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Systematic review of interventions for low bone mineral density in children with cerebral palsy
Janet P Hough1, Roslyn N Boyd, Jennifer L Keating
1BAppSc, PT, Monash Medical Centre, Victorian Paediatric Rehabilitation Service, 246 Clayton Rd, Clayton, Victoria 3168, Australia. janet.hough@southernhealth.org.au
Insights
Interventions like bisphosphonates and weight-bearing exercises show promise for improving low bone mineral density (LBMD) in children with cerebral palsy (CP). Further large trials are needed to confirm these findings.
Area of Science:
- Pediatrics
- Orthopedics
- Rehabilitation Medicine
Background:
- Low bone mineral density (LBMD) is a common comorbidity in children and adolescents with cerebral palsy (CP).
- LBMD in CP increases the risk of fractures and impacts overall health and mobility.
Purpose of the Study:
- To systematically review the efficacy of interventions aimed at improving LBMD in pediatric and adolescent populations diagnosed with CP.
- To synthesize evidence from randomized controlled trials (RCTs) and controlled clinical trials (CCTs) on various medical and physical therapies.
Main Methods:
- A systematic literature search was conducted for RCTs and CCTs involving children with CP (aged 0-20 years) and LBMD.
- Interventions included bisphosphonates, weight-bearing exercises, vitamin D, calcium, and growth hormone.
- Study validity was assessed using the Physiotherapy Evidence Database (PEDro) scale; standardized mean differences (SMDs) were calculated.
Main Results:
- Eight studies (6 RCTs, 2 CCTs) met inclusion criteria.
- Bisphosphonates demonstrated a significant effect on distal femur bone mineral density (BMD) in one trial (SMD: 1.88).
- Weight-bearing exercises, specifically increased static standing time, showed a significant effect on lumbar spine BMD (SMD: 1.03).
- Vitamin D and calcium, and growth hormone with vitamin D/calcium, yielded nonsignificant effects on lumbar spine BMD.
Conclusions:
- Significant improvements in LBMD were observed in some small, heterogeneous cohorts of children with CP.
- The reasons for nonsignificant findings remain unclear, potentially due to small sample sizes or variable treatment responses.
- Larger, high-quality RCTs are necessary to evaluate both physical and medical interventions for LBMD in CP.
Aim:
To systematically review the efficacy of interventions to improve low bone mineral density (LBMD) in children and adolescents with cerebral palsy (CP).
Methods:
We performed a systematic search for published randomized, controlled trials (RCTs) and controlled clinical trials (CCTs) of children with CP (aged 0-20 years, all Gross Motor Function Classification System [GMFCS] levels) who received various medical and physical interventions for LBMD compared with no intervention or standard care. Study validity was evaluated by using the Physiotherapy Evidence Database (PEDro) scale. Standardized mean differences (SMDs) were calculated when data were sufficient.
Results:
Eight of 2034 articles met the inclusion criteria (6 RCTs, 2 CCTs). There were 3 trials of bisphosphonates, one of which (Henderson RC, Lark RK, Kecskemethy HH, Miller F, Harcke HT, Bachrach SJ. J Pediatr. 2002;141[5]:644-651) revealed a large and significant effect on BMD in 1 of 3 sites in the distal femur (SMD: 1.88 [95% confidence interval (CI): 0.52-3.24]). There were 3 trials of weight-bearing through varying approaches, one of which (Caulton JM, Ward KA, Alsop CW, Dunn G, Adams JE, Mughal MZ. Arch Dis Child. 2004;89[2]:131-135) showed a large and significant effect on the lumbar spine when increasing static standing time (SMD: 1.03 [95% CI: 0.21-1.85]). The administration of vitamin D and calcium produced a large, nonsignificant effect on BMD in the lumbar spine (Jekovec-Vrhovsek M, Kocijancic A, Prezelj J. Dev Med Child Neurol. 2000;42[6]:403-405) (SMD: 0.88 [95% CI: -0.07 to 1.84). Growth hormone combined with vitamin D and/or calcium resulted in effects comparable with vitamin D and/or calcium on BMD in the lumbar spine (Ali O, Shim M, Fowler E, et al. J Clin Endocrinol Metab. 2007;92[3]:932-937) (SMD 0 [95% CI: -1.24 to 1.24]).
Conclusions:
Important effects on LBMD have been observed in small and diverse cohorts of children with CP. It is unclear whether small sample sizes or variable treatment responses account for nonsignificant findings. Additional large RCTs are needed of both physical and medical approaches.
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