Bone health influences a person with cerebral palsy’s overall health and wellbeing across the lifespan. Individuals with cerebral palsy of all ages report that musculoskeletal pain makes it harder to get through the day and be as independent and energetic as they would like.  People with cerebral palsy experience changes in their skeleton over time, making it important to be followed by an orthopedic surgeon. They are at risk for fractures of the long bones of the legs and arms (without falling) and may have pain from damaged nerves. These changes in the skeleton may also lead to a curvature of the back or bent knees. These are conditions that if left unattended may significantly impact quality of life.
There is growing evidence that bone formation of individuals with cerebral palsy (CP) is different than people without cerebral palsy.   The reasons bones form differently among individuals with cerebral palsy are not fully understood, however, they are likely the result of many factors such as low birth weight, prematurity, use of medications for seizures and reflux, diet, lack of opportunity for bearing weight, abnormal growth hormones, and genetics.
A person’s height, weight, and their ratio of muscle to fat, may also have an association with bone mineral density. People who are a “healthy” weight for their height have better bone density, and this is perhaps an indirect measure of good nutrition, physical activity, and/or physical capacity.
Common Skeletal Conditions in Cerebral Palsy
There are a number of skeletal conditions that people with CP are at risk for throughout their lifespan. The risk factors for these conditions will vary by the type of movement disorder/s (ie spasticity, dystonia, athetosis, mixed, etc), its presentation and impact on the person’s movement and activity levels.
Regularly consulting with an orthopedic surgeon will help to address and treat (sometimes proactively) these conditions in a timely manner:
- Hip dislocation: This occurs when the hip does not form properly. It occurs often in individuals with cerebral palsy who do not walk or who have one side much stronger than the other. Hip surveillance should begin for children with CP at age 2 years and continue into skeletal maturity, depending on the clinical presentation. Guidelines exist for non-surgical and surgical treatment of the hip to minimize dislocation.
- Curvature of the spine: Individuals who have one side stronger than the other, or who do not walk without support, have a high risk of curvature of the spine. A clinician should monitor the individual with cerebral palsy pre-puberty until they reach skeletal maturity since the risk for curvature increases during periods of growth in height.
- Foot and knee deformities: Individuals who walk out of alignment are at risk for progressive foot and knee deformities. Energy conservation, joint protection, and adaptive equipment are the preventative measures known at this time.
- Back pain: Adults with cerebral palsy who walk may develop low back pain in the third or fourth decade and should take preventative measures to reduce strain on the low back. Individuals who have a sway back should consult with a therapist about appropriate and supportive stretching exercises.
- Cervical stenosis: All individuals with cerebral palsy are at risk because of joints being out of line. Cervical stenosis is a narrowing of the spinal canal in the neck. This can lead to compression of the spinal cord (myelopathy) and upper motor neuron syndrome. This leads to the potential loss of strength in the arms, stomach and back, and legs. Some people lose the ability to swallow and breathe requiring emergent treatment. Individuals with dystonic CP seem to have high reports of cervical stenosis. Adults with CP should be screened for stenosis at age 50, or earlier, if changes in function occur.
Bone Health in Infants and Toddlers with Cerebral Palsy
Caregivers and individuals with cerebral palsy should focus on bone health shortly after birth regardless of physical ability. Typical infants move in utero, flap and kick their hands and arms in the first few months, and continue to move to build the skeleton. It is critical to provide either active or active assisted movement for infants at high risk for cerebral palsy as early as possible. The brain is primed for developing new connections at this age between eye, hand, and other senses of touch and feeling. 
This would include supporting movement of the hands to the mouth and facilitating reaching by using adaptive toys and equipment. Infants pull to stand and begin standing activities at 9-12 months of age. These movements play an important role in the formation of the hips, spine, and the long bones of the body.
Infants with cerebral palsy should begin standing activities at this age, with the appropriate support for the head, trunk, and lower extremities.
Research has shown that standers that allow some movement, have vibrating platforms, and require muscle activation promote more bone formation than static standers. Also exercise, even non-impact activities like swimming, when performed intensely (such as also moving fast enough to make the heart pump hard and muscle work hard), promotes bone formation and the development of motor skills.
Bone Health in Pre-teens with Cerebral Palsy
Hormones surge just prior to puberty and this increases bone formation. In some children with cerebral palsy, puberty may be early or delayed, and it is important to work with the physician to monitor hormone levels, calcium levels, and Vitamin D. During adolescence is another time to target bone formation as children gain about 25% of their bone during this time.
Monitoring Bone Health in Cerebral Palsy
Bone health is influenced by so many factors that it is helpful to have a baseline for understanding long-term bone health. Bone scans taken pre-puberty, during adolescence, and at skeletal maturity provide a more in-depth perspective of bone health than a scan done at one point in time. Bone scans are useful to identify risks for fragility fractures for children who have difficulty walking.
At skeletal maturity it is helpful to see what the bone mass is like since individuals will lose bone as they age. For children who walk, a bone scan at age 21 is useful for a baseline in adulthood. This is particularly helpful since adults with cerebral palsy are at higher risk for deterioration of the bones also leading to conditions such as osteopenia and osteoporosis
Maintaining and Treating Bone Health in Cerebral Palsy
More information is needed to specifically treat the skeleton of individuals with cerebral palsy. What we do know is that certain forms of exercise can be used to promote bone formation. Bone is stimulated to form when there is approximately 10 minutes of short bursts of high intensity movement, especially when the muscles are working hard, and the bones are bearing weight.
Calisthenics, adapted bike riding, weight lighting, rock climbing, and other adaptive sports provide opportunities to build bone. Swimming, when performed intensely (moving the body as fast as possible and having the heart pump hard for 5- 10 minutes), promotes bone formation.
Bone health is another reason why individuals with cerebral palsy should consider a daily program of physical activity. Ideally this would include short bursts of activity throughout the day, and targeted exercise programs for musculoskeletal and cardiovascular health. All physical exercise programs should be safe, and for individuals with cerebral palsy that includes joint protection and dynamic stretching to prevent injury.
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References and Sources
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