Addressing disparities among children with cerebral palsy: Optimizing enablement, functioning, and participation.

PURPOSE: Recognizing health disparities among children with cerebral palsy (CP) is necessary for understanding potential risk factors for CP and for implementing early and effective preventative and intervention treatments. However, there is currently little and conflicting evidence regarding the direct impact of contextual factors such as socioeconomic status (SES) for children with CP in the United States. These contextual factors include the complex social determinants of health on prematurity, comprehensive informed obstetric management for minority and vulnerable populations, and cumulative adversity disproportionately experienced by children, by gender, minority status, immigration, poverty, and structural racism. METHODS: This study presents results from a review of health disparities among children with CP, using registry and population surveillance data from Australia, Canada, Scandinavia, the United Kingdom, Ireland, Turkey, and the United States. RESULTS: The review confirmed that there are significant health disparities among children with CP, both in terms of prevalence and severity, based on factors such as SES, neighborhood disadvantage, maternal education, gender, and minority status. CONCLUSION: Strategies need to be implemented in the United States to promote enablement and functioning among children with CP who face additional health disparities. This requires a greater understanding of population groups at increased risk, comprehensive assessment and care for young children with motor delays, and systematic population counts of children and adults with CP using registries and systems of neurodevelopmental surveillance across health, education, and community rehabilitation. These efforts also require sensitivity to structural and persistent racism, stigma, trauma-informed care, and culturally sensitive community engagement. Additional efforts are also required to improve outcomes over the life course for individuals living a life with CP from a framework of enablement, self-direction, equity and social justice.

Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: a systematic review.

AIM: The aim of this systematic review was to inform evidence-based clinical practice guidelines for children with cerebral palsy (CP) and low bone mineral density (BMD). METHOD: A computer-assisted literature search was focused on low BMD in children with CP, and was limited to the following interventions: weight-bearing activities, bisphosphonate use, and vitamin D or calcium supplementation. Articles were classified according to American Academy of Neurology guidelines and recommendation classifications were given based on the evidence for the intervention increasing BMD and decreasing fragility fractures. Studies were included if they were English-language full-text studies, focused on children with CP, and included at least 10 participants receiving the studied interventions. RESULTS: Twenty-one articles underwent full-text review and data abstraction, including seven studies of weight-bearing activities, five studies of vitamin D or calcium supplementation, and nine studies of bisphosphonates administration. Overall, the evidence that bisphosphonates administration increases BMD was assessed as level B (probable) while the evidence that vitamin D or calcium supplementation does so was assessed as level C (possible); there was insufficient evidence to suggest that weight-bearing activities are an effective intervention to improve BMD. The evidence that bisphosphonates help to prevent fragility fractures was assessed as level C (possible); there was inadequate evidence to support the use of weight-bearing activities or vitamin D or calcium supplementation to decrease fragility fractures. INTERPRETATION: Evidence-based clinical practice guidelines were created outlining the suggested role of weight-bearing activities, vitamin D and calcium supplementation, and bisphosphonate use for children with CP with low BMD at risk of fragility fractures.

Characterization of spasticity in cerebral palsy: dependence of catch angle on velocity.

AIM: To evaluate spasticity under controlled velocities and torques in children with cerebral palsy (CP) using a manual spasticity evaluator. METHOD: The study involved 10 children with spastic CP (six males, four females; mean age 10 y 1 mo, SD 2 y 9 mo, range 7-16 y; one with quadriplegia, six with right hemiplegia, three with left hemiplegia; Gross Motor Function Classification System levels I [n=2], II [n=3], III [n=2], IV [n=2], and V [n=1]; Manual Ability Classification System levels II [n=5], III [n=4], and V [n=1]) and 10 typically developing participants (four males, six females; mean age 10 y 3 mo, SD 2 y 7 mo, range 7-15 y). Spasticity and catch angle were evaluated using joint position, resistance torque, and torque rate at velocities of 90 degrees, 180 degrees, and 270 degrees per second, controlled using real-time audio-visual feedback. Biomechanically, elbow range of motion (ROM), stiffness, and energy loss were determined during slow movement (30 degrees/s) and under controlled terminal torque. RESULTS: Compared with typically developing children, children with CP showed higher reflex-mediated torque (p<0.001) and the torque increased more rapidly with increasing velocity (p<0.001). Catch angle was dependent on velocity and occurred later with increasing velocity (p=0.005). Children with CP showed smaller ROM (p<0.05), greater stiffness (p<0.001), and more energy loss (p=0.003). INTERPRETATION: Spasticity with velocity dependence may also be position-dependent. The delayed catch angle at higher velocities indicates that the greater resistance felt by the examiner at higher velocities was also due to position change, because the joint was moved further to a stiffer position at higher velocities.