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Xu Y, Li Y, Richard SA, Sun Y, Zhu C. Genetic pathways in cerebral palsy: a review of the implications for precision diagnosis and understanding disease mechanisms. Neural Regen Res 2024; 19:1499-1508. [PMID: 38051892 PMCID: PMC10883492 DOI: 10.4103/1673-5374.385855] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/02/2023] [Indexed: 12/07/2023] Open
Abstract
ABSTRACT Cerebral palsy is a diagnostic term utilized to describe a group of permanent disorders affecting movement and posture. Patients with cerebral palsy are often only capable of limited activity, resulting from non-progressive disturbances in the fetal or neonatal brain. These disturbances severely impact the child's daily life and impose a substantial economic burden on the family. Although cerebral palsy encompasses various brain injuries leading to similar clinical outcomes, the understanding of its etiological pathways remains incomplete owing to its complexity and heterogeneity. This review aims to summarize the current knowledge on the genetic factors influencing cerebral palsy development. It is now widely acknowledged that genetic mutations and alterations play a pivotal role in cerebral palsy development, which can be further influenced by environmental factors. Despite continuous research endeavors, the underlying factors contributing to cerebral palsy remain are still elusive. However, significant progress has been made in genetic research that has markedly enhanced our comprehension of the genetic factors underlying cerebral palsy development. Moreover, these genetic factors have been categorized based on the identified gene mutations in patients through clinical genotyping, including thrombosis, angiogenesis, mitochondrial and oxidative phosphorylation function, neuronal migration, and cellular autophagy. Furthermore, exploring targeted genotypes holds potential for precision treatment. In conclusion, advancements in genetic research have substantially improved our understanding of the genetic causes underlying cerebral palsy. These breakthroughs have the potential to pave the way for new treatments and therapies, consequently shaping the future of cerebral palsy research and its clinical management. The investigation of cerebral palsy genetics holds the potential to significantly advance treatments and management strategies. By elucidating the underlying cellular mechanisms, we can develop targeted interventions to optimize outcomes. A continued collaboration between researchers and clinicians is imperative to comprehensively unravel the intricate genetic etiology of cerebral palsy.
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Affiliation(s)
- Yiran Xu
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- National Health Council (NHC) Key Laboratory of Birth Defects Prevention, Henan Key Laboratory of Population Defects Prevention, Zhengzhou, Henan Province, China
| | - Yifei Li
- Department of Human Anatomy, School of Basic Medicine and Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Seidu A Richard
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yanyan Sun
- Department of Human Anatomy, School of Basic Medicine and Institute of Neuroscience, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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Alenazi KA, Alanezi AA. Prevalence of Vitamin D Deficiency in Children With Cerebral Palsy: A Meta-Analysis. Pediatr Neurol 2024; 159:56-61. [PMID: 39137591 DOI: 10.1016/j.pediatrneurol.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/20/2024] [Accepted: 03/19/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Vitamin D deficiency stands out as a significant contributor to reduced bone mineral density in children diagnosed with cerebral palsy (CP). The objective of the meta-analysis was to estimate the prevalence of vitamin D deficiency in children with CP. METHODS This meta-analysis adhered to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guide. For children with CP aged between zero and 18 years with vitamin D deficiency, relevant articles were retrieved from PubMed, Scopus, ScienceDirect, and Cochrane. Following keywords were used: "cerebral palsy," "children," "childhood," "vitamin D," "vitamin D deficiency," "prevalence," and "frequency." Newcastle-Ottawa Scale was used to assess methodologic quality. Meta-analysis was performed using Stata 13.0. RESULTS In total, seven articles were considered suitable for inclusion in the meta-analysis of 411 articles initially identified. These studies involved a total of 430 children diagnosed with CP, ranging in age from zero to 18 years. Among the seven studies, two followed a cross-sectional approach, whereas the remaining five utilized a case-control design. Six of these studies were determined to have a low risk of bias, whereas one exhibited a moderate risk of bias. The combined prevalence of vitamin D deficiency in children with CP was determined to be 42.18% (95% confidence interval = 32.90% to 51.73%, I2 = 74.41%, and P < 0.001). CONCLUSIONS In conclusion, this meta-analysis reveals evidence of high prevalence of vitamin D deficiency in children with CP. This finding underscores the importance of addressing nutritional factors in the management of CP among pediatric populations.
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Leow XYJ, Tan JTC, Yeo TH, Wong KPL, Mahadev A, Ang B, Vasanwala RF, Ng ZM. Evaluation of risk factors associated with fragility fractures and recommendations to optimise bone health in children with long-term neurological condition. Singapore Med J 2023; 64:550-556. [PMID: 34600448 PMCID: PMC10564096 DOI: 10.11622/smedj.2021124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/25/2021] [Indexed: 11/18/2022]
Abstract
Introduction The growing years are paramount for bone growth and mineral accrual. Children with long-term neurological condition (LTNC) have multiple risk factors for poor bone health and fragility fractures. In Singapore, this has not been studied systematically. Therefore, we aimed to evaluate the risk factors associated with fragility fractures in children with LTNC. Methods In this study, the search for fragility fractures was done by a retrospective review of patients with LTNC on follow-up in the paediatric neurology clinic and patients who presented with fracture to the paediatric orthopaedic clinic. Information on patients' demographics, medical history, intervention, biochemical bone markers and fracture history was collected. Results In a tertiary clinic population of 136 patients with LTNC, 65% were dependent on mobility (Gross Motor Function Classification System [GMFCS] V), 60% were underweight and 60% were fed via gastrostomy or nasogastric tube, or were on oral pureed diet. Furthermore, 60% were on anticonvulsants. The fracture rate was 3% in this population and was associated with low-impact activities such as transfer and dressing. Only 7.4% and 33% of the patients had undergone measurements of vitamin D and calcium levels, respectively. Conclusion The local prevalence of fragility fractures in children with LTNC on follow-up at the neurology clinic was found to be 3%. Risk factors identified were limited ambulation and compromised nutritional status associated with feeding difficulty. Recommendations to optimise bone health in children with LTNC were made. These include promoting weight-bearing activities, looking out for underweight children, avoiding vitamin D deficiency and ensuring adequate calcium intake.
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Affiliation(s)
- Xue Yi Jessica Leow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Tong Hong Yeo
- Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore
| | | | - Arjandas Mahadev
- Department of Paediatric Orthopaedics, KK Women’s and Children’s Hospital, Singapore
| | - Bixia Ang
- Department of Nutrition and Dietetics, KK Women’s and Children’s Hospital, Singapore
| | - Rashida Farhad Vasanwala
- Department of Paediatrics, Endocrine and Diabetes Service, KK Women’s and Children’s Hospital, Singapore
| | - Zhi Min Ng
- Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore
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Granild-Jensen JB, Pedersen LK, Langdahl B, Starup-Linde J, Rackauskaite G, Farholt S, Søndergaard C, Vestergaard ET, Møller-Madsen B. Cerebral palsy and bisphosphonates - and what can be learned from other types of secondary osteoporosis in children: A scoping review. Acta Paediatr 2023; 112:617-629. [PMID: 36644940 DOI: 10.1111/apa.16671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/17/2023]
Abstract
AIM We aimed to improve bone health management of children with cerebral palsy (CP) by reviewing studies investigating bisphosphonate therapy in children with CP and other types of secondary osteoporosis. METHODS We included trials on bisphosphonate treatment reporting any direct bone measurement or fracture outcome. All studies of patients with CP were included. We also included all controlled trials of children with secondary bone fragility as well as observational studies with ≥20 participants or at least 3 years of follow-up. Studies were assessed according to PRISMA guidelines using the RoB2-tool and the Newcastle-Ottawa Scale. RESULTS We reviewed 1104 studies and found 37 eligible. Some studies were sufficiently homogeneous to include in a meta-analysis, and we found a 1-year effect on lumbar spine bone mineral density (BMD) Z-score of +0.65 after oral and + 1.21 after intravenous bisphosphonates in children with secondary osteoporosis. Further, data on adverse events and post-treatment follow-up were reviewed. Limitations were heterogeneity and small size of the included studies. CONCLUSION Meta-analysis consistently showed significant BMD increases with bisphosphonates in children with secondary osteoporosis. Direct evidence of the effect of bisphosphonates on reducing fractures is lacking. We found no reports of long-term adverse events yet longer studies are needed.
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Affiliation(s)
| | - Line K Pedersen
- Department of Children's Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jakob Starup-Linde
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center, Aarhus University Hospital, Aarhus, Denmark
| | - Gija Rackauskaite
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Stense Farholt
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Charlotte Søndergaard
- Department of Paediatrics and Adolescent Medicine, Regional Hospital of Gødstrup, Gødstrup, Denmark
| | | | - Bjarne Møller-Madsen
- Department of Children's Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
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Solanki P, Ansari MD, Alam MI, Aqil M, Ahmad FJ, Sultana Y. Precision engineering designed phospholipid-tagged pamidronate complex functionalized SNEDDS for the treatment of postmenopausal osteoporosis. Drug Deliv Transl Res 2023; 13:883-913. [PMID: 36414929 DOI: 10.1007/s13346-022-01259-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/24/2022]
Abstract
Disodium pamidronate, a second-generation bisphosphonate is a potent drug for the treatment of osteoporosis, which has been very well established by previous literature. It has very low oral permeability, leading to its low oral bioavailability, which restrict this drug to being administered orally. Therefore, the present research work includes the development of an orally effective nanoformulation of pamidronate. In this work, disodium pamidronate was complexed with phospholipon 90G for the enhancement of permeability and to investigate the phospholipon 90G-tagged pamidronate complex-loaded SNEDDS for oral delivery with promises of enhanced bioavailability and anti-osteoporotic activity. The rational design and optimization was employed using Central Composite Design (Design Expert® 12, software) to optimize nanoformulation parameters. In this work, a commercially potential self nano-emulsifying drug delivery system (SNEDDS) has been developed and evaluated for improved oral bioavailability and better clinical acceptance. The hot micro-emulsification and ultracentrifugation method with vortex mixing was utilized for effective tagging of phospholipon 90G with pamidronate and then loading into the SNEDDS nanocarrier. The optimized Pam-PLc SNEDDS formulation was characterized for particle size, PDI, and zeta potential and found to be 56.38 ± 1.37 nm, 0.218 ± 0.113, and 22.41 ± 1.14 respectively. Also, a 37.9% improved bioavailability of pamidronate compared to marketed tablet was observed. Similarly, in vivo pharmacokinetic studies suggest a 31.77% increased bone density and significant enhanced bone biomarkers compared to marketed tablets. The developed formulation is safe and effectively overcomes anti-osteoporosis promises with improved therapeutic potential. This work provides very significant achievements in postmenopausal osteoporosis treatment and may lead to possible use of nanotherapeutic-driven emerging biodegradable carriers-based drug delivery.
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Affiliation(s)
- Pavitra Solanki
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062, India
| | - Mohd Danish Ansari
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062, India
| | - Mohd Iqbal Alam
- Department of Physiology, Hamdard Institute of Medical Sciences & Research, Jamia Hamdard, New Delhi-110062, India
| | - Mohd Aqil
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062, India
| | - Farhan J Ahmad
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062, India
| | - Yasmin Sultana
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi-110062, India.
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Linton G, Hägglund G, Czuba T, Alriksson-Schmidt AI. Epidemiology of fractures in children with cerebral palsy: a Swedish population-based registry study. BMC Musculoskelet Disord 2022; 23:862. [PMID: 36104768 PMCID: PMC9476295 DOI: 10.1186/s12891-022-05813-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background Children with cerebral palsy (CP) form a heterogeneous group and may have risk or protective factors for fractures compared with typically developing children. The fracture sites may also differ from those of children who do not have CP. We analyzed the fracture epidemiology in a total population of children with CP. Methods This was a retrospective registry study based on data from the Swedish Cerebral Palsy Follow-Up Program (CPUP) and the Swedish National Patient Register. All children in the CPUP born in 2000–2015 were included. The Gross Motor Function Classification System (GMFCS) level, reported fractures, fracture site, and epilepsy diagnosis were recorded up to 2018. Hazards and hazard ratios were calculated for first-time fractures. Results Of the 3,902 participants, 368 (9.4%) had at least one reported fracture. The cumulative risk of sustaining a fracture before age 16 years was 38.3% (95% confidence interval 33.9–42.4). The hazard for fracture was 7 times higher in children with epilepsy. The overall fracture incidence was not statistically significantly related to sex or GMFCS level. Fractures in the upper extremities were most prevalent in children with a lower GMFCS level, and femoral fractures were most prevalent in children at GMFCS level V. Most fractures occurred in early childhood and after 8 years of age. Conclusions Children with CP were at similar risk of sustaining fractures as typically developing children, but the risk was higher in children with comorbid epilepsy. Fractures occurred in children at GMFCS levels I–III at sites similar to those for typically developing children; fractures in the upper extremities were the most frequent. Children at GMFCS levels IV or V and those with epilepsy were more likely to have a fracture in the lower extremities, and the femur was the most frequent site.
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Abstract
Osteoporosis is a major public health problem with serious long-term complications. In children, the definition of osteoporosis is not only based on densitometric criteria but also takes into account vertebral and long bone fragility fractures. Several factors, such as long-term high-dose steroids, chronic inflammation, malnutrition, immobility, lack of sex steroids, and medication can reduce bone density and increase the risk for fragility fractures when left untreated. Also, genetic conditions can predispose to primary bone fragility disorders, with osteogenesis imperfecta being the most common. Furthermore, since the growing skeleton is at an increased rate of bone remodeling, the ability to heal long bone fractures and reshape vertebral fractures differentiates children from adults. The scope of this chapter is to review the risk factors of osteoporosis and fragility fractures and describe the commonest causes of primary and secondary osteoporosis and their management in children and young adults.
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Affiliation(s)
- Sophia D Sakka
- Department of Endocrinology and Diabetes, Evelina London Children's Hospital, London, UK; GKT School of Medical Education, King's College London, UK; Department of Endocrinology, Metabolism and Diabetes, First Department of Paediatrics, Athens University Medical School, 'Aghia Sophia Children's Hospital', Athens, Greece.
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Characteristics of Interventions to Improve Bone Health in Children With Cerebral Palsy: A Systematic Review. Pediatr Phys Ther 2022; 34:163-170. [PMID: 35385446 DOI: 10.1097/pep.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE A systematic review evaluated exercise parameters and ages that produced the most improvement in bone among individuals with cerebral palsy (CP) ages 3 to 21 years. METHODS PubMed, Scopus, Ebscohost, and Web of Science identified potential articles. Covidence was used to identify eligible citations and assess bias. The osteogenic index (OI) was used to evaluate intervention parameters. RESULTS The database search identified 312 citations. Twelve full-text articles were included. A 1-hour calisthenic exercise program performed 2 to 3 times a week for 8 months targeting each body region had the highest effect size and a substantial OI. Most of the interventions reviewed had low OIs. Activities of longer duration and greater intensity had greater OIs and prepubertal age-enhanced treatment effects. CONCLUSION Bone interventions for individuals with CP have low OIs, and principles of mechanostat theory should be applied to exercise dosing.
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Alenazi KA. Vitamin D deficiency in children with cerebral palsy: A narrative review of epidemiology, contributing factors, clinical consequences and interventions. Saudi J Biol Sci 2022; 29:2007-2013. [PMID: 35531196 PMCID: PMC9072905 DOI: 10.1016/j.sjbs.2021.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/16/2021] [Accepted: 12/12/2021] [Indexed: 11/02/2022] Open
Abstract
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.
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Lee YA, Kwon A, Kim JH, Nam HK, Yoo JH, Lim JS, Cho SY, Cho WK, Shim KS. Clinical practice guidelines for optimizing bone health in Korean children and adolescents. Ann Pediatr Endocrinol Metab 2022; 27:5-14. [PMID: 35368191 PMCID: PMC8984748 DOI: 10.6065/apem.2244060.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 02/10/2022] [Indexed: 11/25/2022] Open
Abstract
The Committee on Pediatric Bone Health of the Korean Society of Pediatric Endocrinology has newly developed evidence-based clinical practice guidelines for optimizing bone health in Korean children and adolescents. These guidelines present recommendations based on the Grading of Recommendations, which includes the quality of evidence. In the absence of sufficient evidence, conclusions were based on expert opinion. These guidelines include processes of bone acquisition, definition, and evaluation of low bone mineral density (BMD), causes of osteoporosis, methods for optimizing bone health, and pharmacological treatments for enhancing BMD in children and adolescents. While these guidelines provide current evidence-based recommendations, further research is required to strengthen these guidelines.
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Affiliation(s)
- Young Ah Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ahreum Kwon
- Department of Pediatrics, Severance Children's Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyo-Kyoung Nam
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jae-Ho Yoo
- Department of Pediatrics, Dong-A University Hospital, Busan, Korea
| | - Jung Sub Lim
- Department of Pediatrics, Korea Cancer Center Hospital, Seoul, Korea
| | - Sung Yoon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Kyoung Cho
- Department of Pediatrics, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kye Shik Shim
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
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Debelle G, Morris H, Shaw N, Oates A. Fifteen-minute consultation: Fractures in non-ambulant children with cerebral palsy. Arch Dis Child Educ Pract Ed 2022; 107:15-20. [PMID: 33361095 DOI: 10.1136/archdischild-2020-319882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/16/2020] [Accepted: 12/09/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe a safeguarding decision pathway for the assessment of osteopenic fractures in non-ambulant children with cerebral palsy. METHOD Literature review and consensus practice of a child safeguarding team, including clinicians and social workers. CONCLUSION Low-energy fractures of the lower limb in non-ambulant children with cerebral palsy are relatively common and explained by the presence of reduced bone strength, in the absence of any other unexplained injuries or safeguarding concerns.
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Affiliation(s)
- Geoff Debelle
- Safeguarding Team, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Helen Morris
- Department of General Paediatrics, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Nick Shaw
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Department of Radiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Adam Oates
- Department of Radiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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Danzig JA, Katz EB. Musculoskeletal and skin considerations in children with medical complexity: Common themes and approaches to management. Curr Probl Pediatr Adolesc Health Care 2021; 51:101074. [PMID: 34656455 DOI: 10.1016/j.cppeds.2021.101074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The term "children with medical complexity" (CMC) describes a population of heterogeneous genetic and metabolic disorders with multi-system involvement, with shared common abnormalities within the musculoskeletal system. Disorders that affect the central nervous system (CNS) result in abnormal muscular tone, ranging from dystonia and spasticity, to hypotonia, to combinations of both (axial hypotonia with appendicular hypertonia). Abnormal tone can impair movement and function and contribute to development of contractures, progressive scoliosis and hip dislocation. Impaired mobility, chronic illness and polypharmacy can result in fragile bones and increased risk of fracture, which can be difficult to diagnose and associated with pain. Additionally, CMC with impaired ability to communicate, total dependence on caregivers and frequent use of support devices can develop unintended skin injuries. There are a variety of treatments available for CMC with musculoskeletal disorders ranging from physical supports to pharmacologic treatments to surgeries. Medical and surgical treatments can promote changes in tone and support bone health to improve comfort, hygiene and proper positioning. These therapies may also carry significant risk in medically fragile patients. It is important for CMC to have a care team with a good understanding of the patient's overall health and goals of care and that can advocate for the patient to balance optimization of function and reduction of pain while also minimizing risk.
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Affiliation(s)
- Jennifer A Danzig
- Division of General Pediatrics, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Elana B Katz
- Center for Rehabilitation, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
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Hurley T, Zareen Z, Stewart P, McDonnell C, McDonald D, Molloy E. Bisphosphonate use in children with cerebral palsy. Cochrane Database Syst Rev 2021; 7:CD012756. [PMID: 34224134 PMCID: PMC8256778 DOI: 10.1002/14651858.cd012756.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cerebral palsy (CP) is a heterogeneous group of non-progressive disorders of posture or movement, caused by a lesion of the developing brain. Osteoporosis is common in children with cerebral palsy, particularly in children with reduced gross motor function, and leads to an increased risk of fractures. Gross motor function in children with CP can be categorised using a tool called the Gross Motor Function Classification System (GMFCS). Bisphosphonate increases bone mineral density (BMD) and reduces fracture rates. Bisphosphonate is used widely in the treatment of adult osteoporosis. However, the use of bisphosphonate in children with CP remains controversial, due to a paucity of evidence and a lack of recent trials examining the efficacy and safety of bisphosphonate use in this population. OBJECTIVES To examine the efficacy and safety of bisphosphonate therapy in the treatment of low BMD or secondary osteoporosis (or both) in children with cerebral palsy (GMFCS Levels III to V) who are under 18 years of age. SEARCH METHODS In September 2020, we searched CENTRAL, MEDLINE, Embase, six other databases, and two trial registers for relevant studies. We also searched the reference lists of relevant systematic reviews, trials, and case studies identified by the search, and contacted the authors of relevant studies in an attempt to identify unpublished literature. SELECTION CRITERIA All relevant randomised controlled trials (RCTs), and quasi-RCTs, comparing at least one bisphosphonate (given at any dose, orally or intravenously) with placebo or no drug, for the treatment of low BMD or osteoporosis in children up to 18 years old, with cerebral palsy (GMFCS Levels III to V). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We were unable to conduct any meta-analyses due to insufficient data, and therefore provide a narrative assessment of the results. MAIN RESULTS We found two relevant RCTs (34 participants). Both studies included participants with non-ambulatory CP or CP and osteoporosis. Participants in both studies were similar in severity of CP, age distribution, and sex distribution. The two trials used different bisphosphonate medications and different intervention durations, but further comparison of the interventions was not possible due to a lack of published data from one trial. One trial received funding and support from research, academic, and hospital foundations, with pharmaceutical companies providing components of the calcium and vitamin supplement; the other trial did not report sources of funding. We judged one study at an overall high risk of bias; the other as overall unclear risk of bias. PRIMARY OUTCOME Compared to placebo or no treatment, both studies provided very low certainty evidence of improved BMD at least four months post-intervention in children treated with bisphosphonate. Only one study (12 participants) provided sufficient detail to assess a measure of the effect, and reported an improvement at six months post-intervention in lumbar spine z-score (mean difference (MD) 18%, 95% confidence interval (CI) 6.57 to 29.43; very low certainty evidence). SECONDARY OUTCOMES Very low certainty evidence from one study found that bisphosphonate reduced serum N-telopeptides (NTX) more than placebo; the other study reported that both bisphosphonate plus alfacalcidol and alfacalcidol alone reduced NTX, but did not compare groups. One study reported inconclusive results between groups for serum bone-specific alkaline phosphatase (BAP). The other study reported that both bisphosphonate plus alfacalcidol and alfacalcidol alone reduced BAP, but did not compare groups. Neither study reported data for the effect of bisphosphonate treatment on changes in volumetric BMD in the distal radius or tibia, changes in fracture frequency, bone pain, or quality of life. One study reported that two participants had febrile events noted during their first dosing schedule, but no further adverse events were reported in either relevant study. AUTHORS' CONCLUSIONS Based on the available evidence, there is very low certainty evidence that bisphosphonate treatment may improve bone health in children with cerebral palsy. We could only include one study with 14 participants in the assessment of the effect size; therefore, the precision of the effect estimate is low. We could only evaluate one planned primary outcome, as there was insufficient detail reported in the relevant studies. Further research from RCTs on the effect and safety of bisphosphonate to improve bone health in children with cerebral palsy is required. These studies should clarify the optimal standard treatment regarding weight-bearing exercises, vitamin D and calcium supplementation, and should include fracture frequency as a primary outcome.
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Affiliation(s)
- Tim Hurley
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
| | - Zunera Zareen
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
| | - Philip Stewart
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
| | - Ciara McDonnell
- Department of Paediatric Endocrinology & Diabetes, The National Children's Hospital, Tallaght, Dublin, Ireland
| | - Denise McDonald
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
| | - Eleanor Molloy
- Department of Paediatrics, Trinity College Dublin, Dublin, Ireland
- Department of Paediatrics, The National Children's Hospital, Dublin, Ireland
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14
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Zhuang C, Wang Z, Chen W, Tian B, Li J, Lin H. Osteoporosis and Endplate Damage Correlation Using a Combined Approach of Hounsfield Unit Values and Total Endplate Scores: A Retrospective Cross-Sectional Study. Clin Interv Aging 2021; 16:1275-1283. [PMID: 34262267 PMCID: PMC8275111 DOI: 10.2147/cia.s315213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/20/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose Osteoporosis and endplate damage, two primary orthopedic disorders that have adverse effects on the quality of life of older adults, may have some previously unknown relationship. The purpose of this study was to determine the potential association between osteoporosis and endplate damage with two specific imaging scoring systems and analyze the underlying mechanisms. Patients and Methods A cross-sectional study including 156 patients with degenerative disc disease (DDD) who visited our department in 2018 was performed. Data including age, sex, body mass index, Hounsfield unit (HU) values utilizing computed tomography (CT), and total endplate scores (TEPSs) using magnetic resonance imaging (MRI) of all patients were retrospectively collected and analyzed. The average HU value and TEPS of L1–L4 were used to represent the degrees of bone mineral density (BMD) and endplate damage, respectively. Patients with an HU value < 110 were defined as having osteoporosis and placed in the low-BMD group; otherwise, they were placed in the normal-BMD group. Multivariate logistic regression models were used to determine the independent factors of endplate damage. Results The TEPSs in the low-BMD group were significantly higher (6.4 ± 1.6 vs 5.0 ± 0.9, p < 0.001) overall and in every segment of L1–L4 (p < 0.01). A significant negative correlation was found between TEPS and HU values (p < 0.001). The HU value (odds ratio [OR] 0.221; 95% confidence interval [CI], 0.148–0.295, p < 0.001), age (OR 0.047; 95% CI, 0.029–0.224, p < 0.001), and BMD (OR 3.796; 95% CI, 2.11–7.382, p < 0.05) were independent factors influencing endplate damage. Conclusion A significantly positive correlation was observed between osteoporosis and endplate damage, indicating the requirement for a more comprehensive therapeutic regimen for treating patients with DDD complicated with osteoporosis.
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Affiliation(s)
- Chenyang Zhuang
- Department of Orthopedics, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Zixiang Wang
- Department of Orthopedics, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Weisin Chen
- Department of Orthopedics, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Bo Tian
- Department of Orthopedics, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Juan Li
- Department of Orthopedics, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Department of Orthopedics, Shanghai Geriatrics Center, Fudan University, Shanghai, People's Republic of China
| | - Hong Lin
- Department of Orthopedics, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Department of Orthopedics, Shanghai Geriatrics Center, Fudan University, Shanghai, People's Republic of China
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15
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Kannikeswaran S, French ZP, Walsh K, Swallow J, Caird MS, Whitney DG. Fracture characteristics by age, sex, and ambulatory status among individuals with cerebral palsy: a descriptive study. Disabil Rehabil 2021; 44:4806-4812. [PMID: 33962527 DOI: 10.1080/09638288.2021.1921860] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Sanjana Kannikeswaran
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Zachary P French
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kevin Walsh
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jennylee Swallow
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michelle S Caird
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Daniel G Whitney
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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16
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Le Roy C, Barja S, Sepúlveda C, Guzmán M, Olivarez M, Figueroa M, Alvarez M. Deficiencia de vitamina D y de hierro en niños y adolescentes con parálisis cerebral. Neurologia 2021; 36:112-118. [DOI: 10.1016/j.nrl.2017.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/23/2017] [Accepted: 11/05/2017] [Indexed: 11/25/2022] Open
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17
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Vitamin D and iron deficiencies in children and adolescents with cerebral palsy. NEUROLOGÍA (ENGLISH EDITION) 2021. [DOI: 10.1016/j.nrleng.2017.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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18
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Damiano DL, Longo E, Carolina de Campos A, Forssberg H, Rauch A. Systematic Review of Clinical Guidelines Related to Care of Individuals With Cerebral Palsy as Part of the World Health Organization Efforts to Develop a Global Package of Interventions for Rehabilitation. Arch Phys Med Rehabil 2021; 102:1764-1774. [PMID: 33453191 DOI: 10.1016/j.apmr.2020.11.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 10/29/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The World Health Organization's (WHO) Rehabilitation 2030 initiative is working to develop a set of evidence-based interventions selected from clinical practice guidelines for Universal Health Coverage. As an initial step, the WHO Rehabilitation Programme and Cochrane Rehabilitation convened global content experts to conduct systematic reviews of clinical practice guidelines for 20 chronic health conditions, including cerebral palsy. DATA SOURCES Six scientific databases (Pubmed, EMBASE, Scopus, Web of Science, PEDro, CINAHL), Google Scholar, guideline databases, and professional society websites were searched. STUDY SELECTION A search strategy was implemented to identify clinical practice guidelines for cerebral palsy across the lifespan published within 10 years in English. Standardized spreadsheets were provided for process documentation, data entry, and tabulation of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Each step was completed by 2 or more group members, with disagreements resolved by discussion. Initially, 13 guidelines were identified. Five did not meet the AGREE II established threshold or criteria for inclusion. Further review by the WHO eliminated 3 more, resulting in 5 remaining guidelines. DATA EXTRACTION All 339 recommendations from the 5 final guidelines, with type (assessment, intervention, or service), strength, and quality of evidence, were extracted, and an International Classification of Functioning, Disability and Health Functioning (ICF) category was assigned to each. DATA SYNTHESIS Most guidelines addressed mobility functions, with comorbid conditions and lifespan considerations also included. However, most were at the level of body functions. No guideline focused specifically on physical or occupational therapies to improve activity and participation, despite their prevalence in rehabilitation. CONCLUSIONS Despite the great need for high quality guidelines, this review demonstrated the limited number and range of interventions and lack of explicit use of the ICF during development of guidelines identified here. A lack of guidelines, however, does not necessarily indicate a lack of evidence. Further evidence review and development based on identified gaps and stakeholder priorities are needed.
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Affiliation(s)
- Diane L Damiano
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD.
| | - Egmar Longo
- Federal University of Rio Grande do Norte-UFRN-FACISA, Santa Cruz, Brazil
| | - Ana Carolina de Campos
- Department of Physical Therapy, Federal University of São Carlos-UFSCar, São Carlos, Brazil
| | - Hans Forssberg
- Department of Women's and Children's Health, Karolinska Institutet, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Alexandra Rauch
- Sensory Functions, Disability and Rehabilitation Unit, Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
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19
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Abstract
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.
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20
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Foster BA, Lane JE, Massey E, Noelck M, Green S, Austin JP. The Impact of Malnutrition on Hospitalized Children With Cerebral Palsy. Hosp Pediatr 2020; 10:1087-1095. [PMID: 33154081 PMCID: PMC7684553 DOI: 10.1542/hpeds.2020-0177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
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.
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Affiliation(s)
| | - Jennifer E Lane
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Elizabeth Massey
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Michelle Noelck
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Sarah Green
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Jared P Austin
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
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21
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Abstract
PURPOSE OF REVIEW To summarize the last 10 years of literature regarding the effects of whole-body vibration (WBV) on bone in children, and if WBV results in increased bone acquisition. RECENT FINDINGS WBV intervention appears to be a safe intervention with beneficial effects on bone mass in some diseases and syndromes, but there is still low evidence for WBV in clinical practice. The positive effects on muscle strength, balance, and walking speed are more conclusive. One of the takeaways of this review is that well-trained individuals may not further improve bone mass with WBV; thus, interventions are more beneficial in pediatric individuals with Down syndrome or severe motor disabilities with low bone mass and reduced activity levels. WBV appears to be a safe non-pharmacological anabolic approach to increase bone mass in some pediatric populations; however, longer (> 6 months) and larger prospective studies are needed to elucidate the efficacy of WBV on bone health in young individuals.
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Affiliation(s)
- Diana Swolin-Eide
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Pediatrics, The Queen Silvia Children's Hospital, Gothenburg, Sweden.
| | - Per Magnusson
- Department of Clinical Chemistry, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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22
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Rozenberg S, Bruyère O, Bergmann P, Cavalier E, Gielen E, Goemaere S, Kaufman JM, Lapauw B, Laurent MR, De Schepper J, Body JJ. How to manage osteoporosis before the age of 50. Maturitas 2020; 138:14-25. [PMID: 32631584 DOI: 10.1016/j.maturitas.2020.05.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 12/16/2022]
Abstract
This narrative review discusses several aspects of the management of osteoporosis in patients under 50 years of age. Peak bone mass is genetically determined but can also be affected by lifestyle factors. Puberty constitutes a vulnerable period. Idiopathic osteoporosis is a rare, heterogeneous condition in young adults due in part to decreased osteoblast function and deficient bone acquisition. There are no evidence-based treatment recommendations. Drugs use can be proposed to elderly patients at very high risk. Diagnosis and management of osteoporosis in the young can be challenging, in particular in the absence of a manifest secondary cause. Young adults with low bone mineral density (BMD) do not necessarily have osteoporosis and it is important to avoid unnecessary treatment. A determination of BMD is recommended for premenopausal women who have had a fragility fracture or who have secondary causes of osteoporosis: secondary causes of excessive bone loss need to be excluded and treatment should be targeted. Adequate calcium, vitamin D, and a healthy lifestyle should be recommended. In the absence of fractures, conservative management is generally sufficient, but in rare cases, such as chemotherapy-induced osteoporosis, antiresorptive medication can be used. Osteoporosis in young men is most often of secondary origin and hypogonadism is a major cause; testosterone replacement therapy will improve BMD in these patients. Diabetes is characterized by major alterations in bone quality, implying that medical therapy should be started sooner than for other causes of osteoporosis. Primary hyperparathyroidism, hyperthyroidism, Cushing's syndrome and growth hormone deficiency or excess affect cortical bone more often than trabecular bone.
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Affiliation(s)
- S Rozenberg
- Department of Gynaecology-Obstetrics, CHU St Pierre, Université Libre de Bruxelles, Brussels, Belgium.
| | - O Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium.
| | - P Bergmann
- Honorary Consulent, Nuclear Medicine CHU Brugmann CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - E Cavalier
- Department of Clinical Chemistry, UnilabLg, CIRM, University of Liège, CHU de Liège, Domaine du Sart-Tilman, 4000 Liège, Belgium
| | - E Gielen
- Gerontology & Geriatrics, Department of Public Health and Primary Care, KU Leuven & Department of Geriatric Medicine, UZ Leuven, Leuven, Belgium
| | - S Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - J M Kaufman
- Department of Endocrinology and Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - B Lapauw
- Department of Endocrinology Ghent University Hospital, Ghent, Belgium
| | - M R Laurent
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Imelda Hospital, Bonheiden, Belgium
| | - J De Schepper
- Department of Pediatrics, UZ Brussel, Brussels, Belgium, Belgium
| | - J J Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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23
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Roden RC, Noritz G, McKnight ER, Bonny AE. An exploratory study of depot-medroxyprogesterone acetate and bone mineral density in adolescent and young adult women with cerebral palsy. Contraception 2020; 101:273-275. [DOI: 10.1016/j.contraception.2019.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/05/2019] [Accepted: 12/08/2019] [Indexed: 10/25/2022]
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24
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Ko A, Kong J, Samadov F, Mukhamedov A, Kim YM, Lee YJ, Nam SO. Bone health in pediatric patients with neurological disorders. Ann Pediatr Endocrinol Metab 2020; 25:15-23. [PMID: 32252212 PMCID: PMC7136510 DOI: 10.6065/apem.2020.25.1.15] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/02/2020] [Accepted: 03/10/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with neurological disorders are at high risk of developing osteoporosis, as they possess multiple risk factors leading to low bone mineral density. Such factors include inactivity, decreased exposure to sunlight, poor nutrition, and the use of medication or treatment that can cause lower bone mineral density such as antiepileptic drugs, ketogenic diet, and glucocorticoids. In this article, mechanisms involved in altered bone health in children with neurological disorders and management for patients with epilepsy, cerebral palsy, and Duchenne muscular dystrophy regarding bone health are reviewed.
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Affiliation(s)
- Ara Ko
- Division of Pediatric Neurology, Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Juhyun Kong
- Division of Pediatric Neurology, Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Furkat Samadov
- Division of Pediatric Neurology, Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Neuroscience Center, National Children's Medical Center, Tashkent, Uzbekistan
| | - Akmal Mukhamedov
- Division of Pediatric Neurology, Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Neuroscience Center, National Children's Medical Center, Tashkent, Uzbekistan
| | - Young Mi Kim
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Yun-Jin Lee
- Division of Pediatric Neurology, Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Ook Nam
- Division of Pediatric Neurology, Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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25
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Galindo-Zavala R, Bou-Torrent R, Magallares-López B, Mir-Perelló C, Palmou-Fontana N, Sevilla-Pérez B, Medrano-San Ildefonso M, González-Fernández MI, Román-Pascual A, Alcañiz-Rodríguez P, Nieto-Gonzalez JC, López-Corbeto M, Graña-Gil J. Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children. Pediatr Rheumatol Online J 2020; 18:20. [PMID: 32093703 PMCID: PMC7041118 DOI: 10.1186/s12969-020-0411-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteoporosis incidence in children is increasing due to the increased survival rate of patients suffering from chronic diseases and the increased use of drugs that can damage bones. Recent changes made to the definition of childhood osteoporosis, along with the lack of guidelines or national consensuses regarding its diagnosis and treatment, have resulted in a wide variability in the approaches used to treat this disease. For these reasons, the Osteogenesis Imperfecta and Childhood Osteoporosis Working Group of the Spanish Society of Pediatric Rheumatology has sounded the need for developing guidelines to standardize clinical practice with regard to this pathology. METHODS An expert panel comprised of 6 pediatricians and 5 rheumatologists carried out a qualitative literature review and provided recommendations based on evidence, when that was available, or on their own experience. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A Delphi survey was conducted for those recommendations with an evidence level of IV or V. This survey was sent to all members of the SERPE. All recommendations that had a level of agreement higher or equal to 70% were included. RESULTS Fifty-one recommendations, categorized into eight sections, were obtained. Twenty-four of them presented an evidence level 4 or 5, and therefore a Delphi survey was conducted. This was submitted electronically and received a response rate of 40%. All recommendations submitted to the Delphi round obtained a level of agreement of 70% or higher and were therefore accepted. CONCLUSION In summary, we present herein guidelines for the prevention, diagnosis and treatment of secondary childhood osteoporosis based on the available evidence and expert clinical experience. We believe it can serve as a useful tool that will contribute to the standardization of clinical practice for this pathology. Prophylactic measures, early diagnosis and a proper therapeutic approach are essential to improving bone health, not only in children and adolescents, but also in the adults they will become in the future.
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Affiliation(s)
- Rocío Galindo-Zavala
- UGC Pediatría. Sección Reumatología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - Rosa Bou-Torrent
- 0000 0001 0663 8628grid.411160.3Unidad de Reumatología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Berta Magallares-López
- 0000 0004 1768 8905grid.413396.aServicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Concepción Mir-Perelló
- 0000 0004 1796 5984grid.411164.7Unidad de Pediatría, Sección Reumatología Pediátrica, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Natalia Palmou-Fontana
- 0000 0001 0627 4262grid.411325.0Unidad de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Belén Sevilla-Pérez
- UGC Pediatría, Sección Reumatología Pediátrica, Hospital Campus de la Salud, Granada, Spain
| | | | - Mª. Isabel González-Fernández
- 0000 0001 0360 9602grid.84393.35Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital La Fe, Valencia, Spain
| | | | - Paula Alcañiz-Rodríguez
- Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital Virgen de la Arriaxaca, Murcia, Spain
| | - Juan Carlos Nieto-Gonzalez
- 0000 0001 0277 7938grid.410526.4Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mireia López-Corbeto
- 0000 0001 0675 8654grid.411083.fServicio de Reumatología Hospital Vall d’Hebron, Barcelona, Spain
| | - Jenaro Graña-Gil
- 0000 0004 1771 0279grid.411066.4Servicio de Reumatología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain ,Osteogenesis Imperfecta and Secondary Osteoporosis Working Group from the Spanish Pediatric Rheumatology Society, Madrid, Spain
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26
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Kane KJ, Musselman KE, Lanovaz J. Effects of solid ankle-foot orthoses with individualized ankle angles on gait for children with cerebral palsy and equinus. J Pediatr Rehabil Med 2020; 13:169-183. [PMID: 32444574 DOI: 10.3233/prm-190615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE For children with cerebral palsy (CP) and equinus, the conventional practice of setting the ankle angle in an ankle-foot orthosis (AA-AFO) at 90∘ may not adequately accommodate gastrocnemius length/stiffness. Therefore, this study compared the effects of statically-optimized solid AFOs with individualized AA-AFOs (iAA-AFOs) and conventionally-prescribed AFOs on gait for children with CP and equinus. METHODS Ten children with CP and equinus (15 limbs with AFOs), and 15 typically-developing (TD) children participated. For the children with CP, solid AFOs with iAA-AFOs (range = 5∘-25∘ plantarflexion) were compared with their usual AFOs using three-dimensional gait analysis. TD children walked in shoes only. Peak values and Gait Variable Scores (GVS) for joint and segment variables were calculated for stance phase. Responses were categorized using 90% confidence intervals relative to TD data, for each affected leg. RESULTS Net responses to iAA-AFOs were positive for 60% of limbs and negative for 40%. Knee variables (GVS and peak extension, flexion, and midstance moment) were most positively affected, and foot-floor angle and vertical ground reaction force were most negatively impacted. CONCLUSION Individualized AFO prescription and iAA-AFOs can impact gait biomechanics for some children with equinus, compared to conventionally-prescribed AFOs. Optimizing dynamic alignment for walking may further improve outcomes.
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Affiliation(s)
- Kyra J Kane
- School of Rehabilitation Science, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.,Saskatchewan Health Authority, Children's Program, Regina, SK, Canada
| | - Kristin E Musselman
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Joel Lanovaz
- College of Kinesiology, University of Saskatchewan, Saskatoon, SK, Canada
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27
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Jesus AO, Stevenson RD. Optimizing Nutrition and Bone Health in Children with Cerebral Palsy. Phys Med Rehabil Clin N Am 2019; 31:25-37. [PMID: 31760992 DOI: 10.1016/j.pmr.2019.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Children with cerebral palsy (CP) are at risk of growth and nutrition disorders. There are numerous challenges to measure and assess growth and nutritional status in children with CP. Addressing these challenges is imperative, because the consequences of poor growth and malnutrition range from decreased bone density, muscle mass, and quality of life to impacts on intellectual quotient, behavior, attention, social participation, healthcare utilization, and health care costs. In addition to discussing approaches to assess growth and nutrition, this article examines some of the methods of optimizing nutrition and bone health, including when preparing for and recovering from surgery.
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Affiliation(s)
- Anna O Jesus
- University of Virginia, UVA Neurodevelopmental and Behavioral Pediatrics, Stacey Hall, PO Box 800828, Charlottesville, VA 22908, USA
| | - Richard D Stevenson
- Division of Neurodevelopmental and Behavioral Pediatrics, University of Virginia School of Medicine, University of Virginia, UVA Neurodevelopmental and Behavioral Pediatrics, Stacey Hall, PO Box 800828, Charlottesville, VA 22908, USA.
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Kao KT, Denker M, Zacharin M, Wong SC. Pubertal abnormalities in adolescents with chronic disease. Best Pract Res Clin Endocrinol Metab 2019; 33:101275. [PMID: 31047817 DOI: 10.1016/j.beem.2019.04.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pubertal disorders in the context of chronic disease especially in those with chronic inflammatory disorders or those requiring prolonged periods of treatment with glucocorticoid are common reasons for referral to the paediatric endocrine clinic. Disorders of puberty are also common in adolescents with disability requiring management by paediatric endocrinologists. In these adolescents, impaired skeletal development is also observed and this can be associated with fragility fractures. Chronic inflammation, glucocorticoid and sub-optimal nutrition all impact on the hypothalamic-pituitary gonadal axis, and can also impact on skeletal development locally by their effects on the growth plate and bone. Addressing pubertal disorders is important to ensure adolescents with chronic disease are matched with their peers, promote adequate bone mass accrual and linear growth. Careful discussion with primary clinicians, the young person and the family is needed when instituting endocrine therapies to address puberty and manage bone health.
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Affiliation(s)
- K T Kao
- Department of Endocrinology, Royal Children's Hospital, Melbourne, Australia; Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, United Kingdom
| | - M Denker
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, United Kingdom
| | - M Zacharin
- Department of Endocrinology, Royal Children's Hospital, Melbourne, Australia
| | - S C Wong
- Developmental Endocrinology Research Group, Royal Hospital for Children, Glasgow, United Kingdom.
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Brandenburg JE, Fogarty MJ, Sieck GC. A Critical Evaluation of Current Concepts in Cerebral Palsy. Physiology (Bethesda) 2019; 34:216-229. [PMID: 30968751 PMCID: PMC7938766 DOI: 10.1152/physiol.00054.2018] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/11/2019] [Accepted: 01/23/2019] [Indexed: 11/22/2022] Open
Abstract
Spastic cerebral palsy (CP), despite the name, is not consistently identifiable by specific brain lesions. CP animal models focus on risk factors for development of CP, yet few reproduce the diagnostic symptoms. Animal models of CP must advance beyond risk factors to etiologies, including both the brain and spinal cord.
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Affiliation(s)
- Joline E Brandenburg
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine , Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine , Rochester, Minnesota
| | - Matthew J Fogarty
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine , Rochester, Minnesota
| | - Gary C Sieck
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine , Rochester, Minnesota
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine , Rochester, Minnesota
- Department of Anesthesiology, Mayo Clinic College of Medicine , Rochester, Minnesota
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Goodwin J, Lecouturier J, Basu A, Colver A, Crombie S, Smith J, Howel D, McColl E, Parr JR, Kolehmainen N, Roberts A, Miller K, Cadwgan J. Standing frames for children with cerebral palsy: a mixed-methods feasibility study. Health Technol Assess 2019; 22:1-232. [PMID: 30234480 DOI: 10.3310/hta22500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Standing frames are recommended as part of postural management for young people with cerebral palsy (CP) Gross Motor Function Classification System (GMFCS) level IV or V. They may have a variety of benefits, including improving bone mineral density, gastrointestinal function and social participation. The NHS needs to know if these benefits are real, given the cost implications of use and the reported negative effects (e.g. pain). The lack of evidence for the clinical effectiveness of standing frames demonstrates the need for evaluative research. OBJECTIVE(S) The aim of the study was to explore the acceptability of a future trial to determine the clinical effectiveness of standing frames. DESIGN A sequential mixed-methods design was used. The findings of each stage informed the next stage. We conducted surveys, focus groups and in-depth interviews. PARTICIPANTS Professionals who work with young people who use standing frames and parents who have a child who uses a standing frame took part in a survey of current standing frame practice (n = 551), a series of focus groups (seven focus groups, 49 participants in total) and a survey of research trial acceptability and feasibility (n = 585). Twelve young people who use a standing frame were interviewed. RESULTS Standing frames were widely used as part of postural management for young people with CP both in school and at home but more frequently in school, and particularly by young people in primary school. Achieving the prescribed use was not always possible owing to resources, environment and family factors. Participation and activity engagement were important to young people. The majority of participants believed that standing frames research is necessary. Some reported concern that stopping standing frame use for a trial would cause irreversible damage. The maximum amount of time most health professionals and parents would agree to suspend standing frame use would be 12 weeks. LIMITATIONS Owing to the nature of recruitment, we could not calculate response rates or determine non-response bias. Therefore, participants may not be representative of all standing frame users. CONCLUSIONS Although parents and professionals who engaged in the qualitative aspect of this research and stakeholders who took part in the design workshops appreciated the lack of clinical evidence, our surveys, qualitative information and PPI demonstrated that most people had strong beliefs regarding the clinical effectiveness of standing frames. However, with key stakeholder engagement and careful planning, a trial would be acceptable. FUTURE WORK We recommend a carefully planned trial that includes a pilot phase. The trial should evaluate the following question: 'does using a standing frame in school improve patient-reported outcomes of participation (primary outcome), quality of life, subjective well-being, body function and body structure (secondary outcomes) in young children (aged 4-11 years) with CP GMFCS III-V?'. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Jane Goodwin
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jan Lecouturier
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Anna Basu
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Allan Colver
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Crombie
- Sussex Community NHS Foundation Trust, Chailey Clinical Services, Sussex, UK
| | - Johanna Smith
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jeremy R Parr
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Niina Kolehmainen
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Roberts
- Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, UK
| | - Keith Miller
- Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, UK
| | - Jill Cadwgan
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK
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Wiedemann A, Renard E, Hernandez M, Dousset B, Brezin F, Lambert L, Weryha G, Feillet F. Annual Injection of Zoledronic Acid Improves Bone Status in Children with Cerebral Palsy and Rett Syndrome. Calcif Tissue Int 2019; 104:355-363. [PMID: 30554334 DOI: 10.1007/s00223-018-0505-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/07/2018] [Indexed: 12/27/2022]
Abstract
Osteoporosis is a common complication of cerebral palsy and Rett's syndrome. It is responsible for multiple fractures, bone pain, and impaired quality of life. In case of Rett's syndrome, a specific dysfunction of osteoblasts causes bone fragility. We observed the effects of annual zoledronic acid (ZA) infusion in a cohort of children with cerebral palsy and Rett's syndrome. 27 children under 18 years (19 with cerebral palsy and 8 girls with Rett syndrome confirmed by MCEP2 mutation) were treated with an annual injection of 0.1 mg/kg (max 4 mg) of ZA. Calcium and vitamin D were combined in all patients from the first injection of ZA. Dental examination was performed before treatment. Data were analyzed retrospectively. Bone mineral density was measured at diagnosis and yearly thereafter. Bone mass density (BMD) is decreased in patient with cerebral palsy and RS. One year after injection of ZA, we observe an increase of Lumbar spine BMD from - 2.99 to - 2.14 SD (p < 0.0001) and femoral BMD from - 4.26 to - 3.32 SD (p < 0.001) In the subgroup of patient with Rett syndrome, we also observe an increase from - 3.27 to 2.50 SD (p = 0.018) of Lumbar spine BMD. No fractures have been observed in our cohort since the first infusion. Side effects (flu-like syndrome and hypocalcemia) were more common in younger patients and after the first infusion. No serious complications were noticed. This study confirms the efficacy and the safety of an annual injection of ZA to improve bone status in children with cerebral palsy and Rett syndrome. No severe adverse effects were observed.
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Affiliation(s)
- Arnaud Wiedemann
- Centre de référence des erreurs innées du métabolisme, Hôpital d'Enfants, CHRU Nancy, Nancy, France.
- Réanimation pédiatrique spécialisée, Hôpital d'enfants, CHRU Nancy, Nancy, France.
- Faculté de médecine, INSERM U-1256, Vandoeuvre les Nancy, France.
| | - Emeline Renard
- Service de Médecine Infantile, Hôpital d'enfants, CHRU Nancy, Nancy, France
- Faculté de médecine, INSERM U-1256, Vandoeuvre les Nancy, France
| | | | | | - François Brezin
- Service de Médecine Infantile, Hôpital d'enfants, CHRU Nancy, Nancy, France
| | | | | | - François Feillet
- Centre de référence des erreurs innées du métabolisme, Hôpital d'Enfants, CHRU Nancy, Nancy, France
- Service de Médecine Infantile, Hôpital d'enfants, CHRU Nancy, Nancy, France
- Faculté de médecine, INSERM U-1256, Vandoeuvre les Nancy, France
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Assessment of nutritional status and bone health in neurologically impaired children: a challenge in pediatric clinical practice. NUTR HOSP 2019; 36:1241-1247. [DOI: 10.20960/nh.02553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Mus-Peters CTR, Huisstede BMA, Noten S, Hitters MWMGC, van der Slot WMA, van den Berg-Emons RJG. Low bone mineral density in ambulatory persons with cerebral palsy? A systematic review. Disabil Rehabil 2018; 41:2392-2402. [PMID: 29783868 DOI: 10.1080/09638288.2018.1470261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Purpose: Non-ambulatory persons with cerebral palsy are prone to low bone mineral density. In ambulatory persons with cerebral palsy, bone mineral density deficits are expected to be small or absent, but a consensus conclusion is lacking. In this systematic review bone mineral density in ambulatory persons with cerebral palsy (Gross Motor Function Classification Scales I-III) was studied. Materials and methods: Medline, Embase, and Web of Science were searched. According to international guidelines, low bone mineral density was defined as Z-score ≤ -2.0. In addition, we focused on Z-score ≤ -1.0 because this may indicate a tendency towards low bone mineral density. Results: We included 16 studies, comprising 465 patients aged 1-65 years. Moderate and conflicting evidence for low bone mineral density (Z-score ≤ -2.0) was found for several body parts (total proximal femur, total body, distal femur, lumbar spine) in children with Gross Motor Function Classification Scales II and III. We found no evidence for low bone mineral density in children with Gross Motor Function Classification Scale I or adults, although there was a tendency towards low bone mineral density (Z-score ≤ -1.0) for several body parts. Conclusions: Although more high-quality research is needed, results indicate that deficits in bone mineral density are not restricted to non-ambulatory people with cerebral palsy. Implications for Rehabilitation Although more high-quality research is needed, including adults and fracture risk assessment, the current study indicates that deficits in bone mineral density are not restricted to non-ambulatory people with CP. Health care professionals should be aware that optimal nutrition, supplements on indication, and an active lifestyle, preferably with weight-bearing activities, are important in ambulatory people with CP, also from a bone quality point-of-view. If indicated, medication and fall prevention training should be prescribed.
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Affiliation(s)
| | - Bionka M A Huisstede
- b Department of Rehabilitation, Physical Therapy Science & Sports, Rudolf Magnus Institute of Neurosciences , University Medical Centre Utrecht, Utrecht University , Utrecht , The Netherlands
| | - Suzie Noten
- c Department of Rehabilitation Medicine , Erasmus University Medical Centre , Rotterdam , The Netherlands
| | | | - Wilma M A van der Slot
- c Department of Rehabilitation Medicine , Erasmus University Medical Centre , Rotterdam , The Netherlands.,d Rijndam Rehabilitation , Rotterdam , The Netherlands
| | - Rita J G van den Berg-Emons
- a Libra Rehabilitation & Audiology , Eindhoven/Tilburg , The Netherlands.,c Department of Rehabilitation Medicine , Erasmus University Medical Centre , Rotterdam , The Netherlands
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Goodwin J, Lecouturier J, Crombie S, Smith J, Basu A, Colver A, Kolehmainen N, Parr JR, Howel D, McColl E, Roberts A, Miller K, Cadwgan J. Understanding frames: A qualitative study of young people's experiences of using standing frames as part of postural management for cerebral palsy. Child Care Health Dev 2018; 44:203-211. [PMID: 29168216 DOI: 10.1111/cch.12540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/22/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Consensus opinion supports standing frame use as part of postural management for nonambulant young people with cerebral palsy. Although the rationale for standing frame use and the associated challenges have been described, little attention has been given to the users' experiences. The aim of the current study was to explore young people's positive and negative experiences, and attitudes regarding standing frame use. METHODS Framework analysis informed an open exploration of young people's opinions of standing frames. Using semistructured interviews, 12 young people with cerebral palsy (6 female) were interviewed, providing the data set for transcription and thematic analysis. FINDINGS The first theme "attitudes to standing frames" describes the young people's understanding of why they use standing frames. Although standing frames can be painful, some young people believe they should be endured to improve their body structure and function. There were mixed views about the impact standing frames have socially, with some young people feeling excluded from their peers, and others feeling as though standing frames helped them "fit in." Some young people are not offered a choice about how and when they use their standing frame. The second theme "challenges of standing frame use" highlights the issues with standing frame use such as manual handling, interference from siblings, and the lack of aesthetically pleasing standing frame designs. CONCLUSIONS Young people report benefits related to choice, pain relief, and participation but can also cause pain, discomfort, and reduced independence and participation. Healthcare professionals should have open, informative conversations about potential benefits and challenges of standing frames on all aspects of the young people's lives, including participation and activity.
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Affiliation(s)
- J Goodwin
- Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK
| | - J Lecouturier
- Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK
| | - S Crombie
- Sussex Community NHS Foundation Trust, Chailey Clinical Services, Brighton, UK
| | - J Smith
- Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK
| | - A Basu
- Newcastle University, Institute of Neuroscience, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A Colver
- Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK
| | - N Kolehmainen
- Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - J R Parr
- Newcastle University, Institute of Neuroscience, Newcastle upon Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - D Howel
- Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK
| | - E McColl
- Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK
| | - A Roberts
- Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, UK
| | - K Miller
- Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust, Oswestry, UK
| | - J Cadwgan
- Newcastle University, Institute of Neuroscience, Newcastle upon Tyne, UK.,Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust (Kings Health Partners), London, UK
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Goodwin J, Colver A, Basu A, Crombie S, Howel D, Parr JR, McColl E, Kolehmainen N, Roberts A, Lecouturier J, Smith J, Miller K, Cadwgan J. Understanding frames: A UK survey of parents and professionals regarding the use of standing frames for children with cerebral palsy. Child Care Health Dev 2018; 44:195-202. [PMID: 28809057 PMCID: PMC5811781 DOI: 10.1111/cch.12505] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/13/2017] [Accepted: 07/22/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Standing frames are used for children with cerebral palsy (CP). They may improve body structure and function (e.g., reducing risk of hip subluxation, and improving bladder and bowel function), improving activity (e.g., motor abilities) and participation (e.g., interaction with peers), but there is little evidence that they do. We aimed to identify current UK standing frame practice for children with CP and to understand stakeholder views regarding their clinical benefits and challenges to use. METHOD Three populations were sampled: clinicians prescribing standing frames for children with CP (n = 305), professionals (health and education) working with children with CP who use standing frames (n = 155), and parents of children with CP who have used standing frames (n = 91). Questionnaires were developed by the co-applicant group and piloted with other professionals and parents of children with CP. They were distributed online via clinical and parent networks across the UK. RESULTS Prescribing practice was consistent, but achieving the prescribed use was not always possible. Respondents in all groups reported the perceived benefits of frames, which include many domains of the International Classification of Functioning Disability and Health for Children and Youth. Challenges of use are related to physical space and child-reported pain. CONCLUSIONS These survey findings provide information from key stakeholders regarding current UK standing frame practice.
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Affiliation(s)
- J. Goodwin
- Institute of Health and SocietyNewcastle UniversityNewcastle Upon TyneUK
| | - A. Colver
- Institute of Health and SocietyNewcastle UniversityNewcastle Upon TyneUK
| | - A. Basu
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUK,Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - S. Crombie
- Sussex Community NHS Foundation TrustChailey Clinical ServicesBrightonUK
| | - D. Howel
- Institute of Health and SocietyNewcastle UniversityNewcastle Upon TyneUK
| | - J. R. Parr
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUK,Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - E. McColl
- Institute of Health and SocietyNewcastle UniversityNewcastle Upon TyneUK
| | - N. Kolehmainen
- Institute of Health and SocietyNewcastle UniversityNewcastle Upon TyneUK
| | - A. Roberts
- Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS TrustOswestryUK
| | - J. Lecouturier
- Institute of Health and SocietyNewcastle UniversityNewcastle Upon TyneUK
| | - J. Smith
- Institute of Health and SocietyNewcastle UniversityNewcastle Upon TyneUK
| | - K. Miller
- Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS TrustOswestryUK
| | - J. Cadwgan
- Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUK,Evelina London Children's HospitalGuys and St Thomas' NHS Foundation Trust (Kings Health Partners) UKLondonUK
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Yaşar E, Adigüzel E, Arslan M, Matthews DJ. Basics of bone metabolism and osteoporosis in common pediatric neuromuscular disabilities. Eur J Paediatr Neurol 2018; 22:17-26. [PMID: 28830650 DOI: 10.1016/j.ejpn.2017.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 07/31/2017] [Accepted: 08/06/2017] [Indexed: 01/30/2023]
Abstract
Bone modeling is a process that starts with fetal life and continues during adolescence. Complex factors such as hormones, nutritional and environmental factors affect this process. In addition to these factors, physical conditioning and medications that have toxic effects on bony tissue should be carefully considered in patient follow-up. Osteoporosis is a significant problem in pediatric population because of ongoing growth and development of skeletal system. Two types of osteoporosis are primary and secondary types and children with neuromuscular disabilities constitute a major group with secondary osteoporosis. Low bone mass in patients with cerebral palsy, spina bifida, and Duchenne muscular dystrophy cause increased bone fragility in even slight traumas. Maximizing peak bone mass and prevention of bone loss are very important to reduce the fracture risk in neuromuscular diseases. This article aims to review the determinants of bone physiology and bone loss in children with cerebral palsy, spina bifida, and Duchenne muscular dystrophy.
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Affiliation(s)
- Evren Yaşar
- Health Sciences University, Gülhane Medical School, Department of Physical Medicine and Rehabilitation, Ankara, Turkey
| | - Emre Adigüzel
- Gaziler Physical Medicine and Rehabilitation Education and Research Hospital, Ankara, Turkey.
| | - Mutluay Arslan
- Health Sciences University, Gülhane Medical School, Department of Pediatric Neurology, Ankara, Turkey
| | - Dennis J Matthews
- Physical Medicine and Rehabilitation, Children's Hospital Colorado, Aurora, CO, USA
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Abstract
BACKGROUND Osteoporosis can lead to spontaneous fractures in adults with cerebral palsy (CP). Undercarboxylated osteocalcin (ucOC) is a useful marker for vitamin K insufficiency in osteoporosis. The primary objective of this study was to determine the effect of vitamin K2 on bone mineral density (BMD) in adults with CP and vitamin K insufficiency. METHODS Sixteen adults, median age of 56years, with CP and osteoporosis in whom the serum ucOC concentration exceeded 4.5ng/mL were included. All patients received 45mg of vitamin K2 per day. BMD was measured and presented as a percentage of the young adult mean (%YAM). Serum levels of ucOC and BMD were measured at baseline and after 6 and 12months. RESULTS Serum levels of ucOC decreased from 7.8ng/mL (range, 4.9-32) at baseline to 3.9ng/mL (range, 1.9-6.8) after 6months (P=0.001). BMD increased from 59%YAM (range, 45-67) at baseline to 68%YAM (range, 50-79) after 12months (P=0.003). CONCLUSIONS Vitamin K2 had a positive effect on BMD in osteoporotic adults with CP and high serum concentrations of ucOC, and might be useful as a first line treatment for osteoporotic adults with CP and vitamin K insufficiency.
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Shin YK, Yoon YK, Chung KB, Rhee Y, Cho SR. Patients with non-ambulatory cerebral palsy have higher sclerostin levels and lower bone mineral density than patients with ambulatory cerebral palsy. Bone 2017; 103:302-307. [PMID: 28720522 DOI: 10.1016/j.bone.2017.07.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/29/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
Abstract
Bone loss is a serious clinical issue in patients with cerebral palsy (CP). Sclerostin has garnered interest as a key mechanosensor in osteocytes, leading to considerations of the therapeutic utilization of anti-sclerostin medications. This study was undertaken to determine associations among mechanical unloading, sclerostin levels, and bone imbalance in patients with CP. A total of 28 patients with CP participated in this cross-sectional study. The following measurements were taken: anthropometrics, clinical diagnosis of CP subtype and ambulatory status, bone mineral density (BMD) z-scores at the lumbar spine and hip, and blood biochemical markers, including sclerostin, parathyroid hormone (PTH), osteocalcin, C-terminal telopeptide, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, creatinine, calcium, and phosphorus. In analysis according to CP subtype, patients with spastic CP showed significantly lower BMD z-scores at the lumbar spine and femur neck regions than patients with dyskinetic CP. In analysis according to ambulatory status, patients with non-ambulatory CP showed significantly lower BMD z-scores at all lumbar spine and femoral sites, lower PTH and creatinine levels, and higher plasma sclerostin levels than patients with ambulatory CP. In regression analysis, ambulatory status was a significant determinant of plasma sclerostin levels. This study is the first to report on sclerostin levels and BMD in patients with CP, based on the hypothesis that patients who lack sufficient weight-bearing activities would show increased sclerostin levels and decreased BMD scores, compared with patients who sustain relatively sufficient physical activity. Therefore, this report may provide clinical insights for clinicians considering ambulatory status, sclerostin levels, and bone loss in patients with CP.
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Affiliation(s)
- Yoon-Kyum Shin
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea; Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Young Kwon Yoon
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea; Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Kyung Bae Chung
- Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea; Avison Biomedical Research Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Sung-Rae Cho
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea; Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea; Avison Biomedical Research Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea; Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul 03722, Republic of Korea.
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Zareen Z, McDonnell C, Mc Donald D, Molloy E. Bisphosphonate use in children with cerebral palsy. Cochrane Database Syst Rev 2017; 2017:CD012756. [PMCID: PMC6483615 DOI: 10.1002/14651858.cd012756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To examine the efficacy and safety of bisphosphonate therapy in the treatment of low BMD or secondary osteoporosis (or both) in children with cerebral palsy (GMFCS Levels III to V) who are under 18 years of age.
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Affiliation(s)
| | - Ciara McDonnell
- The National Children’s Hospital, TallaghtDepartment of Paediatric Endocrinology & DiabetesDublinIreland24
| | - Denise Mc Donald
- The National Children’s Hospital, TallaghtDepartment of PaediatricsDublinIreland24
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Gannotti ME. Coupling Timing of Interventions With Dose to Optimize Plasticity and Participation in Pediatric Neurologic Populations. Pediatr Phys Ther 2017; 29 Suppl 3:S37-S47. [PMID: 28654476 PMCID: PMC5488702 DOI: 10.1097/pep.0000000000000383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this article is to propose that coupling of timing of interventions with dosing of interventions optimizes plasticity and participation in pediatric neurologic conditions, specifically cerebral palsy. Dosing includes frequency, intensity, time per session, and type of intervention. Interventions focus on body structures and function and activity and participation, and both are explored. Known parameters for promoting bone, muscle, and brain plasticity and evidence supporting critical periods of growth during development are reviewed. Although parameters for dosing participation are not yet established, emerging evidence suggests that participation at high intensities has the potential for change. Participation interventions may provide an additional avenue to promote change through the life span. Recommendations for research and clinical practice are presented to stimulate discussions and innovations in research and practice.
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Affiliation(s)
- Mary E Gannotti
- Department of Rehabilitation Sciences, University of Hartford, West Hartford, Connecticut
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King G, Parker K, Peacocke S, Curran C, McPherson AC, Chau T, Widgett E, Fehlings D, Milo-Manson G. Centres for Leadership: a strategy for academic integration. J Health Organ Manag 2017; 31:302-316. [DOI: 10.1108/jhom-11-2016-0225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to describe how an Academic Health Science Centre, providing pediatric rehabilitation services, research, and education, developed a Centres for Leadership (CfL) initiative to integrate its academic functions and embrace the goal of being a learning organization.
Design/methodology/approach
Historical documents, tracked output information, and staff members’ insights were used to describe the ten-year evolution of the initiative, its benefits, and transformational learnings for the organization.
Findings
The evolutions concerned development of a series of CfLs, and changes over time in leadership and management structure, as well as in operations and targeted activities. Benefits included enhanced clinician engagement in research, practice-based research, and impacts on clinical practice. Transformational learnings concerned the importance of supporting stakeholder engagement, fostering a spirit of inquiry, and fostering leaderful practice. These learnings contributed to three related emergent outcomes reflecting “way stations” on the journey to enhanced evidence-informed decision making and clinical excellence: enhancements in authentic partnerships, greater innovation capacity, and greater understanding and actualization of leadership values.
Practical implications
Practical information is provided for other organizations interested in understanding how this initiative evolved, its tangible value, and its wider benefits for organizational collaboration, innovation, and leadership values. Challenges encountered and main messages for other organizations are also considered.
Originality/value
A strategy map is used to present the structures, processes, and outcomes arising from the initiative, with the goal of informing the operations of other organizations desiring to be learning organizations.
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Scarpato E, Staiano A, Molteni M, Terrone G, Mazzocchi A, Agostoni C. Nutritional assessment and intervention in children with cerebral palsy: a practical approach. Int J Food Sci Nutr 2017; 68:763-770. [DOI: 10.1080/09637486.2017.1289502] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Elena Scarpato
- Department of Translational Medical Sciences – Section of Paediatrics, University of Naples “Federico II”, Naples, Italy
| | - Annamaria Staiano
- Department of Translational Medical Sciences – Section of Paediatrics, University of Naples “Federico II”, Naples, Italy
| | - Massimo Molteni
- Child Psychopathology Unit, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS) “Eugenio Medea”, Lecco, Italy
| | - Gaetano Terrone
- Department of Translational Medical Sciences – Section of Paediatrics, University of Naples “Federico II”, Naples, Italy
| | - Alessandra Mazzocchi
- Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS “Cà Granda Ospedale Maggiore Policlinico”, Milan, Italy
| | - Carlo Agostoni
- Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS “Cà Granda Ospedale Maggiore Policlinico”, Milan, Italy
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Ozel S, Switzer L, Macintosh A, Fehlings D. Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: an update. Dev Med Child Neurol 2016; 58:918-23. [PMID: 27435427 DOI: 10.1111/dmcn.13196] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/30/2022]
Abstract
AIM To investigate the impact of new evidence for weight-bearing, bisphosphonates, and vitamin D and calcium interventions, towards updating the systematic review and clinical practice guidelines for osteoporosis in children with cerebral palsy (CP) published in 2011. METHOD Computer-assisted literature searches were conducted for articles published from 2010 to 2016. Searches focused on children with CP functioning at Gross Motor Function Classification System levels III to V and limited to weight-bearing activities, bisphosphonates, and vitamin D and/or calcium supplementation. Articles were classified according to the American Academy of Neurology guidelines to update the grading of the evidence for improving bone mineral density (BMD) and decreasing fragility fractures. RESULTS Six new articles underwent full-text review and data abstraction. These included one weight-bearing, three bisphosphonate, and two mixed intervention studies (bisphosphonate and vitamin D/calcium supplementation). Overall, there continues to be 'probable' evidence for bisphosphonates, 'possible' evidence for vitamin D/calcium, and 'insufficient' evidence for weight-bearing activities as effective interventions to improve low BMD in children with CP. There is 'possible' evidence for bisphosphonates in reducing fragility fractures. INTERPRETATION The grading of evidence to support the use of weight-bearing activities, bisphosphonates, and vitamin D and calcium supplementation in pediatric CP osteoporosis clinical practice guidelines remained the same.
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Affiliation(s)
- Sezgi Ozel
- Bloorview Research Institute, Toronto, ON, Canada
| | | | | | - Darcy Fehlings
- Bloorview Research Institute, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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Trinh A, Wong P, Ebeling PR, Fuller PJ, Milat F. Severe acute phase response after intravenous zoledronic acid in adult patients with cerebral palsy. Intern Med J 2016; 46:506-7. [PMID: 27062209 DOI: 10.1111/imj.13030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 12/20/2015] [Accepted: 12/21/2015] [Indexed: 11/30/2022]
Affiliation(s)
- A Trinh
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia.,Hudson Institute of Medical Research, Centre for Endocrinology and Metabolism, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - P Wong
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia.,Hudson Institute of Medical Research, Centre for Endocrinology and Metabolism, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - P R Ebeling
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - P J Fuller
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia.,Hudson Institute of Medical Research, Centre for Endocrinology and Metabolism, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - F Milat
- Department of Endocrinology, Monash Health, Melbourne, Victoria, Australia.,Hudson Institute of Medical Research, Centre for Endocrinology and Metabolism, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
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Abstract
Cerebral palsy is the most common cause of childhood-onset, lifelong physical disability in most countries, affecting about 1 in 500 neonates with an estimated prevalence of 17 million people worldwide. Cerebral palsy is not a disease entity in the traditional sense but a clinical description of children who share features of a non-progressive brain injury or lesion acquired during the antenatal, perinatal or early postnatal period. The clinical manifestations of cerebral palsy vary greatly in the type of movement disorder, the degree of functional ability and limitation and the affected parts of the body. There is currently no cure, but progress is being made in both the prevention and the amelioration of the brain injury. For example, administration of magnesium sulfate during premature labour and cooling of high-risk infants can reduce the rate and severity of cerebral palsy. Although the disorder affects individuals throughout their lifetime, most cerebral palsy research efforts and management strategies currently focus on the needs of children. Clinical management of children with cerebral palsy is directed towards maximizing function and participation in activities and minimizing the effects of the factors that can make the condition worse, such as epilepsy, feeding challenges, hip dislocation and scoliosis. These management strategies include enhancing neurological function during early development; managing medical co-morbidities, weakness and hypertonia; using rehabilitation technologies to enhance motor function; and preventing secondary musculoskeletal problems. Meeting the needs of people with cerebral palsy in resource-poor settings is particularly challenging.
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Dietary Intakes and Nutritional Issues in Neurologically Impaired Children. Nutrients 2015; 7:9400-15. [PMID: 26580646 PMCID: PMC4663597 DOI: 10.3390/nu7115469] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/28/2015] [Accepted: 11/03/2015] [Indexed: 12/16/2022] Open
Abstract
Neurologically impaired (NI) children are at increased risk of malnutrition due to several nutritional and non-nutritional factors. Among the nutritional factors, insufficient dietary intake as a consequence of feeding difficulties is one of the main issues. Feeding problems are frequently secondary to oropharyngeal dysphagia, which usually correlates with the severity of motor impairment and presents in around 90% of preschool children with cerebral palsy (CP) during the first year of life. Other nutritional factors are represented by excessive nutrient losses, often subsequent to gastroesophageal reflux and altered energy metabolism. Among the non-nutritional factors, the type and severity of neurological impairment, ambulatory status, the degree of cognitive impairment, and use of entiepileptic medication altogether concur to determination of nutritional status. With the present review, the current literature is discussed and a practical approach for nutritional assessment in NI children is proposed. Early identification and intervention of nutritional issues of NI children with a multidisciplinary approach is crucial to improve the overall health and quality of life of these complex children.
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Kim MJ, Kim SN, Lee IS, Chung S, Lee J, Yang Y, Lee I, Koh SE. Effects of bisphosphonates to treat osteoporosis in children with cerebral palsy: a meta-analysis. J Pediatr Endocrinol Metab 2015. [PMID: 26214607 DOI: 10.1515/jpem-2014-0527] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In childhood and adolescence, some patients with cerebral palsy (CP) have long-term limited mobility, which can lead to secondary osteoporosis, Prevention and treatment strategies have been evaluated for the management of low bone mineral density (BMD) and fragility fractures. Currently, however, there are no established guidelines for the stratification and individualization of therapeutic interventions. Recently, an increasing number of studies have reported on the use of bisphosphonates to increase BMD in various pediatric conditions, and bisphosphonates have been suggested as a method to treat osteoporosis and prevent fractures. PURPOSE We performed the current meta-analysis to assess the effects of bisphosphonates on increasing BMD in children who have CP with secondary osteoporosis. MATERIALS AND METHODS A search of PubMed, Cochrane, and Embase from inception to April 2014 was performed with the following keywords: (bone disease, metabolic OR osteoporosis OR osteopenia) AND (child OR pediatric OR adolescent) AND (cerebral palsy) AND (bisphosphonate). Four studies were ultimately included in the meta-analysis: one randomized, double-blinded, placebo-controlled study and three case-controlled studies. RESULTS The Z-score of lumbar spine was significantly improved after bisphosphonates treatment compared with pre-treatment values (standardized mean difference [SMD], 0.799; 95% confidence interval [CI], 0.499-1.100; p<0.001). The Z-score of femur was also improved significantly compared with that of the baseline value (SMD, 0.748; 95% CI, 0.382-1.114; p<0.001). CONCLUSIONS Bisphosphonates have a significant effect on improving BMD in children with CP. Further standardization of treatment protocols including treatment dosage and duration needs to be established, and long-term follow up studies are needed.
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Grossberg R, Blackford MG, Kecskemethy HH, Henderson R, Reed MD. Longitudinal assessment of bone growth and development in a facility-based population of young adults with cerebral palsy. Dev Med Child Neurol 2015; 57:1064-9. [PMID: 25951240 DOI: 10.1111/dmcn.12790] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2015] [Indexed: 11/30/2022]
Abstract
AIM Osteoporosis is a significant clinical problem in persons with moderate to severe cerebral palsy (CP), causing fractures with minimal trauma. Over the past decade, most studies examining osteoporosis and CP have been cross-sectional in nature, focused exclusively on children and adolescents and only involving one evaluation of bone mineral density (BMD). The purpose of this study was to assess BMD in a group including adults with CP, and changes in each individual's BMD over a 5- to 6-year period. METHOD The study group included 40 residents of a long-term care facility aged 6 to 26 years at the time of their initial evaluation. Twenty-one patients (52.5%) were male, 35 (88%) were white, and 38 (95%) were in Gross Motor Function Classification System level V. BMD was assessed by dual-energy X-ray absorptiometry on the right and left distal femurs for three distinct regions of interest. RESULTS Five residents had a fracture that occurred during the study period; this represented a fracture rate of 2.1% per year in the study group. Longitudinally, annualized change in the median BMD was 0.7% to 1.0% per year in the different regions of the distal femur, but ranged widely among the study group, with both increases and decreases in BMD. Increase in BMD over time was negatively correlated with age and positively correlated with change in weight. INTERPRETATION Changes in BMD over time in profoundly involved persons with CP can range widely, which is important to recognize when evaluating potential interventions to improve BMD. Age and changes in body weight appear the most relevant factors.
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Affiliation(s)
- Richard Grossberg
- Hattie Larlham Center for Children with Disabilities, Mantua, OH, USA.,Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Martha G Blackford
- Department of Pediatrics, Northeast Ohio Medical University, Rootstown, OH, USA.,Division of Clinical Pharmacology & Toxicology, Akron Children's Hospital, Akron, OH, USA.,Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH, USA
| | - Heidi H Kecskemethy
- Department of Biomedical Research, Nemours/A.I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Medical Imaging, Nemours/A.I. duPont Hospital for Children, Wilmington, DE, USA
| | - Richard Henderson
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC, USA
| | - Michael D Reed
- Hattie Larlham Center for Children with Disabilities, Mantua, OH, USA.,Department of Pediatrics, Northeast Ohio Medical University, Rootstown, OH, USA.,Division of Clinical Pharmacology & Toxicology, Akron Children's Hospital, Akron, OH, USA.,Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, OH, USA
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[Effect of supplementation with a single dose of vitamin D in children with cerebral palsy. Preliminary randomised controlled study]. ACTA ACUST UNITED AC 2015; 86:393-8. [PMID: 26471311 DOI: 10.1016/j.rchipe.2015.07.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/22/2015] [Accepted: 07/08/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Children with cerebral palsy (CP) have an increased risk of vitamin D (VD) deficiency. Although there are many studies on VD and CP, there is limited information about VD supplementation in these patients. OBJECTIVE To evaluate the effect of supplementation with a single dose of VD on the plasma concentrations of 25-hydroxy-vitamin-D (25OHD) in children with CP. PATIENTS AND METHOD Prospective-randomised-controlled-trial, including 30 Chilean children (19 males) with CP, median age 9.9 years (6.2-13.5). Clinical and biochemical variables including 25OHD, were recorded (time 0 and 8 weeks). Patients were allocated to the supplemented (S) group receiving 100,000 IU oral D3 at baseline, and compared with the placebo (P) group. RESULTS Among clinical features are highlighted: gastrostomy (60%), underweight (30%), bed-ridden (93.3%), antiepileptic drugs (70%), and 43.3% used VD metabolism inducing antiepileptics. Baseline biochemical measurements were normal. The 25OHD was insufficient in 4/30 and deficient in 6/30. 25OHD levels were not associated with the variables studied. Eight patients completed the study in the S group, and 10 in P group. The placebo and supplementation groups had no significant difference in baseline variables. Serum calcium, phosphate, and alkaline phosphatase levels at 8 weeks were normal in both groups, with no statistically significant differences. 25OHD in the P group was normal in 6/10, and insufficient+deficient in 4/10, and the S group was normal in all (8/8) (exact Fisher test P=.07). CONCLUSIONS A single dose of 100,000 IU VD could normalise the concentrations of 25OHD after 8 weeks of supplementation in Children with CP, but more studies are required to confirm these results.
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