The risk, burden, and management of non-communicable diseases in cerebral palsy: a scoping review

Body mass index is not suitable for assessing body composition in children with spastic cerebral palsy

PURPOSE

To measure body composition by using bioelectrical impedance analysis (BIA) and body mass index (BMI) and to investigate the correlation and agreement between BMI and fat mass percentage in children with spastic Cerebral Palsy.

MATERIALS AND METHODS

BIA was used to assess fat mass percentage and BMI was determined from body weight and height. BMI and fat mass percentage were both categorized into five categories. The association between fat mass percentage and BMI was assessed using Pearson's correlation coefficient. Agreement between BMI and fat mass percentage was investigated with weighted Cohen's kappa coefficient.

RESULTS

One hundred and three children with CP across all Gross Motor Function Classification Levels (61% boys, mean age 9 years) were included. Mean BMI was 18.3 kg/m2 and mean fat mass was 24.9%. A large inter-subject variability was found with a weak correlation between BMI and fat mass percentage in children with a BMI < 20 kg/m2. Little agreement (k = 0.299, CI 0.16-0.44) between the categorization of children based on BMI and based on fat mass percentage was found.

INTERPRETATION

The large inter-subject variability in fat mass percentage combined with little agreement between the BMI and BIA categories suggests that BMI is not a suitable measure of fat mass in children with CP.IMPLICATIONS FOR REHABILITATIONUsing body mass index (BMI) and instead of fat mass percentage increases the risk of misclassifying body composition in children with spastic Cerebral Palsy.Children with a BMI < 20 kg/m2 are more at risk to be misclassified for body composition.

The evolution of nutrition management in children with severe neurological impairment with a focus on cerebral palsy

Nutritional management of children with severe neurological impairment (SNI) is highly complex, and the profile of this population is changing. The aim of this narrative review was to give the reader a broad description of evolution of the nutritional management of children with SNI in a high resource setting. In the last decade, there has been an emphasis on using multiple anthropometric measures to monitor nutritional status in children with SNI, and several attempts at standardising the approach have been made. Tools such as the Feeding and Nutrition Screening Tool, the Subjective Global Nutrition Assessment, the Eating and Drinking Ability Classification System and the Focus on Early Eating and Drinking Swallowing (FEEDS) toolkit have become available. There has been an increased understanding of how the gut microbiome influences gastrointestinal symptoms common in children with SNI, and the use of fibre in the management of these has received attention. A new diagnosis, 'gastrointestinal dystonia', has been defined. The increased use and acceptance of blended food tube feeds has been a major development in the nutritional management of children with SNI, with reported benefits in managing gastrointestinal symptoms. New interventions to support eating and drinking skill development in children with SNI show promise. In conclusion, as the life expectancy of people with SNI increases due to advances in medical and nutrition care, our approach necessitates a view to long-term health and quality of life. This involves balancing adequate nutrition to support growth, development and well-being while avoiding overnutrition and its associated detrimental long-term effects.

Determinants of Frame Running Capacity in Athletes With Cerebral Palsy to Improve Training Routines and Classification Strategies: A Cross-sectional Observational Study

OBJECTIVES

The aim of the study were to (1) investigate what physical and physiological parameters are most important for Frame Running capacity, a parasport for individuals with ambulatory difficulties, and (2) determine whether Frame Running capacity can be predicted in athletes with cerebral palsy.

DESIGN

Athletes with cerebral palsy ( N = 62, Gross Motor Classification System I-V; 2/26/11/21/2) completed a 6-min Frame Running test. Before the 6-min Frame Running test, muscle thickness, passive range of motion (hip, knee, ankle), selective motor control, and spasticity (hip, knee, ankle) were measured in both legs. In total, 54 variables per individual were included. Data were analyzed using correlations, principal component analysis, orthogonal partial least square regression, and variable importance in projection analysis.

RESULTS

The mean 6-min Frame Running test distance was 789 ± 335 m and decreased with motor function severity. The orthogonal partial least square analysis revealed a modest degree of covariance in the variables analyzed and that the variance in the 6-min Frame Running test distance could be predicted with 75% accuracy based on all the variables measured. Variable importance in projection analysis indicated hip and knee extensor spasticity (negative effect), and muscle thickness (positive effect) arose as the most important factors contributing to Frame Running capacity.

CONCLUSIONS

These results are an important resource to enable optimization of training regimes to improve Frame Running capacity and contribute to evidence-based and fair classification for this parasport.

Heart rate responses, agreement and accuracy among persons with severe disabilities participating in the indirect movement program: Team Twin-an observational study

Introduction

Heart rate (HR) monitors are rarely used by people living with disabilities (PLWD), and their accuracy is undocumented. Thus, this study aims to describe the HR response during the Team Twin co-running program and, secondly, to assess the agreement and accuracy of using HR monitors among PLWD.

Methods

This 16-week single-arm observational study included 18 people with various disabilities. During the study, the subjects wore a Garmin Vivosmart 4 watch (wrist). To evaluate the agreement and accuracy we applied Garmin's HRM-DUAL™ chest-worn HR monitors for comparison with the Vivosmart 4. The HR response analysis was performed descriptively and with a mixed regression model. The HR agreement and accuracy procedure was conducted on a subsample of five subjects and analyzed using Lin's concordance analysis, Bland and Altman's limits of agreement, and Cohen's kappa analysis of intensity zone agreement. This study was prospectively registered at Clinical Trials.gov (NCT04536779).

Results

The subjects had a mean age of 35 (±12.6), 61% were male, 72% had cerebral palsy were 85% had GMFCS V-IV. HR was monitored for 202:10:33 (HH:MM:SS), with a mean HR of 90 ± 17 bpm during training and race. A total of 19% of the time was spent in intensity zones between light and moderate (30%-59% HR reserve) and 1% in vigorous (60%-84% HR reserve). The remaining 80% were in the very light intensity zone (<29% HR reserve). HR was highest at the start of race and training and steadily decreased. Inter-rater agreement was high (k = 0.75), limits of agreement were between -16 and 13 bpm, and accuracy was acceptable (Rc = 0.86).

Conclusion

Disability type, individual, and contextual factors will likely affect HR responses and the agreement and accuracy for PLWD. The Vivosmart 4, while overall accurate, had low precision due to high variability in the estimation. These findings implicate the methodical and practical difficulties of utilizing HR monitors to measure HR and thus physical activity in adapted sports activities for severely disabled individuals.

Policy brief: adaptive cycling equipment for individuals with neurodevelopmental disabilities as durable medical equipment

- Durable medical equipment (DME) policies require that the equipment be medically necessary; however, adaptive cycling equipment (bicycles and tricycles) are usually not deemed medically necessary. - Individuals with neurodevelopmental disabilities (NDD) are at high risk for secondary conditions, both physical and mental, that can be mitigated by increasing physical activity. - Significant financial costs are associated with the management of secondary conditions. - Adaptive cycling can provide improved physical health of individuals with NDD potentially reducing costs of comorbidities. - Expanding DME policies to include adaptive cycling equipment for qualifying individuals with NDD can increase access to equipment. - Regulations to ensure eligibility, proper fitting, prescription, and training can optimize health and wellbeing. - Programs for recycling or repurposing of equipment are warranted to optimize resources.

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.

Population- and individual-level trajectories of opioid prescription patterns among adults with cerebral palsy: a retrospective cohort study

BACKGROUND

There is little epidemiologic evidence on opioid prescription among adults with cerebral palsy (CP).

AIM

To describe the population- and individual-level opioid prescription patterns for adults with versus without CP.

METHOD

This retrospective cohort study used commercial claims (Optum's de-identified Clinformatics® Data Mart Database) from the USA from 01/01/2011-12/31/2017 from adults ≥ 18 years old with CP and matched adults without CP. For the population-level analysis, monthly estimates of opioid exposure were described for adults ≥ 18 years old with CP and matched adults without CP. For the individual-level analysis, group based trajectory modelling (GBTM) was used to identify groups of similar individual-level monthly opioid exposure patterns for adults with CP and matched adults without CP for 1-year starting from their first opioid exposure month.

RESULTS

For the population-level, adults with (n = 13,929) versus without (n = 278,538) CP had a higher prevalence of opioid exposure (~ 12%, ~ 8%) and days supplied (median, ~ 23, ~17) monthly over 7 years. For the individual-level, there were 6 trajectory groups for CP (n = 2099) and 5 for non-CP (n = 10,361). Notably, 14% of CP (comprising 4 distinct trajectory groups) and 8% (comprising 3 distinct groups) of non-CP had variably high monthly opioid volume for extended periods; exposure was higher for CP. The remaining had low/absent opioid exposure trajectories; for CP (non-CP), 55.7% (63.3%) had nearly absent exposure and 30.4% (28.9%) had consistently low exposure to opioids.

CONCLUSION

Adults with versus without CP were more likely to be exposed to opioids and for a longer duration, which may alter the risk-benefit balance of opioids.

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.

Effects of a 12-week, seated, virtual, home-based tele-exercise programme compared with a prerecorded video-based exercise programme in people with chronic neurological impairments: protocol for a randomised controlled trial

INTRODUCTION

Exercise is vital to staying well and preventing secondary complications in people with chronic neurological impairments (CNI). Appropriate exercise is often inaccessible to this population. The purpose of the study is to investigate the effects of a seated, virtual exercise programme on heart rate, recovery, fatigue, pain, motivation, enjoyment and quality of life in people with CNI.

METHODS AND ANALYSIS

Individuals with CNI will be screened for eligibility, and 60 participants will be randomised 1:1 into either a live or prerecorded group. There is no geographical limitation to where participants reside, since participation is virtual. The study will be coordinated by one site in White Plains, New York, USA. The live group will exercise with an instructor via Zoom while the prerecorded group will exercise at their chosen time using prerecorded videos, 3×/week for 12 weeks.

PRIMARY OUTCOME MEASURES

change in heart rate during exercise/recovery.

SECONDARY OUTCOME MEASURES

fatigue, motivation, level of pain and exertion, physical well-being, enjoyment of physical activity, motivation and quality of life. Outcomes will be assessed at baseline, midpoint, end of study and 1-month poststudy. Adverse events, medication changes and physical activity will be tracked throughout. Within-group and between-group comparisons will be performed by using analysis of covariance and regression.

ETHICS AND DISSEMINATION

BRANY IRB approval: 22 September 2020, protocol #20-08-388-512. All participants will provide written informed consent. Results will be disseminated through presentations, publications and ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT04564495.

Access, use and satisfaction with physiotherapy services among adults with cerebral palsy living in the United Kingdom and Ireland

PURPOSE

The aims of this study were to describe how and why adults with CP living in the UK and Ireland accessed and used physiotherapy services; to describe the type of physiotherapy accessed and satisfaction with physiotherapy services and to examine the associations between relevant factors.

METHODS

A cross-sectional semi-structured online survey was employed. Participants were adults with CP aged 18 and above living in the UK and Ireland; able to complete an online questionnaire in English independently or with technical or physical assistance. Data were collected from April 2019 to February 2020.

RESULTS

Participants (n = 162) were aged 18-74 years. The majority were female (75%) and lived in the UK (83%). Ninety percent of participants reported a need for physiotherapy but only 35% received physiotherapy services. The most common reason for visiting physiotherapy was mobility decline (62%). Satisfaction with the availability and quality of physiotherapy services were 21% and 27%, respectively. Adults with scoliosis and mobility decline were less likely to report that they received the physiotherapy they needed.

CONCLUSION

Adults with CP did not receive the physiotherapy services that they perceived they needed. There is a need to develop physiotherapy services in collaboration with people living with CP.Implications of rehabilitationAdults with cerebral palsy (CP) needed physiotherapy services, but were not receiving the physiotherapy services that they perceive they needed.Adults were not satisfied with the availability or quality of physiotherapy services received.Adults with scoliosis and mobility decline were less likely to report that they received the physiotherapy they needed.There is a need to develop physiotherapy services from a life-span perspective for adults living with CP.

A core outcome set for multimorbidity risk in individuals with cerebral palsy

AIM

To: (1) investigate the importance of outcome measurement instruments (OMIs) within a core outcome set (COS) for multimorbidity (at least two chronic health conditions) risk in individuals with cerebral palsy (CP); (2) investigate the feasibility of OMIs within the COS in international clinical research settings in adolescents and adults with CP; and (3) describe the associations between the COS data and Gross Motor Function Classification System (GMFCS) levels.

METHOD

Eighty-three individuals with CP completed a survey on health outcomes: physical behaviour, nutrition, sleep, endurance, body composition, blood pressure, blood lipids, and glucose. A cross-sectional study assessed the feasibility of the COS in 67 adolescents and adults with CP (mean age 30y, SD 15y 1mo, min-max: 14-68y, 52.2% male) at four centres. Prevalence of multimorbidity risk and associations with GMFCS levels are described.

RESULTS

Most participants rated physical behaviour, nutrition, sleep, and endurance as very important. Body composition, blood pressure, nutrition, and sleep were highly feasible since data were collected in 88% or more participants who consented to having the assessments. Physical behaviour, cardiorespiratory endurance, and blood draws were collected in less than 60% of participants. Total time sedentary (ρ=0.53, p<0.01) and endurance (ρ=-0.46, p<0.01) were significantly associated with GMFCS level.

INTERPRETATION

The COS identified that most participants had poor sleep quality and endurance, did not have healthy diets, and showed increased sedentary behaviour. Individuals with CP valued these outcomes as most important, suggesting a need to assess these modifiable behaviours in this population. Objective measures of physical behaviour and cardiorespiratory endurance in the COS required additional personnel, time, and participant burden. We recommend that healthcare providers should perform a simpler first screen using questionnaire-based assessments and then focus the use of the remainder of the COS if required for the patient.

Vitamin D deficiency in children with cerebral palsy: A narrative review of epidemiology, contributing factors, clinical consequences and interventions

Sufficient vitamin D levels are necessary, not only for mineralization, normal growth and development of bones, but also for the prevention of fatal chronic diseases like diabetes mellitus, metabolic syndrome and cancer. This is of particular importance in children with neuro- and musculoskeletal disorders, especially cerebral palsy (CP). CP is a heterogeneous group of childhood developmental disability disorders described by uncharacteristic posture, balance, and movement. Patients with CP are at an increased risk of vitamin D deficiency and as a result reduced bone mineral density, bone fragility, osteopenia, and rickets. The present review aims to combine and summarize available evidence, regarding the epidemiology, underlying contributing factors, clinical consequences, and treatment interventions of vitamin D deficiency in children with CP.

Risk of early- and late-onset Alzheimer disease and related dementia in adults with cerebral palsy

AIM

To examine the risk of Alzheimer disease and related dementia (ADRD) among adults with cerebral palsy (CP).

METHOD

Using administrative insurance claims data for 2007 to 2017 in the USA, we identified adults (45y or older) with a diagnosis of CP (n=5176). Adults without a diagnosis of CP were included as a typically developing comparison group (n=1 119 131). Using age, sex, ethnicity, other demographic variables, and a set of chronic morbidities, we propensity-matched individuals with and without CP (n=5038). Cox survival models were used to estimate ADRD risk within a 3-year follow up.

RESULTS

The unadjusted incidence of ADRD was 9 and 2.4 times higher among cohorts of adults 45 to 64 years (1.8%) and 65 years and older (4.8%) with CP than the respective unmatched individuals without CP (0.2% and 2.0% among 45-64y and 65y or older respectively). Fully adjusted survival models indicated that adults with CP had a greater hazard for ADRD (among 45-64y: unmatched hazard ratio 7.48 [95% confidence interval {CI} 6.05-9.25], matched hazard ratio 4.73 [95% CI 2.72-8.29]; among 65y or older: unmatched hazard ratio 2.21 [95% CI 1.95-2.51], matched hazard ratio 1.73 [1.39-2.15]).

INTERPRETATION

Clinical guidelines for early screening of cognitive function among individuals with CP need updating, and preventative and/or therapeutic services should be used to reduce the risk of ADRD.

Diet quality in adults with cerebral palsy: a modifiable risk factor for cardiovascular disease prevention

AIM

To assess diet quality and its relationship with cardiovascular health measures for adults with cerebral palsy (CP).

METHOD

A convenience sample of 45 adults with CP (26 females, 19 males; mean age 35y 10mo [SD 14y 9mo]). were recruited for this cross-sectional study. Demographic, medical, and Gross Motor Function Classification System (GMFCS) information were obtained through in-person visits. Participants completed two 24-hour dietary recalls using the Automated Self-Administered 24-hour Dietary Assessment Tool. Specific macronutrient intake was compared to 2015 to 2020 US Department of Agriculture (USDA) guidelines. Other data included body mass index (BMI), waist-to-hip ratio (WHR), blood pressure, and hemoglobin A1c (HgA1c;n=43).

RESULTS

Adults across GMFCS levels I to V were enrolled, 20 participants were in GMFCS levels IV or V. Mean calorie intake was 1777.91/day (SD 610.54), while sodium intake was 3261.75mg/day (SD 1484.92). Five participants met USDA vegetable and seven fruit guidelines. None met whole grain targets. Sixteen were overweight/obese by BMI. Sixteen participants without hypertension diagnoses had elevated blood pressure and nine had abnormal HgA1c without prediabetes/diabetes history. Percent calories from saturated fat was inversely associated with WHR in unadjusted and adjusted models (p=0.002 and p=0.003 respectively); all other dietary recommendations assessed (total calories, sodium, and sugar) were non-significant. Post hoc analyses were unchanged using 2020 to 2025 USDA guidelines.

INTERPRETATION

Assessment of nutrient intake and diet quality is feasible and warrants further study in adults with CP, as USDA guidelines are largely unmet. What this paper adds Adults with cerebral palsy (CP) do not meet US Department of Agriculture dietary quality recommendations. Prediabetes and hypertension may be common, but unrecognized, in adults with CP. Screening for nutrient intake and diet quality should be performed to facilitate nutritional counseling.

When Movement Moves: Study Protocol for a Multi-Method Pre/Post Evaluation Study of Two Programmes; the Danish Team Twin and Cycling Without Age

Physical activity (PA) can improve physical, mental, and social health, leading to quality of life (QoL). However, some are unable to participate independently due to age-related impairments or disabilities. This study protocol presents the design, methods, outcomes, strengths and limitations of the study “When Movement Moves” (WMM). WMM investigates whether indirect PA in a social context, where persons are unable to participate independently, can result in outcomes similar to those of independent PA, by evaluating the effects of disabled’s, elderly, volunteers’, relatives’ and nursing staff’s participation in either the running programme (Team Twin) or cycling programme (Cycling Without Age). Both programmes seek to enhance QoL through indirect PA in a social context, making PA possible for elderly and disabled persons through PA conducted by abled-bodied volunteers. WMM is a multi-method 12–16-week pre/post evaluation with quality of life, physical, mental and social health as main outcomes. Pre/post measurements consist of questionnaires, clinical examinations, and physical and cognitive appraisal. Throughout, interviews and participant observations will be conducted. Combined results will provide essential knowledge on the effects and experiences of indirect PA. Explorative data will pave the way for further research. Findings may inform policies, guidelines and health promotion among the elderly and disabled.

Navigating the Pathway to Care in Adults With Cerebral Palsy

As individuals with cerebral palsy (CP) age, they face unique challenges which complicate their ability to access and receive appropriate health care. These problems exist at the level of the health care system, the clinician, and the individual. At the system level, there is an inadequate number of professionals who are informed of and interested in the care of adults with CP. Pediatric clinicians prefer treating children, and adult caregivers are not knowledgeable about and may feel less competent about CP. Pediatric care does not translate well to the adult population, and information about best practices for adults is just starting to develop. Differences in the physiologic development of individuals with CP render well-established clinical protocols for risk screening of chronic diseases less effective. Moreover, lack of supportive resources decreases a caregiver's sense of self-efficacy in treating this population. The patient's ability to navigate these barriers is complicated by the high prevalence of comorbid cognitive impairment and mental health issues including anxiety, depression, and other psychiatric disorders; a bidirectional relationship between challenges in navigating care/needs and comorbid mental health conditions appears likely. Many patients have additional barriers related to social determinants of health, such as access to transportation, accessible health care facilities, and other personal and environmental factors that may impede health maintenance and wellness. Increasing and disseminating knowledge, harnessing the power of new technologies such as telemedicine, and addressing mental health issues are some of the methods that are available to help adults with CP navigate this road.

Is Physical Activity-Related Self-Efficacy Associated with Moderate to Vigorous Physical Activity and Sedentary Behaviour among Ambulatory Children with Cerebral Palsy?

Purpose: To determine how physical activity-related self-efficacy is associated with physical activity and sedentary behaviour time among ambulatory children with cerebral palsy (CP). Method: Children with CP, Gross Motor Function Classification System (GMFCS) Levels I-III ( N = 26; aged 9–18 y), completed the task self-efficacy component of a self-efficacy scale and wore Actigraph GT3X+ accelerometers for 5 days. Correlations (Pearson and Spearman’s rank-order; a = 0.050) were conducted to evaluate the relationships among age, GMFCS level, self-efficacy, and both daily moderate-to-vigorous physical activity (MVPA) and sedentary time. Linear regression models were used to determine the relationships among the independent variables and MVPA and sedentary time. Results: Self-efficacy was positively associated with MVPA time ( r = 0.428, p = 0.015) and negatively correlated with sedentary time ( r = –0.332, p = 0.049). In our linear regression models, gross motor function (β = –0.462, p = 0.006), age (β = –0.344, p = 0.033), and self-efficacy (β = 0.281, p = 0.080) were associated with MVPA time ( R2 = 0.508), while GMFCS level (β = 0.439, p = 0.003) and age (β = 0.605, p < 0.001) were associated with sedentary time ( R2 = 0.584). Conclusions: This research suggests that self-efficacy, age, and gross motor function are associated with MVPA in children with CP. Additional research is needed to confirm these findings and further explore the influence of self-efficacy on sedentary behaviour.

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Early indicators of cardiovascular disease are evident in children and adolescents with cerebral palsy

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of early mortality among young adults with cerebral palsy. While low physical activity in childhood has been hypothesized as a potential contributor to increased CVD risk in early adulthood, little is known about timing of vascular disease progression and the presence of subclinical atherosclerosis has not been extensively evaluated in children with cerebral palsy.

OBJECTIVE

The aim of this study was to determine if measures of vascular structure and function are different between children and adolescents with and without cerebral palsy.

METHODS

In this cross-sectional study, we measured carotid intima-media thickness (CIMT), and brachial artery flow-mediated dilation (FMD) of children with and without cerebral palsy. Group means for CIMT and brachial artery FMD absolute (FMDA) and percent of relative change (FMDR%) were compared using Wilcoxon rank-sum tests.

RESULTS

A total of 26 children and adolescents with cerebral palsy (46.1% girls, mean age = 15.0 ± 2.0 years) and 19 controls (68.4% girls, mean age = 13.3 ± 2.6 years) participated. Children with cerebral palsy had significantly greater average CIMT (0.43 ± 0.02 mm) than children without cerebral palsy (0.41 ± 0.01 mm, p = 0.04), and lower FMDA (0.16 ± 0.15 mm vs. 0.29 ± 0.20 mm; respectively, p = 0.03).

CONCLUSIONS

Children and adolescents with cerebral palsy may exhibit impairments in vascular structure and function which represent an increased risk of premature atherosclerosis compared to children without cerebral palsy. Additional research to identify risk factors specific to children with cerebral palsy that would support the development of effective screening processes for early identification would enable clinicians to implement targeted preventive strategies.

Adults with Cerebral Palsy Require Ongoing Neurologic Care: A Systematic Review

Cerebral palsy (CP) neurologic care and research efforts typically focus on children. However, most people with CP are adults. Adults with CP are at increased risk of new neurologic conditions, such as stroke and myelopathy, that require ongoing neurologic surveillance to distinguish them from baseline motor impairments. Neurologic factors could also contribute to the motor function decline, chronic pain, and chronic fatigue that are commonly experienced by adults with CP. Based on a systematic literature review, we suggest (1) guidelines for neurologic surveillance and neurologist referral and (2) clinical research questions regarding the evolving neurologic risks for adults with CP. ANN NEUROL 2021;89:860-871.

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.

Population-based study on the prevalence and clinical profile of adults with cerebral palsy in Northern Ireland

OBJECTIVES

This study aimed to report the prevalence and clinical characteristics of adults with cerebral palsy (CP) in a geographically defined region of the UK.

DESIGN AND SETTING

Cross-sectional study using the Northern Ireland Cerebral Palsy Register (NICPR).

PARTICIPANTS

All validated cases known to the NICPR, born 1981-2001 and alive and resident in Northern Ireland at age 19 years were included.

RESULTS

The study included 1218 persons with CP aged 19-39 years, 46 of whom died in adulthood. The prevalence of CP was 2.38 per 1000. The majority of cases had spastic CP (n=1132/1218, 93%) and could walk (n=949/1218, 78%). Those that died in adulthood typically had bilateral spastic CP (n=39/46) and used a wheelchair (n=40/46).

CONCLUSION

The prevalence of CP in adults is similar to other common neurological conditions such as multiple sclerosis and Parkinson's disease. The needs of adults with CP vary widely with almost half having two or more associated impairments that may require multiprofessional and multiagency coordination. Results from this study can be used to inform transformation of health and care services for adults with CP.

The Impact of Malnutrition on Hospitalized Children With Cerebral Palsy

Children with cerebral palsy (CP) and other medical complexity comprise an outsized proportion of health care use. In this review, we describe the current science of assessment of nutritional status for children with CP, outline a systematic approach to assessing their nutritional status, delineate ramifications of malnutrition on hospitalization-associated outcomes, and identify knowledge gaps and means of addressing those gaps using quality improvement and clinical research tools. Methods to accurately assess body composition and adiposity in this population by using skinfolds, age, sex, and activity level are available but are not widely used. There are limitations in our current method of estimating energy needs in children with CP, who are at higher risk of both obesity and micronutrient deficiencies. There is some evidence of an association between malnutrition, defined as either underweight or obesity, and hospitalization-associated outcomes in children generally, although we lack specific data for CP. The gaps in our current understanding of optimal nutritional status and between current science and practice need to be addressed to improve health outcomes for this vulnerable patient population.

Obesity and cardio-metabolic risk factors among children and adolescents with cerebral palsy

Introduction

Background: obesity and associated cardiometabolic complications are increasing among adults with cerebral palsy (CP). Information in children is scarce, and there is no consensus definition of obesity. Objectives: to describe the frequency of obesity and metabolic complications in children and adolescents with CP. Methods: a descriptive, cross-sectional study performed in two outpatient pediatric special needs centers. Demographic, anthropometric (Brooks 2011), and motor function (GMFCS) data, as well as antiepileptic use, were recorded. Fasting triglycerides (TG), total cholesterol (TC), vitamin D (25OHD), glycemia (GLY), and insulinemia levels were measured. The HOMA index was calculated. Results: sixty-five patients were enrolled. Aage was 10.8 ± 4.9 years; 63.1 % were male; 81.6 % had GMFCS IV-V; 43.5 % had a gastrostomy; and 83.1 % were on antiepileptics. According to their BMI, 15.4 % were underweight (< 10th percentile) and 10.8 % overweight (> 75th percentile). Overall, 6.1 % had TC ≥ 200 mg/dL, 21.4 % had TG ≥ 110 or 130 mg/dL, 4.6 % had GLY ≥ 100 mg/dL, 16.9 % had HOMA ≥ 3, and 76.9 % had 25OHD < 30 ng/mL. Children with BMI ≥ 75th percentile had higher HOMA and insulin resistance rates than those with BMI < 75th percentile. Elevated TGs were associated with high motor impairment and low vitamin D. HOMA was associated to feminine gender and BMI ≥ 75th percentile. Conclusions: the frequency of cardiometabolic risk factors was high in this sample of pediatric patients with CP, associated with overweight, low mobility, and vitamin D deficiency. We propose a BMI > 75th percentile as cutoff point for metabolic risk factors.

Profile of hospital admissions for adults with cerebral palsy: a retrospective cohort study

AIM

To retrospectively profile acute hospital admissions for a defined cohort of adults with cerebral palsy (CP).

METHOD

Five years of health service data were interrogated to identify acute health service use by adults with CP. Admission types were described, admission reasons categorized using International Classification of Diseases, 10th Revision codes, and length of stay (LOS) calculated. Any differences between paediatric and adult subsets were explored.

RESULTS

Individuals with CP constituted 2922 admissions. Of these, 850 (29%) were adult admissions. There were significant differences between admission reasons for paediatric and adult cohorts, with adults predominantly seeking hospital admission for emergency rather than planned care (emergency reason: adults 62.1%, paediatrics 25.2%; p<0.001). The median adult admission LOS was longer than that of children (p<0.001). The primary diagnosis admission reason in the adult data set was respiratory illness (20%) followed closely by gastrostomy dysfunction (19%).

INTERPRETATION

Adults with CP predominantly access acute hospital services for emergency health care. A high frequency of admissions is associated with respiratory illness and gastrostomy dysfunction in adults with CP. What this paper adds Adults with cerebral palsy (CP) access acute inpatient services for emergency health care. Hospital admissions are predominantly because of respiratory illness and gastrostomy dysfunction. Admission length of stay is longer for adults than children. Many adults with CP require hospitalization more than once a year.

Quality of Life and Health Services Utilization for Spanish Children With Cerebral Palsy

PURPOSE

To examine the health-related quality of life of children with cerebral palsy and its relationship with their use of health resources, taking into account sociodemographic factors concerning the family context.

DESIGN AND METHODS

Cross-sectional study of children with cerebral palsy in Granada (Spain). Quality of life was evaluated with PedsQL questionnaire.

RESULTS

A total of 75 children were analysed (mean age 7.41 years; SD 4.37; 50.7% male). They made an average of 22.80 visits (SD 12.43) per year; greater use was made of resources by children who had been diagnosed with cerebral palsy for <45 months (36.00 vs. 26.93 visits per year, p < 0.0001). Older children suffered more fatigue and pain. Children aged 2-4 years who presented with fatigue had more hospitalizations (r = -0.35; p = 0.20), whereas those >4 years who had a higher quality of life for daily activities had made more visits to hospital A&E (r = 0.35, p = 0.043). Among the children studied, there was no significant association between HRQOL and the parents' education or occupation.

CONCLUSION

These findings highlight variables that may influence children's quality of life and their use of health resources, identifying certain profiles of children who might need individualized interventions.

PRACTICE IMPLICATIONS

These findings could inform services provided by paediatric nurses to children with cerebral palsy, to individualize interventions and improve patient centred care.

Effect of RaceRunning on cardiometabolic disease risk factors and functional mobility in young people with moderate-to-severe cerebral palsy: protocol for a feasibility study

INTRODUCTION

There is consistent evidence that people with cerebral palsy (CP) do not engage in the recommended physical activity guidelines for the general population from a young age. Participation in moderate-to-vigorous physical activity is particularly reduced in people with CP who have a moderate-to-severe disability. RaceRunning is a growing disability sport that provides an opportunity for people with moderate-to-severe disability to participate in physical activity in the community. It allows those who are unable to walk independently to propel themselves using a RaceRunning bike, which has a breastplate for support but no pedals. The aim of this study is to examine the feasibility and acceptability of RaceRunning for young people with moderate-to-severe CP and the feasibility of conducting a definitive study of the effect of RaceRunning on cardiometabolic disease risk factors and functional mobility.

METHODS AND ANALYSIS

Twenty-five young people (age 5-21 years) with CP or acquired brain injury affecting coordination will be included in this single-arm intervention study. Participants will take part in one RaceRunning session each week for 24 weeks. Outcomes assessed at baseline, 12 and 24 weeks include body mass index, waist circumference, blood pressure, muscle strength, cardiorespiratory fitness, physical activity and sedentary behaviour, functional mobility, activity competence and psychosocial impact. Adverse events will be systematically recorded throughout the 24 weeks. Focus groups will be conducted with participants and/or parents to explore their views and experiences of taking part in RaceRunning.

ETHICS AND DISSEMINATION

Approval has been granted by Queen Margaret University Research Ethics Committee (REC) and the South East of Scotland REC. Results will be disseminated through peer-reviewed journals and distributed to people with CP and their families through RaceRunning and Athletic Clubs, National Health Service trusts and organisations for people with disabilities.

TRIAL REGISTRATION NUMBER

NCT04034342; pre-results.

Risk of Depression and Anxiety in Adults With Cerebral Palsy

Importance

Cerebral palsy (CP) is considered a pediatric condition despite most individuals with CP living into adulthood. Thus, there is a lack of evidence in adults with CP, which includes a paucity of research examining mental health in this population.

Objectives

To determine the risk of depression and anxiety in adults with CP compared with an age-, sex-, and practice-matched reference group of adults without CP, using primary care data.

Design, Setting, and Participants

Retrospective longitudinal cohort study set in UK primary care. Data were analyzed using Cox proportional hazards regression analyses adjusted for chronic conditions and visits to their physician. The study period ran from January 1987 to November 2015. Data of entry into the study ranged from January 1987 to September 2015. Data for 1705 adults 18 years or older with CP and 5115 matched adults without CP were extracted. Cerebral palsy was identified using diagnostic codes, and each person with CP was compared with 3 age-, sex-, and practice-matched controls.

Exposures

Diagnosis of CP, with a second analysis accounting for comorbidity of intellectual disability (ID).

Main Outcomes and Measures

Time to diagnosis for depression or anxiety following the date of entry into the study in adults with CP (with and without ID) compared with matched controls.

Results

The mean (SD) age of the 1705 patients with CP and the 5115 adults without CP was 33.3 (15.5) years, and 798 participants (46.8%) were women. Individuals with CP had an increased adjusted hazard of depression (hazard ratio [HR], 1.28; 95% CI, 1.09-1.51) and anxiety (HR, 1.40; 95% CI, 1.21-1.63) compared with the matched reference group. When we accounted for ID comorbidity, there were 363 adults with CP who also had ID (mean [SD] age, 32.1 [13.2] years; 159 women [47.6%]) and 1342 adults with CP who did not have ID (mean [SD] age, 33.6 [16.1] years; 639 women [43.8%]). Only those individuals with CP and no comorbid ID had a higher risk of incident depression (HR, 1.44; 95% CI, 1.20-1.72) and anxiety (HR, 1.55; 95% CI, 1.28-1.87) than their matched controls.

Conclusions and Relevance

Adults with CP have an increased risk of depression or anxiety. In particular, these results indicate that this association is driven largely by those individuals with CP with no co-occurring ID. Future work is needed in community-based samples to fully elucidate the causal mechanisms driving these associations.

Total Joint Arthroplasty in Patients With Cerebral Palsy

INTRODUCTION

Cerebral palsy (CP) is a neurodevelopmental condition with a wide range of presentations that usually lead to muscle imbalance culminating with precocious knee and hip arthrosis, often leading to total hip (THA) and knee arthroplasty (TKA). This study sought to determine the following: (1) the inherent differences of in-hospital characteristics and comorbidities between CP and non-CP patients undergoing total joint arthroplasty (TJA) and (2) do patients with CP have an increased risk of perioperative complications after TJA?

METHODS

The Nationwide Inpatient Sample database from 2005 to 2014 was queried in this retrospective cohort study to compare patient demographics and comorbidities, hospital characteristics, perioperative complications, and length of stay in patients with CP undergoing TJA compared with their non-CP counterparts. Statistical analyses were performed using the Rao-Scott chi-square test and analysis of variance. All analyses took into account the sampling procedure and weighting.

RESULTS

A total of 2,062 and 2,193 patients with CP underwent THA and TKA, respectively, during the study period. Both CP groups were younger (P < 0.0001), were more likely to have Medicaid insurance (P < 0.0001), and had longer lengths of hospital stay (P < 0.0001) compared with their non-CP counterparts. Non-CP patients had significantly higher rates of obesity, coronary artery disease, diabetes, and peripheral vascular disease (P < 0.05). However, patients with CP undergoing THA had a lower Charlson Comorbidity Index (P = 0.0002), whereas those undergoing TKA had similar comorbidity profile as the non-CP group (P = 0.097). Both THA and TKA CP patients had a higher risk of overall postoperative complications (P < 0.05) and surgical complications (P < 0.05), in particular acute postoperative anemia (P < 0.05).

CONCLUSION

Despite being younger with fewer comorbidities, patients with CP are at an increased risk of immediate perioperative complications after TJA compared with the general osteoarthritis population. Given that these patients have satisfactory long-term outcomes after TJA, these procedures can be performed successfully for patients with CP with careful medical management and surgical planning.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Acupuncture treatment on the motor area of the scalp for motor dysfunction in children with cerebral palsy: study protocol for a multicenter randomized controlled trial

Background

Scalp acupuncture has been widely used as treatment for motor dysfunction in children with cerebral palsy in China. Previous studies have failed to provide high-quality evidence to demonstrate the effectiveness of this treatment in children with cerebral palsy. No high-quality randomized controlled trials on scalp acupuncture have been published. The aim of this study is to evaluate the effectiveness of Jiao’s scalp acupuncture when combined with routine rehabilitation treatment versus routine rehabilitation treatment alone for motor dysfunction in children with cerebral palsy.

Methods/Design

This is a four-centre randomized controlled trial. One hundred cerebral palsy patients with motor dysfunction were enrolled. Patients will be allocated in a 1:1 ratio into either an acupuncture treatment group or a control group. Cerebral palsy patients in the control group will receive conventional rehabilitation treatment, whereas patients in the acupuncture group will receive a combination of scalp acupuncture and conventional rehabilitation treatment. Thirty-six treatment sessions will be performed over a 12-week period. The Gross Motor Function Measure and the Fine Motor Function Measure Scale will be assessed as the primary outcome measures. The Paediatric Evaluation of Disability Inventory and the Cerebral Palsy Quality of Life Questionnaire for Children will be selected as secondary outcome measures. All assessments will be conducted at baseline, week 4 (treatment 12), week 8 (treatment 24), week 12 (treatment 36) and week 24 (follow-up).

Discussion

This is the first trial evaluating the efficacy and safety of scalp acupuncture as a treatment for motor dysfunction in children with cerebral palsy. The results of this trial are expected to provide relevant evidence demonstrating that scalp acupuncture can be used as an effective rehabilitation treatment method for improving motor dysfunction in children with cerebral palsy.

Trial registration

ClinicalTrials.gov, NCT03921281. Registered on 19 April 2019.

[The need to act together in every way possible: inter-sector action in health and education for children living with the congenital Zika syndrome]

The experience with an intervention program conducted in an educational institution and targeted to families of children with congenital Zika syndrome, which includes multiple disabilities, revealed the challenges and strides with the entry of these families in the school system. This article aimed to explore the findings from a study conducted after the conclusion of an intervention program, using semi-open interviews with professional staff at the institution and the possible contributions towards establishing inter-sector relations aimed at school inclusion of children with disabilities. A change was seen, as a result of the program, in the relationship between the families and the professionals at the educational institution, whereby the families had room to voice their fears and discuss the school's role in the lives of their children with disabilities. The professionals thus came to see the families taking a more active stance. This experience can favor other services and municipalities that seek school inclusion for children and adolescents with disabilities, as well as their social inclusion and that of their families.

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.

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.

Validity of the International Physical Activity Questionnaire Short Form (IPAQ-SF) as a measure of physical activity (PA) in young people with cerebral palsy: A cross-sectional study

OBJECTIVES

The aim of this study was to examine the validity of the International Physical Activity Questionnaire Short Form (IPAQ-SF) as a measure of physical activity (PA) in young people with cerebral palsy (CP).

DESIGN

Cross-sectional.

SETTING

Participants were recruited through 8 National Health Service (NHS) trusts, one school, one university and through organisations that provide services for people with disabilities in England.

PARTICIPANTS

Sixty-four, ambulatory young people aged 10-19 years with CP [Gross Motor Function Classification System (GMFCS) levels I-III] participated in this study.

MAIN OUTCOME MEASURE

The IPAQ-SF was administered to participants. Participants were then asked to wear a wGT3X-BT triaxial accelerometer (ActiGraph, Pensacola, FL) for 7 days to objectively assess PA. Time spent in sedentary behaviour, in moderate to vigorous PA (MVPA) and in total PA (TPA) was compared between measures.

RESULTS

Young people with CP self-reported less time in sedentary behaviour and underestimated the time spent in TPA, when compared to accelerometer measurements. Bland-Altman plots demonstrated poor agreement between the measures for MVPA, with upper and lower 95% limits of agreement of -147 to 148.9minute. After adjusting for gender and GMFCS level, age was a predictor of the difference between measures for MVPA (P<0.001) and TPA (P<0.001).

CONCLUSIONS

These findings suggest that the IPAQ-SF is not a valid method of measuring TPA or sedentary behaviour in young people with CP and it is not appropriate for use when assessing an individual's time in MVPA. Therefore, where feasible, an objective measure of PA should be used.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN90378161.

Incidence of osteoarthritis, osteoporosis and inflammatory musculoskeletal diseases in adults with cerebral palsy: A population-based cohort study

BACKGROUND

People with cerebral palsy (CP) may be at increased risk of musculoskeletal conditions due to various factors including malnutrition and abnormal levels of skeletal loading. This study aimed to compare the incidence of osteoporosis, osteoarthritis and inflammatory musculoskeletal diseases between adults with and without CP.

METHODS

A population based cohort study was conducted using data from the Clinical Practice Research Datalink collected between 1987 and 2015. Adults with CP were matched to adults without CP for age, sex and general practice. Cox models, stratified by matched set and adjusted for potential confounders, were fitted to compare the risk of osteoporosis, osteoarthritis and inflammatory musculoskeletal diseases.

RESULTS

1705 adults with CP were matched to 5115 adults without CP. Adults with CP had an increased risk of osteoporosis in unadjusted (Hazard Ratio (HR) 3.67, 95% Confidence Interval (CI) 2.32 to 5.80, p < 0.001) and adjusted (HR 6.19, 95% CI 3.37 to 11.39, p < 0.001) analyses. No evidence of increased risk of inflammatory musculoskeletal diseases was observed in unadjusted or adjusted analyses. For osteoarthritis no evidence of increased risk was seen in the unadjusted analysis, but evidence of an increased risk was seen when the analysis was adjusted for alcohol consumption, smoking status, and mean yearly general practice (GP) visits (HR 1.54, 95% CI 1.17 to 2.02, p < 0.001).

CONCLUSIONS

After accounting for potential confounding variables, we found that CP is associated with increased risk of osteoporosis and osteoarthritis. These findings provide the strongest epidemiological evidence to date for increased risk of osteoporosis and osteoarthritis in people with CP, and highlight need for clinical awareness of such conditions in this population.

Mortality due to cardiovascular disease, respiratory disease, and cancer in adults with cerebral palsy

AIM

To compare mortality rates for cardiovascular disease, cancer, and respiratory disease between adults with cerebral palsy (CP) and the general population.

METHOD

A cohort study was conducted using data from adults with CP in England, identified through a primary care data set (the Clinical Practice Research Datalink), with linked data on death registrations from the Office for National Statistics. Cause of death was categorized according to International Classification of Diseases codes. Standardized mortality ratios (SMRs) were calculated to compare mortality rates between adults with CP and the general population, adjusted for age, sex, and calendar year.

RESULTS

Nine hundred and fifty-eight adults with CP were identified (52.5% males, 47.5% females; median age at start of follow-up 31y [interquartile range 22-43y]) and followed for a total of 7693 person-years. One hundred and forty-two patients (15%) died during follow-up. Adults with CP had an increased risk of death due to cardiovascular disease (SMR: 3.19, 95% confidence interval [CI] 2.20-4.62) and respiratory disease (SMR: 13.59, 95% CI 9.89-18.67), but not from malignant neoplasms (SMR: 1.42, 95% CI 0.83-2.45).

INTERPRETATION

We found that adults with CP in England have increased risk of death due to diseases of the circulatory and respiratory systems, supporting findings from two studies that compared cause-specific mortality rates between adults with CP in the USA and the general population. Further research is required into primary and secondary prevention of cardiovascular and respiratory disease in people with CP worldwide.

WHAT THIS PAPER ADDS

Adults with cerebral palsy (CP) in England have 14-fold increased risk of mortality due to diseases of the respiratory system. They have a 3-fold increased risk of mortality due to diseases of the circulatory system. Adults with CP had an increased risk of death due to cerebrovascular disease and ischaemic heart disease. The elevated risk of ischaemic heart disease, however, did not reach statistical significance at the 5% per cent level.

Evaluating the Effects of Performance-Focused Swimming Training on People with Cerebral Palsy Who Have High Support Needs – A Study Protocol Using Single-Case Experimental Design

Background:

People with cerebral palsy (CP) are less physically active than the general population and, consequently, are at increased risk of preventable disease. Evidence indicates that low-moderate doses of physical activity can reduce disease risk and improve fitness and function in people with CP. Para athletes with CP typically engage in ‘performance-focused’ sports training, which is undertaken for the sole purpose of enhancing sports performance. Anecdotally, many Para athletes report that participation in performance-focused sports training confers meaningful clinical benefits which exceed those reported in the literature; however, supporting scientific evidence is lacking. The aim of this paper is to describe the protocol for an 18-month study evaluating the clinical effects of a performance-focused swimming training programme for people with CP who have high support needs.

Methods:

This study will use a concurrent multiple-baseline, single-case experimental design across three participants with CP who have high support needs. Each participant will complete a five-phase trial comprising: baseline (A1); training phase 1 (B1); maintenance phase 1 (A2); training phase 2 (B2); and maintenance phase 2 (A3). For each participant, measurement of swim velocity, health-related quality of life and gross motor functioning will be carried out a minimum of five times in each of the five phases.

Discussion:

The study described will produce Level II evidence regarding the effects of performance-focused swimming training on clinical outcomes in people with CP who have high support needs. Findings are expected to provide an indication of the potential for sport to augment outcomes in neurological rehabilitation.

Optimal Management of Undescended Testis in Boys with Cerebral Palsy. A Debate

Cerebral palsy is a rare condition following injury of the developing brain and including nonprogressive neurological disorders, spasticity, intellectual impairment and others. Boys with cerebral palsy have a high incidence of undescended testis. Although the motives for treatment (infertility, cancer prevention, psychological aspects, testicular torsion) are not different in boys without neurological impairment, the decision-making process in boys with cerebral palsy is very difficult. Besides medical and surgical arguments the discussion involves challenging ethical issues.

The Adapted Physical Activity Program: A Theory-Driven, Evidence-Based Physical Activity Intervention for People with Brain Impairment

People with brain impairments are less active than the general population and consequently have an increased risk of chronic disease. To increase activity requires interventions that are theory driven and evidence based. Here, we describe the adapted physical activity program (APAP), a physical activity promotion program with demonstrated efficacy in community dwelling adults with brain impairments. Distinguishing features of the APAP include the following: delivery in the participants home/or community environment and the utilisation of the principals of community-based rehabilitation; the assessment of each of the domains of the International Classification of Functioning, Disability and Health (ICF) (i.e., health conditions, impairments, activity limitations, participation restrictions and personal and environmental characteristics) to determine how they will impact physical activity adoption and maintenance; the incorporation of theory-based physical activity adoption and maintenance strategies; the utilisation of lifestyle physical activity programs (including client-centred selection of activities) and/or structured exercise programs (requiring principles of exercise prescription). It is anticipated that this program description will permit researchers and/or practitioners to implement the program, replicate its evaluation and/or translate the program into multi-professional rehabilitation settings.