-trauma fracture (NTFx) and premature mortality due to respiratory disease (RD); however, very little is known about the contribution of NTFx to RD risk among adults with CP. The purpose of this study was to determine if NTFx is a risk factor for incident RD and if NTFx exacerbates RD risk in the adult CP population.

Methods

Data from 2011 to 2016 Optum Clinformatics® Data Mart and a random 20% sample Medicare fee-for-service were used for this retrospective cohort study. Diagnosis codes were used to identify adults (18+ years) with and without CP, NTFx, incident RD at 3-, 6-, 12-, and 24-month time points (pneumonia, chronic obstructive pulmonary disease, interstitial/pleura disease), and comorbidities. Crude incidence rates per 100 person years of RD were estimated. Cox regression estimated hazard ratios (HR and 95% confidence interval [CI]) for RD measures, comparing: (1) CP and NTFx (CP + NTFx); (2) CP without NTFx (CP w/o NTFx); (3) without CP and with NTFx (w/o CP + NTFx); and (4) without CP and without NTFx (w/o CP w/o NTFx) after adjusting for demographics and comorbidities.

Results

The crude incidence rate was elevated for CP + NTFx vs. CP w/o NTFx and w/o CP + NTFx for each RD measure. After adjustments, the HR was elevated for CP + NTFx vs. CP w/o NTFx for pneumonia and interstitial/pleura disease at all time points (all P < 0.05), but not chronic obstructive pulmonary disease (e.g., 24-month HR = 1.07; 95%CI = 0.88-1.31). The adjusted HR was elevated for CP + NTFx vs. w/o CP + NTFx for pneumonia at all time points, interstitial/pleura disease at 12- and 24-month time points, and chronic obstructive pulmonary disease at 24-months (all P < 0.05). There is evidence of a time-dependent effect of NTFx on pneumonia and interstitial/pleura disease for CP + NTFx as compared to CP w/o NTFx.

Conclusions

Study findings suggest that NTFx is a risk factor for incident RD, including pneumonia and interstitial/pleura disease, among adults with CP and that NTFx exacerbates RD risk for adults with vs. without CP.

Advanced CKD Among Adults With Cerebral Palsy: Incidence and Risk Factors

Rationale & Objective

Recent evidence suggests that adults with cerebral palsy have an elevated risk for developing advanced chronic kidney disease (CKD). To develop effective interventions, the objective was to identify whether demographics and preexisting medical conditions are risk factors for advanced CKD among adults with cerebral palsy.

Study Design

Retrospective cohort study.

Setting & Participants

Data were from the Optum Clinformatics Data Mart. Adults 18 years or older with cerebral palsy and without advanced CKD (CKD stage 4 or later) were identified from 2013 and subsequently followed up from January 1, 2014, to the development of advanced CKD, death, loss to follow-up, or end of the study period (December 31, 2017), whichever came first. Diagnostic, procedure, and diagnosis-related group codes were used to identify cerebral palsy, incident cases of advanced CKD, comorbid intellectual disability, and 10 preexisting medical conditions.

Exposures

Demographic variables and 10 preexisting medical conditions: CKD stages 1-3, hypertension, diabetes, heart and cerebrovascular disease, non-CKD urologic conditions, bowel conditions, respiratory disease, skeletal fragility, arthritis, and dysphagia.

Outcome

Incidence of advanced CKD.

Analytic Approach

Crude incidence rate (IR) of advanced CKD and IR ratios with 95% CIs were estimated. Cox proportional hazards regression models that were adjusted for demographics, intellectual disability, and preexisting medical conditions were used to evaluate the adjusted independent effect of predictor variables.

Results

237 of the 8,011 adults with cerebral palsy developed advanced CKD during follow-up (IR, 10.16/1,000 person years; 95% CI, 8.87-11.46). In the crude analysis, all preexisting medical conditions were associated with an elevated IR and IR ratio of advanced CKD. In the fully adjusted Cox proportional hazards regression model, the HR was elevated for older age, CKD stages 1-3 (HR, 3.32; 95% CI, 2.39-4.61), diabetes (HR, 2.69; 95% CI, 2.03-3.57), hypertension (HR, 1.54; 95% CI, .10-2.16), heart and cerebrovascular disease (HR, 1.53; 95% CI, 1.12-2.07), and non-CKD urologic conditions (HR, 1.39; 95% CI, 1.05-1.84).

Limitations

Private insurance database, short follow-up period, and lack of laboratory values, such as albuminuria/proteinuria.

Conclusions

Advanced CKD was common among adults with cerebral palsy and its development was associated with both traditional and nontraditional urologic risk factors.

Effectiveness of osteoporosis medication on site-specific fracture-risk attenuation among adults with epilepsy

OBJECTIVE

The objective of this propensity score-matched, observational cohort study was to determine the effectiveness of osteoporosis medication on reducing the risk of non-trauma fracture (NTFx) among adults with epilepsy.

METHODS

Data from 01/01/2012 to 09/30/2015 was extracted from Optum Clinformatics Data Mart. NTFx risk attenuation from 12 months prior to 12 months after the individual's index date was examined for each group of adults ≥50 years of age as risk ratios (RRs with 95% confidence intervals [CIs]). Groups were stratified based on: (1) epilepsy status, as with vs without epilepsy (EP); and (2) if and when osteoporosis medication was first prescribed, as new users (treatment naive), consistent users (osteoporosis medication prescribed in pre-index period), and no users. Comparison groups were matched 1:1 to EP new users (n = 828/group) for demographics, glucocorticoid and antiseizure medication, and the Elixhauser comorbidity index. Difference-in-difference analysis compared the change in pre- to post-index NTFx risk among groups as the ratio of the RR (RRR).

RESULTS

The pre- to post-index NTFx risk at any site was reduced for EP new users (RR = 0.49; 95% CI = 0.40-0.61) and EP consistent users (RR = 0.70; 95% CI = 0.38-0.98), but nonsignificantly elevated for EP no users (RR = 1.39; 95% CI = 0.93-2.07)-findings were consistent for most sites (eg, vertebral column). EP new users had a larger NTFx risk attenuation at any site compared to EP no users (RRR = 0.35; 95% CI = 0.23-0.54) and EP consistent users (RRR = 0.70; 95% CI = 0.51-0.97). EP consistent users had a larger NTFx risk attenuation at any site compared to EP no users (RRR = 0.50; 95% CI = 0.32-0.79). The extent of NTFx risk attenuation at any site was similar for new users with vs without epilepsy (RRR = 0.99; 95% CI = 0.73-1.34) and consistent users with vs without epilepsy (RRR = 0.81; 95% CI = 0.55-1.17). There was evidence of site-specific effects (eg, hip).

CONCLUSION

Osteoporosis medication is associated with a clinically meaningful 12-month NTFx risk attenuation for adults with epilepsy, especially for those just starting osteoporosis medication.

The mortality burden of non-trauma fracture for adults with cerebral palsy

Background

Individuals with cerebral palsy (CP) manifest skeletal fragility problems early in life, are vulnerable to non-trauma fracture (NTFx), and have a high burden of premature mortality. No studies have examined the contribution of NTFx to mortality among adults with CP. The purpose of this study was to determine if NTFx is a risk factor for mortality among adults with CP and if NTFx exacerbates mortality risk compared to adults without CP.

Methods

Data from 2011 to 2016 Optum Clinformatics® Data Mart and a random 20% sample Medicare fee-for-service were used for this retrospective cohort study. Diagnosis codes were used to identify adults (18+ years) with and without CP, NTFx, and pre-NTFx comorbidities. Crude mortality rates per 100 person years were estimated. Cox regression estimated hazard ratios (HR and 95% confidence interval [CI]) for mortality, comparing: (1) CP and NTFx (CP + NTFx; n = 1777); (2) CP without NTFx (CP w/o NTFx; n = 12,933); (3) without CP and with NTFx (w/o CP + NTFx; n = 433,560); and (4) without CP and without NTFx (w/o CP w/o NTFx; n = 6.8 M) after adjusting for demographics and pre-NTFx comorbidities.

Results

The 3-, 6-, and 12-month crude mortality rates were highest among CP + NTFx (12-month mortality rate = 6.80), followed by w/o CP + NTFx (12-month mortality rate = 4.91), CP w/o NTFx (12-month mortality rate = 2.15), and w/o CP w/o NTFx (12-month mortality rate = 0.49). After adjustments, the mortality rate was elevated for CP + NTFx for all time points compared to CP w/o NTFx (e.g., 12-month HR = 1.61; 95%CI = 1.29–2.01), w/o CP + NTFx (e.g., 12-month HR = 1.49; 95%CI = 1.24–1.80), and w/o CP w/o NTFx (e.g., 12-month HR = 5.33; 95%CI = 4.42–6.44). There were site-specific effects (vertebral column, lower extremities) on 12-month mortality.

Conclusions

NTFx is associated with an increase of 12-month mortality risk among adults with CP and compared to adults without CP. Findings suggest that NTFx may be a robust risk factor for mortality among adults with CP.

Effect of pain on mood affective disorders in adults with cerebral palsy

AIM

To determine if pain is associated with 12-month incidence of mood affective disorders (MAD) in adults with cerebral palsy (CP).

METHOD

Data from Optum Clinformatics^® Data Mart (2013-2016) were used for this retrospective cohort study. Diagnostic codes were used to identify adults (≥18y) with CP, incident cases of MAD, and covariates (other neurodevelopmental conditions, sleep disorders, arthritis). Pain (any type, location) was identified between 1st October 2014 and 30th September 2015. The pain group was divided into new or consistent pain if they had a history of pain (i.e. consistent) in the 12 months before their first pain claim date. Crude incidence rates of MAD (expressed per 100 person-years) were estimated. Cox regression was used to estimate hazard ratio (95% confidence interval [CI]) of MAD after adjusting for covariates.

RESULTS

Adults that had new pain (n=859; incidence rate=15.5) or consistent pain (n=1303; incidence rate=17.9) had greater crude incidence rate of MAD compared to adults without pain (n=3726; incidence rate=5.9). The elevated rate of MAD remained after adjusting for covariates, for new pain (hazard ratio=2.4; 95% CI=1.9-3.0) and consistent pain (hazard ratio=2.1; 95% CI=1.7-2.7).

INTERPRETATION

Pain is associated with greater incidence of MAD in adults with CP. This association remained after accounting for potential confounding factors.

WHAT THIS PAPER ADDS

What this paper adds Pain was associated with higher 12-month incidence of mood affective disorders (MAD). The 12-month MAD incidence was similar between new and consistent pain groups. The MAD incidence remained higher adjusting for neurodevelopmental comorbidities, sleep disorders, and arthritis.

The cardiovascular disease burden of non-traumatic fractures for adults with and without cerebral palsy

BACKGROUND

Individuals with cerebral palsy (CP) are vulnerable to non-trauma fracture (NTFx) and have an elevated burden of cardiovascular disease (CVD) related morbidity and mortality. However, very little is known about the contribution of NTFx to CVD risk among adults with CP. The purpose of this study was to determine if NTFx is a risk factor for CVD among adults with CP and if NTFx exacerbates CVD risk compared to adults without CP.

METHODS

Data from 2011 to 2016 Optum Clinformatics® Data Mart and a random 20% sample Medicare fee-for-service were used for this retrospective cohort study. Diagnosis codes were used to identify adults (18+ years) with and without CP, NTFx, incident CVD up to 2 years (i.e., ischemic heart disease, heart failure, cerebrovascular disease), and pre-NTFx comorbidities. Crude incidence rates per 100 person years of CVD measures were estimated. Cox regression estimated hazard ratios (HR and 95% confidence interval [CI]) for CVD measures, comparing: (1) CP and NTFx (CP + NTFx; n = 1012); (2) CP without NTFx (CP w/o NTFx; n = 8345); (3) without CP and with NTFx (w/o CP + NTFx; n = 257,355); and (4) without CP and without NTFx (w/o CP w/o NTFx; n = 4.8 M) after adjusting for demographics and pre-NTFx comorbidities.

RESULTS

The crude incidence rate was elevated for CP + NTFx vs. CP w/o NTFx and w/o CP + NTFx for any CVD and for each CVD subtype. After adjustments, the HR was elevated for CP + NTFx vs. CP w/o NTFx for any CVD (HR = 1.16; 95%CI = 0.98-1.38), heart failure (HR = 1.31; 95%CI = 1.01-1.70), and cerebrovascular disease (HR = 1.23; 95%CI = 0.98-1.55); although, only heart failure was statistically significant. The adjusted HR was elevated for CP + NTFx vs. w/o CP + NTFx for any CVD and for each CVD subtype (all P < .05). Stratified analyses showed a higher CVD risk by NTFx location, <65 year olds, and men when comparing CP + NTFx vs. CP w/o NTFx and w/o CP + NTFx.

CONCLUSIONS

NTFx increases 2-year CVD risk among adults with CP and compared to adults without CP. Findings suggest that NTFx is a risk factor for CVD among adults with CP.

Aging With Disability: Populations, Programs, and the New Paradigm An Introduction to the Special Issue

Objective: The purpose of this article is to introduce a special issue dedicated to research at the intersection of aging and disability. Method: We provide some context for the importance of cross-disciplinary collaboration among aging and disability researchers and summarize the nine articles in this issue. Results: Articles in the special issue are centered around several overarching themes. These include meaningful social and community participation, goals and values in the context of disability, and the reach and effectiveness of programs and policies on rehabilitation and service utilization. Conclusion: As care models continue to merge aging and disability services, collaboration among traditional aging and disability research networks can lead to improved outcomes for adults aging with long-term disability.

Walking through life with cerebral palsy: reflections on daily walking by adults with cerebral palsy

Purpose: Walking is a major target in childhood physiotherapy for children with cerebral palsy (CP). Little information exists on the importance or value of walking when these children grow up. The aim of this study was to explore personal reflections on daily walking by adults with CP.

Method: Semi-structured individual interviews were conducted and analysed with systematic text condensation, a four-step thematic cross-case analysis.

Results: Eight ambulatory adults (26–60 years, four women and four men) with CP were interviewed. Almost all had experienced deteriorated walking ability in adulthood and reported that walking was restricted and affected by intrinsic features, such as pain, fatigue, reduced balance and fear of falling. Extrinsic features such as being looked at due to walking abnormality and environmental factors, such as seasonal changes affected their free walking and was common. Some had accepted using mobility aids for energy conservation.

Conclusions: Both intrinsic and extrinsic factors influence walking in adults with CP. Reflections by the adults with CP suggest these features may reduce participation in public spaces and potentially increase acceptance and use of mobility aids.

Low-Trauma Fracture Increases 12-Month Incidence of Cardiovascular Disease for Adults With Cerebral Palsy

Individuals with cerebral palsy (CP) have poor skeletal and cardiovascular health. However, no studies have examined if skeletal fragility enhances cardiovascular disease (CVD) risk for this population. The purpose of this study was to determine whether adults with CP have higher 12-month CVD incidence following a low-trauma fracture compared with adults without CP. Data, from the Optum Clinformatics® Data Mart, were extracted from adults (18+ years) that sustained a low-trauma fracture between 01/01/2012 and 12/31/2016. The primary outcome measure was incident CVD within 12 months following a low-trauma fracture. Cox proportional hazards regression models were used to compare 12-month incident CVD with adjustment for sociodemographics and chronic disease comorbidities. Mean age (SD) at baseline was 54.7 (18.9) for adults with CP (n = 1,025, 43.3% men) and 60.4 (19.7) for adults without CP (n = 460,504, 33.7% men). During the follow-up, 121 adults with CP (11.8%, mean age [SD] = 63.9 [16.3]) and 45,330 adults without CP (9.8%, mean age [SD] = 74.5 [11.9]) developed CVD. In the fully adjusted model, adults with CP had higher 12-month post-fracture CVD incidence (hazard ratio [HR] = 1.63; 95% confidence interval [CI] = 1.37-1.95). When the outcome was stratified by CVD subtype, adults with CP had higher 12-month post-fracture incidence of ischemic heart disease (HR = 1.45; 95% CI = 1.09-1.92), heart failure (HR = 1.68; 95% CI = 1.22-2.31), and cerebrovascular disease (HR = 1.96; 95% CI = 1.54-2.50). Study findings suggest that among adults with CP, low-trauma fracture may enhance 12-month CVD incidence compared with adults without CP. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:803-810, 2020.

Incidence of falls among adults with cerebral palsy: a cohort study using primary care data

AIM

To compare the rate of falls between adults with and without cerebral palsy (CP).

METHOD

We used primary care data on 1705 adults with CP and 5115 adults without CP matched for age, sex, and general practice attended. We compared odds of experiencing a fall between adults with and without CP using conditional logistic regression. We compared the rate of falls using a negative binomial model.

RESULTS

Participants were 3628 males (53%) and 3192 females (47%) (median age 29y, interquartile range 20-42y) at the start of follow-up. Follow-up was 14 617 person-years for adults with CP and 56 816 person-years for adults without CP. Of adults with CP, 15.3% experienced at least one fall compared to 5.7% of adults without CP. Adults with CP had 3.64 times (95% confidence interval [CI] 2.98-4.45) the odds of experiencing a fall compared to adults without CP. The rate of falls was 30.5 per 1000 person-years and 6.7 per 1000 person-years for adults with and without CP respectively (rate ratio 5.83, 95% CI 4.84-7.02) INTERPRETATION: Adults with CP are more likely to fall, and fall more often, than adults without CP. The causes and consequences of falls in adults with CP need examination.

WHAT THIS PAPER ADDS

Twenty adults with CP and 5.3 adults without CP experienced at least one fall per 1000 person-years. Adults with CP experienced 30.5 falls per 1000 person-years compared to 6.7 falls per 1000 person-years among adults without CP. Adults with CP had 3.64 times the odds of experiencing a fall compared to adults without CP. Adults with CP experienced 5.83 times more falls than adults without CP.

Epidemiology of Cerebral Palsy in Adulthood: A Systematic Review and Meta-analysis of the Most Frequently Studied Outcomes

OBJECTIVE

To describe the epidemiology of health status, impairments, activities and participation in adults with cerebral palsy (CP).

DATA SOURCES

Embase, MEDLINE, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health, Cochrane, and Google Scholar were searched for 3 themes ("cerebral palsy," "adult," and "outcome assessment") in literature published between January 2000 and December 2018.

STUDY SELECTION

Full-article peer-reviewed English journal articles on descriptive, observational, or experimental studies describing the most studied outcomes in adults with CP (n≥25, age≥18y) were included. Studies were included in the analyses if frequently studied outcomes were described in at least 3 studies using similar methods of assessment.

DATA EXTRACTION

Data were extracted independently by 2 authors from 65 articles (total N=28,429) using a standardized score sheet.

DATA SYNTHESIS

Meta-analyses revealed that overall, on average 65.1% (95% confidence interval [CI], 55.1-74.5) of adults with CP experienced pain, 57.9% (95% CI, 51.1-64.6) were ambulant, 65.5% (95% CI, 61.2-69.7) had little or no limitation in manual ability, 18.2% (95% CI, 10.6-27.2) had tertiary education, 39.2% (95% CI, 31.5;47.1) were employed, and 29.3% (95% CI, 9.0-55.3) lived independently. In adults without intellectual disability, proportions of individuals who were ambulant (72.6% [95% CI, 58.8-84.5]) and lived independently (90.0% [95% CI, 83.8-94.9]) were higher (P=.014 and P<.01, respectively). The Fatigue Severity Scale score was 4.1 (95% CI, 3.8-4.4). Epilepsy (28.8% [95% CI, 20.1-38.4]) and asthma (28.3% [95% CI, 18.7-38.9]) were especially prevalent comorbidities.

CONCLUSIONS

The present systematic review and meta-analysis on the epidemiology of adults with CP provided state-of-the-art knowledge on the most frequently studied outcomes. On average, adults with CP are fatigued, and a majority experience pain, are ambulant, and have little or no difficulty with manual ability. On average, 40% are employed and 30% live independently. More uniformity in assessment and reports is advised to improve knowledge on epidemiology and gain insight in more outcomes.

Early-Onset Noncommunicable Disease and Multimorbidity Among Adults With Pediatric-Onset Disabilities

OBJECTIVE

To determine the prevalence of major noncommunicable diseases among young adults with pediatric-onset disabilities (PoDs) compared with young adults without PoDs.

PATIENTS AND METHODS

Data were obtained from the Optum Clinformatics Data Mart, a de-identified nationwide claims database of beneficiaries from a single private payer in the United States. Beneficiaries were included if they were 18 to 40 years old and had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for a PoD known to originate in childhood. Diagnostic codes were used to identify high-burden noncommunicable diseases: ischemic heart disease, cerebrovascular disease, hypertensive and other cardiovascular disease, type 2 diabetes, malignant cancer, osteoporosis, mood affective disorders, chronic obstructive pulmonary disease, chronic kidney disease, and liver disease. The prevalence of noncommunicable diseases and multimorbidity (≥2 diseases) was compared between adults with (N=47,077) and without (N=2,180,250) PoDs, before and after adjusting for sociodemographic characteristics. This study was conducted between July 1, 2018, and February 1, 2019.

RESULTS

Adults with PoDs had higher prevalences and adjusted odds of all noncommunicable diseases (odds ratio, 2.1-9.0; all P<.05) and multimorbidity (odds ratio, 3.8; 95% CI, 3.7-3.9) compared with adults without PoDs. After stratifying by the type of PoD (eg, musculoskeletal, circulatory), all PoD categories had higher prevalence of all noncommunicable diseases and multimorbidity compared with young adults without PoDs, except for ischemic heart disease and cerebrovascular disease among adults with PoDs of the genital organs.

CONCLUSION

Young adults with PoDs have an early onset of several noncommunicable diseases that represent major contributors to the global and national burden of disease and mortality.

Preferential deficit of fat-free soft tissue in the appendicular region of children with cerebral palsy and proposed statistical models to capture the deficit

BACKGROUND

Cerebral palsy (CP) is a neurological disorder characterized by a profound skeletal muscle deficit. However, whether there is a regional-specific skeletal muscle deficit in children with CP is unknown. The purpose of this study was to determine whether fat-free soft tissue mass (FFST), a commonly used surrogate for skeletal muscle mass, is more compromised in the limbs than in the trunk in children with CP. A second purpose was to determine whether physical characteristics can be used to accurately estimate appendicular FFST (AFFST) in children with CP.

METHODS

Forty-two children with CP (4-13 y) and 42 typically developing children matched to children with CP for sex, age and race were studied. Whole body FFST (FFST_whole), FFST in the upper limbs (FFST_upper), FFST in the lower limbs (FFST_lower), the ratio of AFFST to height (AFFST/ht), the ratio of AFFST to height² (AFFST/ht²) and non-appendicular FFST were estimated from dual-energy X-ray absorptiometry. Statistical models were developed to estimate AFFST, AFFST/ht and AFFST/ht² in both groups of children, and the leave-one-out method was used to validate the models.

RESULTS

Children with CP had 21% lower FFST_whole, 30% lower AFFST, 34% lower FFST_lower, 14% lower non-appendicular FFST, 23% lower AFFST/ht, 19% lower AFFST/ht² and 9% lower AFFST/FFST_whole (all p < 0.05). Statistical models developed using data from typically developing children overestimated AFFST, AFFST/ht and AFFST/ht² by 35%, 30% and 21% (all p < 0.05), respectively, in children with CP. Separate models developed using data from children with CP yielded better accuracy, with the estimated results highly correlated (r² = 0.78, 0.66 and 0.50, respectively; all p < 0.001) and not different from calculated AFFST, AFFST/ht and AFFST/ht² (all p > 0.99). However, when the difference in estimated values and measured values of AFFST, AFFST/ht and AFFST/ht² were plotted against measured values, there was an inverse relationship (r = -0.38, -0.47 and -0.61, respectively, all p < 0.05).

CONCLUSION

Children with CP have a remarkable deficit in FFST that is more pronounced in the appendicular than in the non-appendicular region and more pronounced in the lower than in the upper limbs. Preliminary models developed using data from children with CP can provide reasonable estimates of AFFST and indexes of AFFST relative to height, but further development of the models may be needed.

Elevated fracture risk for adults with neurodevelopmental disabilities

BACKGROUND

Fracture is a high-burden condition that accelerates unhealthful aging and represents a considerable economic burden. Adults with neurodevelopmental disabilities (NDDs) may be susceptible for fracture at younger ages compared to adults without NDDs; and yet, very little is known about the burden of fracture for these underserved populations. The purpose of this study was to determine the sex-stratified prevalence of all-cause fracture among adults with NDDs, as compared to adults without NDDs, and if comorbidity of NDDs is associated with greater risk of fracture.

METHODS

Data from 2016 were extracted from Optum Clinformatics® Data Mart (private insurance) and a random 20% sample from Medicare fee-for-service (public insurance). ICD-10-CM diagnosis codes were used to identify adults with NDDs, including intellectual disabilities, autism spectrum disorders, and cerebral palsy. Age-standardized prevalence of any fracture and fracture by anatomical location was compared between adults with and without NDDs, and then for adults with 1 NDD vs. 2 and 3 NDDs.

RESULTS

Adults with intellectual disabilities (n=69,456), autism spectrum disorders (n=21,844), and cerebral palsy (n=29,255) had a higher prevalence of any fracture compared to adults without NDDs (n=8.7 million). For women, it was 8.3%, 8.1%, and 8.5% vs. 3.5%, respectively. For men, it was 6.6%, 5.9%, and 6.7% vs. 3.0%, respectively. Women with NDDs had a higher prevalence of fracture of the head/neck, thoracic, lumbar/pelvis, upper extremities, and lower extremities compared to women without NDDs. A similar pattern was observed for men, except for no difference for lumbar/pelvis for all NDDs and thoracic for autism spectrum disorders. For women and men, increasing comorbidity of NDDs was associated with a higher prevalence of any fracture: 1 NDD (women, 7.7%; men, 5.7%); 2 NDDs (women, 9.4%; men, 7.2%); all 3 NDDs (women, 11.3%; men, 13.7%).

CONCLUSIONS

Study findings suggest that adults with NDDs have an elevated prevalence of fracture compared to adults without NDDs, with the fracture risk being higher with greater numbers of comorbid NDD conditions for most anatomical locations. Our study findings indicate a need for earlier screening and preventive services for musculoskeletal frailty for adults with NDDs.

The effect of low-trauma fracture on one-year mortality rate among privately insured adults with and without neurodevelopmental disabilities

BACKGROUND

Individuals with neurodevelopmental disabilities (NDDs) have poor development and preservation of skeletal health throughout the lifespan, and are especially vulnerable to low-trauma fracture and post-fracture health complications. However, no studies have examined if adults with NDDs have greater post-fracture mortality risk compared to adults without NDDs. The purpose of this study was to determine whether adults with NDDs have greater 12-month mortality rates following a low-trauma fracture compared to adults without NDDs.

METHODS

Data from 2011 to 2017 was leveraged from Optum Clinformatics® Data Mart; a nationwide claims database from a single private payer in the U.S. Data were extracted from adults (18+ years) with and without NDDs that sustained a low-trauma fracture between 01/01/2012-12/31/2016, as well as pre-fracture chronic diseases (i.e., cardiovascular diseases, cerebrovascular diseases, diabetes, chronic obstructive pulmonary diseases, cancer). Mortality rate was estimated for adults with and without NDDs, and the mortality rate ratio (RR) and 95% confidence interval (CI) was calculated. Cox regression was used to estimate hazard ratio (HR) and 95% CI for 1-, 3-, 6-, and 12-month post-fracture mortality rates between adults with and without NDDs after adjusting for age, sex, race, U.S. region, and pre-fracture chronic diseases.

RESULTS

Mean age (SD) at baseline was 56.7 (20.6) for adults with NDDs (n = 3749; 45.2% men) and 63.9 (19.2) for adults without NDDs (n = 585,910; 34.4% men). During the 12-month follow-up period, 182 adults with NDDs (mean age [SD] = 69.8 [14.7]; 46.2% men) and 25,456 adults without NDDs (mean age [SD] = 78.9 [9.8]; 38.3% men) died. Crude mortality rate was not different between adults with and without NDDs for any time points (e.g., 12-months: 5.40 vs. 4.96 per 100 person years; RR = 1.09; 95% CI = 0.94-1.26); however, it was greater for adults with intellectual disabilities compared to adults without NDDs (RR = 1.46; 95% CI = 1.23-1.79). After adjustments, adults with NDDs had greater post-fracture mortality rates for 3-, 6-, and 12-month time points (e.g., 12-months: HR = 1.46; 95% CI = 1.27-1.69). When stratified by the type of NDD, adults with intellectual disabilities and adults with autism spectrum disorders, but not adults with cerebral palsy, had greater 12-month post-fracture mortality risk. When stratified by fracture location, lower extremities were associated with greater crude mortality rate (RR = 1.69; 95% CI = 1.22-2.35) and adjusted mortality risk (HR = 2.41; 95% CI = 1.73-3.35), while upper extremities were associated with greater adjusted mortality risk (HR = 1.76; 95% CI = 1.23-2.50) for adults with vs. without NDDs.

CONCLUSIONS

Among privately insured adults with NDDs, low-trauma fracture is associated with greater mortality risk within 1 year of the fracture event, even after adjusting for pre-fracture chronic diseases. Study findings suggest the need for earlier fracture prevention strategies and improved post-fracture healthcare management.

Prevalence of High-Burden Medical Conditions Among Young and Middle-Aged Adults With Pediatric-Onset Medical Conditions: Findings From US Private and Public Administrative Claims Data

Adults with pediatric-onset medical conditions (POMCs) are susceptible to early development of high-burden medical conditions. However, research pertaining to this topic is lacking, which is vital information that could assist in health benefit planning and administration. The purpose of this study was to determine the prevalence of high-burden medical conditions among privately and publicly insured adults with POMCs, as compared to adults without POMCs, from the US. Data from 2016 were extracted from Optum Clinformatics® Data Mart (private insurance) and a random 20% sample from Medicare fee-for-service (public insurance). International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes were used to identify 18–64-year-old beneficiaries with POMCs, as well as several high-burden medical conditions, including pain, fracture, mood affective disorders, anxiety disorders, ischemic heart diseases, cerebrovascular diseases, hypertensive and other cardiovascular diseases, type 2 diabetes, osteoporosis, osteoarthritis, chronic obstructive pulmonary diseases, liver diseases, and cancer. Privately and publicly insured adults with POMCs had higher prevalence of all medical conditions compared to adults without POMCs. Publicly insured adults with POMCs had higher prevalence of all medical conditions compared to privately insured adults with POMCs, except for the lower prevalence of pain and cancer. When stratified by the category of POMCs (eg, musculoskeletal, circulatory), privately and publicly insured groups tended to have higher prevalence of most (private) or all (public) medical conditions compared to adults without POMCs. Adults with POMCs have higher prevalence of several high-burden medical conditions compared to adults without POMCs. This health disparity was present regardless of insurance coverage, but was generally more pronounced for public vs. private insured adults with POMCs.

Osteoporosis Epidemiology Among Adults With Cerebral Palsy: Findings From Private and Public Administrative Claims Data

Individuals with cerebral palsy (CP) have an increased risk for the early development of osteoporosis; however, little is known about the epidemiology of osteoporosis for adults with CP, which is vital to inform clinical practice for osteoporosis prevention, treatment, and management. The purpose of this cross-sectional study was to determine sex-stratified prevalence of osteoporosis among adults with CP, as compared with adults without CP. Data from 2016 were extracted from Optum Clinformatics Data Mart (private insurance administrative claims data) and a random 20% sample from the fee-for-service Medicare (public insurance administrative claims data). Diagnostic codes were used to identify CP and osteoporosis diagnoses. Sex-stratified prevalence of osteoporosis was compared between adults with and without CP for the following age groups: 18 to 30, 31 to 40, 41 to 50, 51 to 60, 61 to 70, and >70 years of age. The overall prevalence of osteoporosis was 4.8% for adults without CP (n = 8.7 million), 8.4% for privately insured adults with CP (n = 7,348), and 14.3% for publicly insured adults with CP (n = 21,907). Women and men with CP had a higher prevalence of osteoporosis compared with women and men without CP for all age groups. Finally, publicly insured women and men with CP had a higher prevalence of osteoporosis compared with privately insured women and men with CP for all age groups, except for the similar prevalence among the 18- to 30-year age group. These findings suggest that osteoporosis is more prevalent among adults with CP compared with adults without CP. Study findings highlight the need for earlier screening and preventive medical services for osteoporosis management among adults with CP. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

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.

Total and regional body fat status among children and young people with cerebral palsy: A scoping review

The purpose of our scoping review was to determine if children and young people with cerebral palsy (CP) have elevated total or regional body fat compared to children and young people without CP. Databases (Ovid MEDLINE, Embase Ovid, CINHAL and Scopus) were systematically searched from 1 January 1993 to 7 December 2018 in order to identify articles that compared weight status, total body fat or regional body fat (eg, abdominal) between children and young people (0-21 years) with and without CP. Extracted data included country, subject characteristics, group sample sizes and matching strategies, methods/measures for weight status/fat depot, fat depot(s) assessed and key findings. Twenty-two studies were included. Of these, 19 studies examined total body fat; the most common method was use of anthropometrics and the more common measures were body mass index and skin-fold thickness. Twelve studies examined at least one regional fat depot; the most common method was use of anthropometrics and the most common measure was skin-fold thickness. Findings were inconsistent across studies. Further, among 10 studies that examined total and regional body fat depots, 8 found differences across fat depots within the same children and young people (eg, no difference in total body fat but higher abdominal fat). This review provides a summary of inconsistent findings from published studies on body fat comparisons between children and young people with vs without CP, highlights limitations for evaluating body fat for children with CP and discusses future research directions.

Clinical factors associated with mood affective disorders among adults with cerebral palsy

Objective

To determine individual and aggregated associations of cerebral palsy (CP)-related symptoms and the effect of comorbid neurodevelopmental conditions on mood (affective) disorders among adults with CP.

Methods

Cross-sectional data from 2016 were extracted from a random 20% sample of the Medicare fee-for-service database. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes were used to identify 18- to -64-year-old beneficiaries with CP, as well as mood (affective) disorders, pain, sleep disorders, fatigue, and comorbid neurodevelopmental conditions (intellectual disabilities [ID], autism spectrum disorders [ASD], and epilepsy).

Results

Four thousand eight hundred twenty-three of the 17,212 adults with CP had mood (affective) disorders (28.0%). After adjusting for age, sex, and race, pain (odds ratio [OR] = 2.15; 99.5% confidence interval [CI] = 1.94-2.39), sleep disorders (OR = 2.43; 99.5% CI = 2.13-2.77), fatigue (OR = 1.38; 99.5% CI = 1.18-1.60), ID (OR = 1.47; 99.5% CI = 1.31-1.63), ASD (OR = 1.44; 99.5% CI = 1.16-1.80), and epilepsy (OR = 0.81; 99.5% CI = 0.73-0.91) were each associated with mood (affective) disorders. When pain, sleep disorders, and fatigue were presented as a count variable, the adjusted odds of mood (affective) disorders increased with the number of factors: 1 factor (OR = 1.99; 99.5% CI = 1.79-2.22), 2 factors (OR = 4.18; 99.5% CI = 3.58-4.89), and all 3 factors (OR = 7.38; 99.5% CI = 5.17-10.53).

Conclusions

Among young and middle-aged adults with CP, mood (affective) disorders were associated with pain, sleep disorders, and fatigue, and increasing co-occurrence of these factors further increased the likelihood of mood (affective) disorders. Further, comorbid neurodevelopmental conditions were also associated with mood (affective) disorders among adults with CP. Study findings could be used to improve screening strategies for mood (affective) disorders among adults with CP in the clinical setting.

Economic burden of paediatric-onset disabilities among young and middle-aged adults in the USA: a cohort study of privately insured beneficiaries

OBJECTIVE

Individuals with paediatric-onset disabilities (PoDs) have complex healthcare needs and are susceptible to adverse health outcomes, which may impose a higher strain on healthcare resources. The burden of healthcare resource utilisation and costs attributed to the population of adults with PoDs is not clearly established. The objective here was to compare healthcare resource utilisation and costs between adults with versus without PoDs.

DESIGN

Cohort.

SETTING

Data were from the 2016 Optum Clinformatics Data Mart, a de-identified nationwide claims database of beneficiaries from a single private payer in the USA.

PARTICIPANTS

International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes were used to identify beneficiaries with PoDs that were between 18 and 64 years of age.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual all-cause healthcare resource utilisation and total healthcare costs were compared between adults with and without PoDs before and after adjusting for sociodemographics and several costly non-communicable diseases.

RESULTS

Adults with PoDs (n=121 446) had greater annual mean counts of service utilisation for all service types (eg, inpatient, outpatient, emergency visits) compared with adults without PoDs (n=5 415 475) before and after adjustments (all p<0.001). Adults with PoDs had greater unadjusted total standardised reimbursement costs (US$26 702 vs US$8464; mean difference=US$18 238; cost ratio (CR)=3.16; 95% CI=3.13 to 3.18) and total patient out-of-pocket costs (US$2226 vs US$1157; mean difference=US$1069; CR=1.88; 95%CI=1.86 to 1.89). After adjustments, total standardised reimbursement costs were 2.32 times higher (95% CI=2.30 to 2.34) and total patient out-of-pocket costs were 1.65 times higher (95% CI=1.64 to 1.66) compared with adults without PoDs.

CONCLUSION

Adults with PoDs had greater healthcare utilisation and costs, even after accounting for costly diseases. Future research is needed to identify the cost drivers for adults with PoDs.

Prevalence of Mental Health Disorders Among Adults With Cerebral Palsy: A Cross-sectional Analysis

BACKGROUND

Persons with cerebral palsy (CP) have an increased risk for secondary chronic conditions during childhood, including mental health disorders. However, little is known about how these disorders affect adults with CP.

OBJECTIVE

To determine the prevalence of mental health disorders among adults with CP compared with those without CP.

DESIGN

Cross-sectional.

SETTING

2016 Optum Clinformatics Data Mart.

PATIENTS

8.7 million adults (including 7348 adults with CP).

MEASUREMENTS

Other neurodevelopmental comorbid conditions (intellectual disabilities, autism spectrum disorders, epilepsy) and 37 mental health disorders (as 6 categories) were identified on the basis of diagnosis codes. Direct age-standardized prevalence of the mental health disorder categories was estimated by sex for adults with CP alone, adults with CP and neurodevelopmental disorders, and adults without CP.

RESULTS

Men with CP alone had higher age-standardized prevalence than men without CP for schizophrenic disorders (2.8% [95% CI, 2.2% to 3.4%] vs. 0.7%), mood affective disorders (19.5% [CI, 18.0% to 21.0%] vs. 8.1%), anxiety disorders (19.5% [CI, 18.0% to 21.0%] vs. 11.1%), disorders of adult personality and behavior (1.2% [CI, 0.8% to 1.6%] vs. 0.3%), and alcohol- and opioid-related disorders (4.7% [CI, 3.9% to 5.5%] vs. 3.0%). The same pattern was observed for women. Compared with adults with CP alone, those with CP and neurodevelopmental disorders had similar or higher age-standardized prevalence of the 6 mental health disorder categories, except for the lower prevalence of alcohol- and opioid-related disorders in men.

LIMITATIONS

Single claims code was used to define the cohort of interest. Information on the severity of CP was not available.

CONCLUSION

Compared with adults without CP, those with CP have an elevated prevalence of mental health disorders, some of which may be more pronounced in patients with comorbid neurodevelopmental disorders.

PRIMARY FUNDING SOURCE

National Institute on Disability, Independent Living, and Rehabilitation Research.