Category: Cerebral Palsy

date: 08/01/1996
author: Wilmshurst S, Ward K, Adams JE, Langton CM, Mughal MZ.
publication: Arch Dis Child. 1996 Aug;75(2):164-5.
pubmed_ID: 8869203

The spinal bone mineral density (SBMD) and calcaneal broadband ultrasound attenuation (BUA) was measured in 27 children with cerebral palsy. They were categorised into four mobility groups: mobile with an abnormal gait, mobile with assistance, non-mobile but weight bearing, non-mobile or weight bearing. Mean SD scores for BUA and SBMD differed among mobility groups (analysis of variance, p < 0.001 and p = 0.078, respectively).

date: 10/01/2006
author: Katz, Danielle,MD, Snyder, Bryan MD, PhD, Dodek, Anton MD, Holm, Ingrid MD Miller, Claire BS
publication: Abstract as published in the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) 2006 Conference Proceedings

Purpose: Pathologic fractures are a significant source of morbidity for non-ambulatory children with neuromuscular dysfunction. We hypothesize that increasing weight-bearing in non-ambulatory children will increase bone material density (BMD) and decrease fracture risk. The aim of this pilot study was to demonstrate that non-ambulatory children participating in a standing program for at least two hours a day will experience an increase in BMD in the weight bearing bones. We also evaluate the reliability of measuring BMD at the calcaneous (weight bearing bones) and distal forearm (non-weight bearing bone) using peripheral DXA in delayed, non-ambulatory children.

Methods: After receiving IRB approval, 12 non-ambulatory, quadriplegic children (ages 12-21) consented to participate in a 2 hour/day, 5 day/week standing program. A history, orthopaedic exam, determination of bone age, laboratory tests for metabolic bone disease and BMD at the calcaneal tuberosity and distal forearm metaphyses were obtained. Compliance with the prescribed standing program was monitored for 6 months. BMD was measured using peripheral DXA at baseline and every 3 months. Using Jan. 2003 BMD data as a baseline, the ratio of change in BMD at the calcaneous and distal forearm was evaluated as a function of percent compliance with standing program.

Results: Intrarater reliability for BMD measured by peripheral DXA was good: Pearson correlation for the calcaneous = 0.90 (p=0.01) and for the forearm = 0.96 (p=0.01). Paired t test between two sets of data measured at each site on the same day were not different for calcaneous (t=0.92, df=15, p=0.37) or forearm (t=0.05, df=15, p=0.96). Compliance with the standing program was inconsistent. No patients were 100% compliant. Patients tended to stand longer at the initiation of the study Jan.-April (Jan vs Apr, p = 0.018; Jan vs Jul, p = 0.89; Apr vs Jul, p = 0.063). Compliance (%) was positively correlated (r = -0.62) with increased calcaneous BMD measured in April. This is in contrast to forearm BMD measured at the same time; which was negatively correlated (r = -0.44) with standing compliance. This support the notion that standing preferentially increases bone mass in the weight-bearing bones. However the BMD at the calcaneous measured in July was decreased, perhaps reflecting the decreased compliance the with standing program over the succeeding interval April-July.

Conclusion: It is feasible to have non-ambulatory children participate in a rigorous standing program. The weight bearing ?dose? affects BMD at the calcaneous but the benefit appears to be transient if the intensive standing program is not sustained.

Significance: The intensive use of standers (10 hours/wk) may have a beneficial effect on BMD of weight bearing bones in non-ambulatory children.

date: 12/01/2005
author: Binkley T, Johnson J, Vogel L, Kecskemethy H, Henderson R, Specker B.
publication: J Pediatr. 2005 Dec;147(6):791-6.
pubmed_ID: 16356433

OBJECTIVE: To use peripheral quantitative computed tomography (pQCT) to determine bone measurements in patients with cerebral palsy (CP) age 3 to 20 years and compare them with control subjects. STUDY DESIGN: A total of 13 (5 male) patients with CP, along with 2 sex- and age-matched controls for each, were included in a mixed-model analysis with matched pairs as random effects for pQCT bone measurements of the 20% distal tibia. RESULTS: Tibia length was similar in the CP and control groups (P = .57). Weight was marginally higher in the control group (P = .06). Cortical bone mineral content (BMC), area, thickness, polar strength-strain index (pSSI), and periosteal and endosteal circumferences were greater in the control group (P < .05 for all). Relationships between bone measurements and weight showed that cortical BMC, area, periosteal circumference, and pSSI were greater at higher weights in the control group (group-by-weight interaction, P < .05 for all). Cortical thickness was greater in the control group and was correlated with weight. Cortical volumetric bone mineral density (vBMD) was greater with higher weights in the CP group (group-by-weight interaction, P = .03). CONCLUSIONS: Bone strength, as indicated by pSSI, is compromised in children with CP due to smaller and thinner bones, not due to lower cortical bone density.

date: 06/01/2005
author: Henderson RC, Kairalla JA, Barrington JW, Abbas A, Stevenson RD.
publication: J Pediatr. 2005 Jun;146(6):769-75
pubmed_ID: 15973316

OBJECTIVE: To assess the natural history of “growth” in bone mineral density (BMD) in children and adolescents with moderate to severe cerebral palsy (CP). STUDY DESIGN: A prospective, longitudinal, observational study of BMD in 69 subjects with moderate to severe spastic CP ages 2.0 to 17.7 years. Fifty-five subjects were observed for more than 2 years and 40 subjects for more than 3 years. Each evaluation also included assessments of growth, nutritional status, Tanner stage, general health, and various clinical features of CP. RESULTS: Lower BMD z-scores at the initial evaluation were associated with greater severity of CP as judged by gross motor function and feeding difficulty, and with poorer growth and nutrition as judged by weight z-scores. BMD increased an average of 2% to 5%/y in the distal femur and lumbar spine, but ranged widely from +42%/y to -31%. In spite of increases in BMD, distal femur BMD z-scores decrease with age in this population. CONCLUSIONS: Children with severe CP develop over the course of their lives clinically significant osteopenia. Unlike elderly adults, this is not primarily from true losses in bone mineral, but from a rate of growth in bone mineral that is diminished relative to healthy children. The efficacy of interventions to increase BMD can truly be assessed only with a clear understanding of the expected changes in BMD without intervention.

date: 01/01/1992
author: Stuberg WA.
publication: Phys Ther. 1992 Jan;72(1):35-40.
pubmed_ID: 1728047

Standing is a common modality used in the management of children with developmental disabilities. The purpose of this article is to examine the scientific basis for standing programs, with specific emphasis on the known effects of weight bearing on bone development. Guidelines for the use of standing programs are presented, and the supporting rationale is discussed.