Literature Review on Non Pharmacological Method of Prevention & Management of Osteoporosis in Cerebral Palsy Children

INTRODUCTION

―Cerebral palsy is non-progressive disorder of posture and movement due to insult to developing brain‖1. Its prevalence on the basis of population according to study reports reveals that 1.2 – 3.6 per live births2.Cerebral palsy is one of the most prevalent childhood condition which has an association with Osteoporosis3.Increase in bone mass occurs throughout the childhood and during early adulthood .Presence of a peak bone mass is one of the key determinant of life time risk of Osteoporosis4,5.According to WHO Osteoporosis is defined as a ―Low bone mass and micro architectural detoriation of bone tissue leading to enhanced bone fragility and consequent increase in fracture risk‖6.Osteoporosis definition with respect to children composites of a BMD Z score less than or equal to-2 adjusted for age, gender and their body size along with significant history of fracture,(1) 2 upper extremity fractures or (2) vertebral compression fracture or (3) a single lower extremity fracture 3. Research findings has proved that osteoporosis has its roots originated from childhood.Childrern with cerebral palsy usually presents significantly decreased bone density , which makes them prone to painful fractures resulting from minimal trauma, which leads to impairment in their normal function3.

Risk factors for Osteoporosis in Cerebral palsy7

Poor growth and nutritional status ----------- Low calcium intake Poor sunlight ------------ Immobility Low Vitamin D ----------- Medications that interpret with Vitamin metabolism Lack of weight bearing ------------ Growth hormone insufficiency ChenCL et al in a research study has mentioned that children and adolescents with Cerebral palsy are at high risk of secondary osteoporosis because of reduced mobility8, 9.For diagnosis of Osteoporosis on children the clinical report should reveal a significant fracture history and low mineral

‗W‘ King et al (2003) in their study on Cerebral palsy has revealed that 39% of children with quadriplegic cerebral palsy presented with history of fracture10.Presedo et al (2007) conducted a study on 1637 patients with cerebral palsy and found that 6% of the total had prevalence of fracture11.A.I.Litt.A.Merfin et al (2006).E.Bischof et al (2002) in their study on cp has reported that 23% of 88 children of quadriplegic cerebral palsy had prevalence of fracture 14. R.D. Stevenson et al (2006) conducted a study on occurrence of fracture on 261 children and reports have shown that 4.8 per 100 person developed fractures14.. It is found that number of chronic childhood disorder are associated with reduced mobility e.g.cerebral palsy, spinal cord injury, head injury, muscular dystrophy, spinal muscular atrophy, neuromuscular conditions with unknown etiology. The main component for bone development is muscle tone and its function with mechanical loading which is more essential for development of bone growth. This particular term is called functional muscle bone unit. It was found that during childhood bone growth takes place both in length as well as width wise due to periosteal expansion, which is aided by mechanical loading created by the muscle tone15.In cerebral palsy during bone growth the mechanical stimulus gets removed and occurrence of long narrow bones with weaker strength takes place which leads to vulnerable fractures15.

In cerebral palsy standing frames are usually encouraged as a postural management approach in cerebral palsy children17.In the standing programmes usually adaptive equipment e.g. standing frame with extended and adjustable support is provided for the patients to facilitate upright position.Literaure reveals that encouraging standing in developmentally appropriate position stimulates antigravity muscles, improves the muscle strength and endurance which facilitates independent standing in cerebral palsy children18,19,20. Han EY et al (2017) conducted a study to find out the effect of weight bearing on bone mineral density and bone growth on spastic cerebral palsy children.The study participants were screened by a dual-energy X-ray absorptiometry scan to measure the BMD of the femur and full-length anteroposterior radiography that programmed weight bearing exercise for at least 2 hours a day for more than 5 days a week could be used as an effective treatment to increase BMD and to achieve normal bone growth in children with cerebral palsy16.C.L Chen e.t al (2011) has conducted a study on ambulatory children with cerebral palsy to find out the efficacy of home based virtual cycling training to improve bone mineral density. Thestudy results have revealed that there was an increase in lower limb strength and increase in femur BMD17.Caulton JM et al conducted a clinical trial on 26 prepubertal children with cerebral palsy to evaluate the impact of standing /weight bearing on BMD.The study was conducted for a period of 9 months with comparison of study group and control group .The period of study was 180-675 minutes for a week. Standing training was given with assisted standing frames .The results had proved that there was considerable improvement in lumber spine BMD by 6%in the standing group compared to that of control group. This shows that increased standing can lead to decrease risk of vertebral fractures 1.

CONCLUSION:

With the review of literature it was found that various studies have reported increased weight bearing activities along with provision of good nutrition and with considerable intake of calcium and vitamin D, together with physical activity, should be enforced when provided to cerebral palsy children as part of treatment, can reduce the occurrence of fractures .It helps them to improve their BMD and also assist them in their mobility.

1. Caulton J.M., Ward K.A., Alsop C.W., Dunn G., Adams J.E., Mughal M.Z. (2004). A randomized controlled trial of standing programme in bone mineral density in nonambulant children with cerebral palsy.Arch Dis child,2004: 89(2): pp. 131-135.doi:10,1136/adc.2002.009316 2. Blair E. (2010). Epidemiology of cerebral palsies,Orthop.clin.North Am 2010:Oct, 41: pp. 441-55 doi:10.1016/j.ocl.2010.05.004 3. Houlihan C.M., Stevenson R.D. (2009). Bone density in cerebral palsy.Phy.Med Rehabil clin N Am.2009; Aug20(3): pp. 493-508.doi:1016/j.pmr.2009.04.004 4. Gelfand I.M., Dimeqlio L.A. (2005). Bone mineral accrual and low bone mass : a pediatric perspective. Rev Endocr Metab

5. Bachrach L.K. (2001). Aquisition of optimal bone mass in childhood and adolescence. Trends Endocrinal Metab. 2001; Jan-Feb 12(1): pp. 22-8[Pub Med] [Google Scholar] 6. Assessment of fracture risk and its application to screening for post menopausal osteoporosis.Report of WHO Study Group.Geneva,World Health Organization,1994(WHO Technical report series; No. 843) 7. Lloyd M.E., Spector T.D., Howard R. (2000). Osteoporosis in neurological disorders Neurol Neurosurg Psychiatr, 68(5): pp. 543-7[PMC free article] [Pub Med] [Google scholar] 8. Chen C.L., Chen C.Y., Liaw M.Y., Chung C.Y., Wang C.J., Hong W.H. (2013). Efficacy of home based virtual cycling training on bone mineral density in ambulatory children with cerebral palsy.Osteoporosis Int; Apr;24(4): pp. 1399-406 9. Dalén, Ylva & Sääf, Maria & Nyrén, Sven & Mattsson, Eva & Haglund-Åkerlind, Yvonne & Klefbeck, Brita. (2012). Observations of four children with severe cerebral palsy using a novel dynamic platform. A case report. European Journal of Physiotherapy. 14. 10.3109/14038196.2012.693948. 10. King, Wilson & Levin, Ronald & Schmidt, Rosemary & Oestreich, Alan & Heubi, James (2003). Prevalence of reduced bone mass in children and adult with spastic quadriplegia. Developmental medicine and child neurology, 45, pp.12-16 11. Presedo, Ana & Dabney, Kirk & Miller, Freeman. (2007). Fractures in Patients With Cerebral Palsy. Journal of pediatric orthopedics. 27. pp. 147-53. 10.1097/BPO.0b013e3180317403. 12. Leet A.I., Mesfin A., Pichard C., Launay F., Brintzenhofeszoc K., Levey E.B., D. Sponseller P. (2006). Fractures in children with cerebral palsy.J Pediatr Orthop, 26, pp. 624-627 13. Bischof, Faith et. al. (2002). ―Pathological long-bone fractures in residents with cerebral palsy in a long-term care facility in South Africa.‖ Developmental medicine and child neurology 44 2: pp. 119-22. Fracture rate in children with cerebral palsy, Pediatric Rehabilitation, 9:4, pp. 396-403, DOI: 10.1080/13638490600668061 15. Rauch, Frank. (2007). Bone Accrual in Children: Adding Substance to Surfaces. Pediatrics. 119 Suppl 2. pp. S137-40. 10.1542/peds.2006-2023E. 16. Han E.Y., Choi J.H., Kim S.H., Im S.H. (2017). The effect of weight bearing on bone mineral density and bone growth in children with cerebral palsy: A randomized controlled preliminary trial. Medicine (Baltimore). 96(10): pp. e5896. doi:10.1097/MD.0000000000005896 17. Chen, Jongyau & Chen, C.Y. & Liaw, Mei-Yun & Chung, C.Y. & Wang, C.J. & Hong, Wei-Hsien (2012). Efficacy of home-based virtual cycling training on bone mineral density in ambulatory children with cerebral palsy. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 24. 10.1007/s00198-012-2137-0.

Sr. Occupational Therapist, JIPMER, Puducherry (INST of National Importance ,Min of H&F Welfare, Govt of India) and Research Scholar, Himalayan University, Arunachal Pradesh, India