Bone Health in Children with Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity

Banu Turhan; Niyazi Yaşar

doi:10.18678/dtfd.1924980

Bone Health in Children with Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity

Abstract

Aim: Cerebral palsy (CP) entails lifelong impairments in movement and posture resulting from non-progressive brain damage. As overall life expectancy increases due to advancements in neonatal conditions, the significance of long-term musculoskeletal health concerns in individuals with CP has grown correspondingly. This study aims to assess bone mineral density (BMD) in pediatric and adolescent populations with CP and investigate clinical, functional, and biochemical factors associated with osteoporosis.

Material and Methods: The study included 71 children and adolescents diagnosed with CP. Demographic data, anthropometric measurements, pubertal status, gross motor function classification system (GMFCS) level, treatment details, and fracture history were obtained from hospital records. Serum biochemical parameters and vitamin D levels, vertebral fractures, and lumbar spine BMD measured by dual-energy X-ray absorptiometry were evaluated. Osteoporosis classification was determined using Z-scores.

Results: A significant negative correlation was found between GMFCS level and BMD. The osteoporosis group had lower albumin levels, while alkaline phosphatase (ALP) values varied between groups. Patients on anticonvulsants showed reduced calcium and corrected calcium levels, but there was no statistically significant difference in BMD. The rate of osteoporosis was similar across subgroups based on vitamin D status. Additionally, no notable differences were observed between osteoporosis groups in body mass index (BMI) or BMI-standard deviation scores.

Conclusion: Metabolic factors, vitamin D levels, and functional limitations influence bone health and the development of secondary osteoporosis in children with CP. GMFCS levels are also a key determinant of bone health. A proactive, multidisciplinary evaluation of bone health is essential for preventing fractures and improving mobility.

Keywords

Ethical Statement

Ethical approval for this study was obtained from the Ankara Bilkent City Hospital Clinical Research Ethics Committee (February 02, 2025, TABED 2/938/2025). The research was conducted in strict accordance with the ethical principles outlined in the Declaration of Helsinki (as revised in 2013).

References

McIntyre S, Goldsmith S, Webb A, Ehlinger V, Hollung SJ, McConnell K, et al. Global CP prevalence group. Global prevalence of cerebral palsy: A systematic analysis. Dev Med Child Neurol. 2022;64(12):1494-506. doi:10.1111/dmcn.15346.
Novak I, Jackman M, Finch-Edmondson M, Fahey M. Cerebral palsy. Lancet. 2025;406(10499):174-88. doi:10.1016/S0140-6736(25)00686-5.
Jung KJ, Kwon SS, Chung CY, Lee KM, Sung KH, Cho BC, et al. Association of gross motor function classification system level and school attendance with bone mineral density in patients with cerebral palsy. J Clin Densitom. 2018;21(4):501-6. doi:10.1016/j.jocd.2016.09.002.
Ko A, Kong J, Samadov F, Mukhamedov A, Kim YM, Lee YJ, et al. Bone health in pediatric patients with neurological disorders. Ann Pediatr Endocrinol Metab. 2020;25(1):15-23. doi:10.6065/apem.2020.25.1.15.
Dias BLS, Duarte LMR, Fava D, de Lima FM. Outpatient management of clinical comorbidities in children with cerebral palsy in low- and middle-income countries. Child Care Health Dev. 2025;51(2):e70052. doi:10.1111/cch.70052.
Trinh A, Wong P, Fahey MC, Ebeling PR, Fuller PJ, Milat F. Trabecular bone score in adults with cerebral palsy. Bone. 2018;117:1-5. doi:10.1016/j.bone.2018.09.001.
Won JH, Jung SH. Bone mineral density in adults with cerebral palsy. Front Neurol. 2021;12:733322. doi:10.3389/fneur.2021.733322.
Pritchett JW. Treated and untreated unstable hips in severe cerebral palsy. Dev Med Child Neurol. 1990;32(1):3-6. doi:10.1111/j.1469-8749.1990.tb08460.x.

Martínez de Zabarte Fernández JM, Ros Arnal I, Peña Segura JL, García Romero R, Rodríguez Martínez G. Bone health impairment in patients with cerebral palsy. Arch Osteoporos. 2020;15(1):91. doi:10.1007/s11657-020-00753-0.
Tsaknakis K, Scheulen C, Lüders KA, Siggelkow H, Lorenz HM, Braunschweig L, et al. Low bone mineral density of the spine in adolescents with cerebral palsy relates to reduced correction of scoliosis after surgery. Sci Rep. 2025;15(1):31567. doi:10.1038/s41598-025-17269-7.
Henderson RC, Kairalla J, Abbas A, Stevenson RD. Predicting low bone density in children and young adults with quadriplegic cerebral palsy. Dev Med Child Neurol. 2004;46(6):416-9. doi:10.1017/s0012162204000672.
Ralston SH, Gaston MS. Management of osteogenesis imperfecta. Front Endocrinol (Lausanne). 2020;10:924. doi:10.3389/fendo.2019.00924.
Arundel P, Bishop N. Primary osteoporosis. Endocr Dev. 2015;28:162-75. doi:10.1159/000381037.
Alvarez Zaragoza C, Vasquez Garibay EM, García Contreras AA, Larrosa Haro A, Romero Velarde E, Rea Rosas A, et al. Bone mineral density and nutritional status in children with quadriplegic cerebral palsy. Arch Osteoporos. 2018;13(1):17. doi:10.1007/s11657-018-0434-8.
Finbråten AK, Syversen U, Skranes J, Andersen GL, Stevenson RD, Vik T. Bone mineral density and vitamin D status in ambulatory and non-ambulatory children with cerebral palsy. Osteoporos Int. 2015;26(1):141-50. doi:10.1007/s00198-014-2840-0.
Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39(4):214-23. doi:10.1111/j.1469-8749.1997.tb07414.x.
Hodgson E, Condliffe EG, Gabel L. Smaller and thinner long bones in children and adolescents with cerebral palsy and other neuromotor impairments. Front Endocrinol (Lausanne). 2025;16:1620573. doi:10.3389/fendo.2025.1620573.
Barbier V, Goeb V, Gouron R, Fritot S, Mentaverri R, Klein C. Bone health in children with severe cerebral palsy. Front Pediatr. 2023;11:1264111. doi:10.3389/fped.2023.1264111.
Nurković JS, Petković P, Tiosavljević D, Vojinović R. Measurement of bone mineral density in children with cerebral palsy from an ethical issue to a diagnostic necessity. Biomed Res Int. 2020;2020:7282946. doi:10.1155/2020/7282946.
Demir K, Özen S, Konakçı E, Aydın M, Darendeliler F. A comprehensive online calculator for pediatric endocrinologists: ÇEDD Çözüm/TPEDS Metrics. J Clin Res Pediatr Endocrinol. 2017;9(2):182-4. doi:10.4274/jcrpe.4526.
Shuhart CR, Yeap SS, Anderson PA, Jankowski LG, Lewiecki EM, Morse LR, et al. Executive summary of the 2019 ISCD position development conference on monitoring treatment, DXA cross-calibration and least significant change, spinal cord injury, peri-prosthetic and orthopedic bone health, transgender medicine, and pediatrics. J Clin Densitom. 2019;22(4):453-71. doi:10.1016/j.jocd.2019.07.001.
Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, et al. Global consensus recommendations on prevention and management of nutritional rickets. Horm Res Paediatr. 2016;85(2):83-106. doi:10.1159/000443136.
Ward KA, Caulton JM, Adams JE, Mughal MZ. Perspective: cerebral palsy as a model of bone development in the absence of postnatal mechanical factors. J Musculoskelet Neuronal Interact. 2006;6(2):154-9.
Hernlund E, Svedbom A, Ivergård M, Compston J, Cooper C, Stenmark J, et al. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the international osteoporosis foundation (IOF) and the european federation of pharmaceutical industry associations (EFPIA). Arch Osteoporos. 2013;8(1):136. doi:10.1007/s11657-013-0136-1.
Gabel L, Macdonald HM, Nettlefold L, McKay HA. Physical activity, sedentary time, and bone strength from childhood to early adulthood: a mixed longitudinal HR-pQCT study. J Bone Miner Res. 2017;32(7):1525-36. doi:10.1002/jbmr.3115.
Willoughby KL, Ang SG, Thomason P, Rutz E, Shore B, Buckland AJ, et al. Epidemiology of scoliosis in cerebral palsy: A population-based study at skeletal maturity. J Paediatr Child Health. 2022;58(2):295-301. doi:10.1111/jpc.15707.
Bauer JS, Henning TD, Müeller D, Lu Y, Majumdar S, Link TM. Volumetric quantitative CT of the spine and hip derived from contrast-enhanced MDCT: conversion factors. AJR Am J Roentgenol. 2007;188(5):1294-301. doi:10.2214/AJR.06.1006.
Iwasaki T, Takei K, Nakamura S, Hosoda N, Yokota Y, Ishii M. Secondary osteoporosis in long-term bedridden patients with cerebral palsy. Pediatr Int. 2008;50(3):269-75. doi:10.1111/j.1442-200X.2008.02571.x.
Yoo JR, Kang JH, Lee SY, Choi JH, Lee HJ. Risk of osteoporosis-related fracture in children and adolescents with intellectual disability. Medicina (Kaunas). 2025;61(10):1761. doi:10.3390/medicina61101761.
Rehberg M, Azim M, Martakis K, Winzenrieth R, Hoyer-Kuhn H, Schoenau E, et al. Bone microarchitecture assessed by trabecular bone score is independent of mobility level or height in pediatric patients with cerebral palsy. J Bone Miner Res. 2020;35(9):1685-94. doi:10.1002/jbmr.4047.
Shepherd JA, Ng BK, Sommer MJ, Heymsfield SB. Body composition by DXA. Bone. 2017;104:101-5. doi:10.1016/j.bone.2017.06.010.
Rachner TD, Khosla S, Hofbauer LC. Osteoporosis: now and the future. Lancet. 2011;377(9773):1276-87. doi:10.1016/S0140-6736(10)62349-5.
Trivić I, Hojsak I. Evaluation and treatment of malnutrition and associated gastrointestinal complications in children with cerebral palsy. Pediatr Gastroenterol Hepatol Nutr. 2019;22(2):122-31. doi:10.5223/pghn.2019.22.2.122.
Trinh A, Lim A, Wong P, Brown J, Pitkin J, Wollenhoven B, et al. A pilot study proposing an algorithm for pubertal induction in cerebral palsy. J Pediatr Endocrinol Metab. 2024;37(3):222-7. doi:10.1515/jpem-2024-0013.
Granild-Jensen JB, Pedersen LK, Langdahl B, Starup-Linde J, Rackauskaite G, Farholt S, et al. Cerebral palsy and bisphosphonates - and what can be learned from other types of secondary osteoporosis in children: a scoping review. Acta Paediatr. 2023;112(4):617-29. doi:10.1111/apa.16671.
Leet AI, Mesfin A, Pichard C, Launay F, Brintzenhofeszoc K, Levey EB, et al. Fractures in children with cerebral palsy. J Pediatr Orthop. 2006;26(5):624-7. doi:10.1097/01.bpo.0000235228.45539.c7.
Simm PJ, Biggin A, Zacharin MR, Rodda CP, Tham E, Siafarikas A, et al. APEG bone mineral working group. Consensus guidelines on the use of bisphosphonate therapy in children and adolescents. J Paediatr Child Health. 2018;54(3):223-33. doi:10.1111/jpc.13768.

Details

Primary Language

English

Subjects

Pediatric Endocrinology, Orthopaedics

Journal Section

Research Article

Authors

Banu Turhan ^*
0000-0001-8474-6835
Türkiye

Niyazi Yaşar
0000-0002-6740-6422
Türkiye

Publication Date

August 21, 2026

Submission Date

April 7, 2026

Acceptance Date

July 22, 2026

Published in Issue

Year 2026 Volume: 28 Number: 2

DOI

https://doi.org/10.18678/dtfd.1924980

IZ

https://izlik.org/JA85BX52PU

Cite

RIS / Bibtex

APA

Turhan, B., & Yaşar, N. (2026). Bone Health in Children with Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity. Duzce Medical Journal, 28(2), 166-173. https://doi.org/10.18678/dtfd.1924980

AMA

1.Turhan B, Yaşar N. Bone Health in Children with Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity. Duzce Med J. 2026;28(2):166-173. doi:10.18678/dtfd.1924980

Chicago

Turhan, Banu, and Niyazi Yaşar. 2026. “Bone Health in Children With Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity”. Duzce Medical Journal 28 (2): 166-73. https://doi.org/10.18678/dtfd.1924980.

EndNote

Turhan B, Yaşar N (August 1, 2026) Bone Health in Children with Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity. Duzce Medical Journal 28 2 166–173.

IEEE

[1]B. Turhan and N. Yaşar, “Bone Health in Children with Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity”, Duzce Med J, vol. 28, no. 2, pp. 166–173, Aug. 2026, doi: 10.18678/dtfd.1924980.

ISNAD

Turhan, Banu - Yaşar, Niyazi. “Bone Health in Children With Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity”. Duzce Medical Journal 28/2 (August 1, 2026): 166-173. https://doi.org/10.18678/dtfd.1924980.

JAMA

1.Turhan B, Yaşar N. Bone Health in Children with Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity. Duzce Med J. 2026;28:166–173.

MLA

Turhan, Banu, and Niyazi Yaşar. “Bone Health in Children With Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity”. Duzce Medical Journal, vol. 28, no. 2, Aug. 2026, pp. 166-73, doi:10.18678/dtfd.1924980.

Vancouver

1.Banu Turhan, Niyazi Yaşar. Bone Health in Children with Cerebral Palsy in an Orthopedic Outpatient Setting: The Role of Functional Severity. Duzce Med J. 2026 Aug. 1;28(2):166-73. doi:10.18678/dtfd.1924980