dimensional imaging using quantitative computed tomography (QCT) or peripheral QCT (pQCT).3,4 Careful interpretation of the results presented by Grossberg et al. may provide additional knowledge regarding deficits in bone accrual in individuals with severe CP. Research is also needed to understand bone development in less impaired persons (Gross Motor Function Classification System levels I–III). It is currently unclear to what
extent, if any, bone mass is deficient in more mildly impaired individuals with CP.4,5 While the severely involved population has the greatest bone deficits and highest risk of atraumatic fracture, less involved groups are more active which will place greater loading on their bones. Smaller deficits in bone could therefore increase fracture risk in more functional individuals with CP.
REFERENCES 1. Grossberg R, Blackford MG, Kecskemethy HH, Henderson R, Reed MD. Longitudinal assessment of bone
in children and adolescents with cerebral palsy. J Pediatr 2005; 146: 769–5.
4. Wren TA, Lee DC, Kay RM, Dorey FJ, Gilsanz V. Bone density and size in ambulatory children with cerebral palsy. Dev Med Child Neurol 2011; 53: 137–41.
growth and development in a facility-based population of
3. Binkley T, Johnson J, Vogel L, Kecskemethy H, Hender-
young adults with cerebral palsy. Dev Med Child Neurol
son R, Specker B. Bone measurements by peripheral
2015; 57: 1064–69.
quantitative computed tomography (pQCT) in children
dren with cerebral palsy. Dev Med Child Neurol 2011; 53:
with cerebral palsy. J Pediatr 2005; 147: 791–6.
102–3.
2. Henderson R, Kairalla JA, Barrington JW, Abbas A,
5. Henderson R. Bone density and size in ambulatory chil-
Stevenson RD. Longitudinal changes in bone density
Measuring body composition: the limitations of body mass index LAURA K VOGTLE Department of Occupational Therapy, University of Alabama at Birmingham, Birmingham, AL, USA. doi: 10.1111/dmcn.12798 This commentary is on the original article by Gutknecht et al. on pages 1070–1075 of this issue.
Children with cerebral palsy (CP) may undergo surgical procedures to manage spasticity, which include intrathecal baclophen pump implantation (ITB) and selective dorsal rhizotomy (SDR). Health care providers have begun to evaluate long-term outcomes after these surgical procedures which can result in associated conditions. For example, there is evidence that weight gain is seen post-ITB, especially in children who are fed by gastrostomy tube.1 Current research indicates that overweight and obesity are growing concerns in children with CP.2 Long-term followup of weight gain after SDR has produced mixed results, with recent retrospective findings suggesting weight gain is not a significant long-term concern.3 While the efforts of researchers to track weight gain resulting from surgical procedures aimed at spasticity management are laudable, the use of body mass index (BMI) as a measure of body composition, nutritional status, and growth in this population is problematic. BMI requires accurate height and weight measurement. Height can be difficult to assess accurately in persons with CP who have scoliosis, lower limb deformities, and difficulty standing. Even if accurate measures are available, BMI does not reflect body composition, information that health care providers require to effectively manage the nutritional needs
of persons with CP. Body composition measures used primarily in research settings include dual-energy X-ray absorptiometry (DXA), bioelectrical impedance analysis, and stable isotope techniques (D2O dilution). DXA is available in some clinical settings, however the individual is required to lie still for a period of time, and the metal from plates inserted in surgical procedures is a contraindication for DXA. There are skinfold thickness (SFT) methods which, with staff training, can provide information on body composition. Efforts to adjust existing equations used with SFT methods for children with CP have been carried out. A recent study compared two such equations in conjunction with SFT to body composition as assessed by DXA.4 Study results provide support for clinical measures of body composition using SFT with the Gurka et al. equation.5 There is an urgent need to use such measures in clinical settings to provide accurate knowledge about body composition resulting in accurate recommendations for nutrition and growth. Tracking postoperative weight gain is important to children and adolescents with CP; however, outcome studies addressing weight gain and body composition over the long run are of particular concern for adults with CP who demonstrate high numbers of secondary conditions. Procedures such as ITB and SDR may have associated consequences, positive or negative, not evident until later in life, a particular concern given the longer lifespan now seen in most persons with CP. Overweight and obesity are associated with adult cardiovascular health in the population at large, an issue which is just beginning to receive attention in the population of adults with CP. A recent study used anthropometric measures (waist circumference, stature, and Commentaries
991
hip circumference), BMI, blood pressure, and fasting glucose blood measures (i.e. insulin resistance, hypercholesterolemia, total serum cholesterol) to assess cardiovascular risk factors in a sample of adults with CP (mean age 37.5y). Results indicated that several cardiovascular risk factors existed, especially in study participants with higher waist circumference and higher BMIs. The same concerns regarding accurate measurement of height and weight that exist in children are present in adults to an even greater degree. Not all clinics have
wheelchair scales, and transferring adults with CP out of their usual mobility devices can be difficult and unsafe without trained personal and equipment. Spinal and lower limb deformities seen in children are present to a greater extent in adults, making height measurement equally difficult. These factors underscore the need to use measures other than BMI to address obesity and body composition in the adult population where accurate information is particularly critical given the potential health risks in this subset of the CP population.
REFERENCES 1. McCoy AA, Fox MA, Schaubel DE, Ayyangar RN.
3. Gutknecht SM, Schwartz MH, Munger ME. Ambulatory
Weight gain in children with hypertonia of cerebral ori-
children with cerebral palsy do not exhibit unhealthy weight
gin receiving intrathecal baclofen therapy. Arch Phys Med
gain following selective dorsal rhizotomy. Dev Med Child
Rehabil 2006; 87: 1503–8.
Neurol 2015; 57: 1070–5.
2. Hurvitz EA, Green LB, Hornyak JE, Khurana SR, Koch
4. Finbr aten A, Martins C, Lillemoen Andersen G, et al.
LG. Body mass index measures in children with cerebral
Assessment of body composition in children with cerebral
palsy related to gross motor function classification: a clinic-
palsy: a cross-sectional study in Norway. Dev Med Child
based study. Am J Phys Med Rehabil 2008; 87: 395–403.
992 Developmental Medicine & Child Neurology 2015, 57: 985–992
Neurol, 2015;
April 1. doi:10.1111/dmcn.12752. [Epub
ahead of print]. 5. Ryan J, Crowley V, Hensey O, McGahey A, Gormley J. Waist circumference provides an indication of numerous cardiometabolic risk factors in adults with cerebral palsy. Arch Phys Med Rehabil 2014; 95: 1540–6.
extent, if any, bone mass is deficient in more mildly impaired individuals with CP.4,5 While the severely involved population has the greatest bone deficits and highest risk of atraumatic fracture, less involved groups are more active which will place greater loading on their bones. Smaller deficits in bone could therefore increase fracture risk in more functional individuals with CP.
REFERENCES 1. Grossberg R, Blackford MG, Kecskemethy HH, Henderson R, Reed MD. Longitudinal assessment of bone
in children and adolescents with cerebral palsy. J Pediatr 2005; 146: 769–5.
4. Wren TA, Lee DC, Kay RM, Dorey FJ, Gilsanz V. Bone density and size in ambulatory children with cerebral palsy. Dev Med Child Neurol 2011; 53: 137–41.
growth and development in a facility-based population of
3. Binkley T, Johnson J, Vogel L, Kecskemethy H, Hender-
young adults with cerebral palsy. Dev Med Child Neurol
son R, Specker B. Bone measurements by peripheral
2015; 57: 1064–69.
quantitative computed tomography (pQCT) in children
dren with cerebral palsy. Dev Med Child Neurol 2011; 53:
with cerebral palsy. J Pediatr 2005; 147: 791–6.
102–3.
2. Henderson R, Kairalla JA, Barrington JW, Abbas A,
5. Henderson R. Bone density and size in ambulatory chil-
Stevenson RD. Longitudinal changes in bone density
Measuring body composition: the limitations of body mass index LAURA K VOGTLE Department of Occupational Therapy, University of Alabama at Birmingham, Birmingham, AL, USA. doi: 10.1111/dmcn.12798 This commentary is on the original article by Gutknecht et al. on pages 1070–1075 of this issue.
Children with cerebral palsy (CP) may undergo surgical procedures to manage spasticity, which include intrathecal baclophen pump implantation (ITB) and selective dorsal rhizotomy (SDR). Health care providers have begun to evaluate long-term outcomes after these surgical procedures which can result in associated conditions. For example, there is evidence that weight gain is seen post-ITB, especially in children who are fed by gastrostomy tube.1 Current research indicates that overweight and obesity are growing concerns in children with CP.2 Long-term followup of weight gain after SDR has produced mixed results, with recent retrospective findings suggesting weight gain is not a significant long-term concern.3 While the efforts of researchers to track weight gain resulting from surgical procedures aimed at spasticity management are laudable, the use of body mass index (BMI) as a measure of body composition, nutritional status, and growth in this population is problematic. BMI requires accurate height and weight measurement. Height can be difficult to assess accurately in persons with CP who have scoliosis, lower limb deformities, and difficulty standing. Even if accurate measures are available, BMI does not reflect body composition, information that health care providers require to effectively manage the nutritional needs
of persons with CP. Body composition measures used primarily in research settings include dual-energy X-ray absorptiometry (DXA), bioelectrical impedance analysis, and stable isotope techniques (D2O dilution). DXA is available in some clinical settings, however the individual is required to lie still for a period of time, and the metal from plates inserted in surgical procedures is a contraindication for DXA. There are skinfold thickness (SFT) methods which, with staff training, can provide information on body composition. Efforts to adjust existing equations used with SFT methods for children with CP have been carried out. A recent study compared two such equations in conjunction with SFT to body composition as assessed by DXA.4 Study results provide support for clinical measures of body composition using SFT with the Gurka et al. equation.5 There is an urgent need to use such measures in clinical settings to provide accurate knowledge about body composition resulting in accurate recommendations for nutrition and growth. Tracking postoperative weight gain is important to children and adolescents with CP; however, outcome studies addressing weight gain and body composition over the long run are of particular concern for adults with CP who demonstrate high numbers of secondary conditions. Procedures such as ITB and SDR may have associated consequences, positive or negative, not evident until later in life, a particular concern given the longer lifespan now seen in most persons with CP. Overweight and obesity are associated with adult cardiovascular health in the population at large, an issue which is just beginning to receive attention in the population of adults with CP. A recent study used anthropometric measures (waist circumference, stature, and Commentaries
991
hip circumference), BMI, blood pressure, and fasting glucose blood measures (i.e. insulin resistance, hypercholesterolemia, total serum cholesterol) to assess cardiovascular risk factors in a sample of adults with CP (mean age 37.5y). Results indicated that several cardiovascular risk factors existed, especially in study participants with higher waist circumference and higher BMIs. The same concerns regarding accurate measurement of height and weight that exist in children are present in adults to an even greater degree. Not all clinics have
wheelchair scales, and transferring adults with CP out of their usual mobility devices can be difficult and unsafe without trained personal and equipment. Spinal and lower limb deformities seen in children are present to a greater extent in adults, making height measurement equally difficult. These factors underscore the need to use measures other than BMI to address obesity and body composition in the adult population where accurate information is particularly critical given the potential health risks in this subset of the CP population.
REFERENCES 1. McCoy AA, Fox MA, Schaubel DE, Ayyangar RN.
3. Gutknecht SM, Schwartz MH, Munger ME. Ambulatory
Weight gain in children with hypertonia of cerebral ori-
children with cerebral palsy do not exhibit unhealthy weight
gin receiving intrathecal baclofen therapy. Arch Phys Med
gain following selective dorsal rhizotomy. Dev Med Child
Rehabil 2006; 87: 1503–8.
Neurol 2015; 57: 1070–5.
2. Hurvitz EA, Green LB, Hornyak JE, Khurana SR, Koch
4. Finbr aten A, Martins C, Lillemoen Andersen G, et al.
LG. Body mass index measures in children with cerebral
Assessment of body composition in children with cerebral
palsy related to gross motor function classification: a clinic-
palsy: a cross-sectional study in Norway. Dev Med Child
based study. Am J Phys Med Rehabil 2008; 87: 395–403.
992 Developmental Medicine & Child Neurology 2015, 57: 985–992
Neurol, 2015;
April 1. doi:10.1111/dmcn.12752. [Epub
ahead of print]. 5. Ryan J, Crowley V, Hensey O, McGahey A, Gormley J. Waist circumference provides an indication of numerous cardiometabolic risk factors in adults with cerebral palsy. Arch Phys Med Rehabil 2014; 95: 1540–6.
