Are physiotherapists reliable proxies for the recognition of pain in individuals with cerebral palsy? A cross sectional study

The psychosocial determinants of adherence to home-based rehabilitation strategies in parents of children with cerebral palsy: A systematic review

INTRODUCTION

Involving parents of children with cerebral palsy (C-CP) in home exercise programmes (HEP) is globally practiced strategy closely linked to improved physical performance and functional outcomes for the child. Nevertheless, non-adherence to HEP is increasing at an alarming rate, and little is known about the factors influencing adherence to HEP (AHEP) especially in parents of C-CP. This systematic review aimed to identify the factors enhancing AHEP among parents of C-CP to reinforce the efficacy of rehabilitation practices proposed by health professionals, researchers, and educators.

MATERIALS AND METHODS

We conducted searches in PubMed, Scopus, CINHAL, PsycINFO, and Embase for articles published up to March 2023, that investigated the factors influencing AHEP among parents of C-CP. A narrative synthesis was conducted using the search results and pertinent material from other sources.

RESULTS

Overall, non-adherence rates to HEP were moderate to high, ranging from 34% to 79.2%. Strong evidence suggests that factors enhancing AHEP fall into three categories: child-related (such as younger age and better gross motor function [GMF]), the caregiver-related (including high self-efficacy and knowledge, strong social support, low levels of depression, anxiety and stress symptoms, and a low perception of barriers), and the physiotherapist-related. For the latter category, the parent's perception of a supportive and collaborative relationship with the therapist is one of the conditions most favourably influences AHEP.

CONCLUSION

Our findings highlight that factors influencing AHEP are multifactorial. Some, such as GMF or the economic and social conditions of the family, are challenging to change. However, the relationship between therapist and parent is an aspect that can be strengthened. These results underscore the importance of substantial training and psychosocial support for therapists to enhance their awareness and competence in building supportive relationship with parents.

Automated facial recognition system using deep learning for pain assessment in adults with cerebral palsy

Objective

Assessing pain in individuals with neurological conditions like cerebral palsy is challenging due to limited self-reporting and expression abilities. Current methods lack sensitivity and specificity, underlining the need for a reliable evaluation protocol. An automated facial recognition system could revolutionize pain assessment for such patients.The research focuses on two primary goals: developing a dataset of facial pain expressions for individuals with cerebral palsy and creating a deep learning-based automated system for pain assessment tailored to this group.

Methods

The study trained ten neural networks using three pain image databases and a newly curated CP-PAIN Dataset of 109 images from cerebral palsy patients, classified by experts using the Facial Action Coding System.

Results

The InceptionV3 model demonstrated promising results, achieving 62.67% accuracy and a 61.12% F1 score on the CP-PAIN dataset. Explainable AI techniques confirmed the consistency of crucial features for pain identification across models.

Conclusion

The study underscores the potential of deep learning in developing reliable pain detection systems using facial recognition for individuals with communication impairments due to neurological conditions. A more extensive and diverse dataset could further enhance the models' sensitivity to subtle pain expressions in cerebral palsy patients and possibly extend to other complex neurological disorders. This research marks a significant step toward more empathetic and accurate pain management for vulnerable populations.

Factors Affecting the Use of Pain-Coping Strategies in Individuals with Cerebral Palsy and Individuals with Typical Development

Many individuals with cerebral palsy (CP) suffer from pain and must develop pain-coping strategies, although the factors determining them are unknown. This observational study aims at exploring the association between different pain-coping strategies and factors such as age, sex, pain, health status, sleep or motor and cognitive function in individuals with cerebral palsy (CP) and typically developing peers (TD). Main caregivers of 94 individuals with CP (age range = 6-69 years, mean age = 17.78 (10.05)) and the closest relative of 145 individuals with TD (age range = 6-51 years, mean age = 19.13 (12.87)) completed questionnaires on the previous topics (Parent Report of the PEDsQL Pediatric Coping Inventory, the Health Utility Index HUI-3, Epworth Sleepiness Score and the Pittsburgh Sleep Quality Index). Pain presence, duration, intensity, location and ratings of current and worst pain in the last week in an 11-point numerical rating scale were assessed in an interview. Global health was the best predictor the of use of any type of pain-coping strategy, including cognitive self-instruction, problem-solving, distraction, seeking social support and catastrophizing, in both individuals with CP and individuals with TD. However, different health attributes predicted their use in each population. Emotional health was the best predictor in individuals with CP, whereas cognition and pain were the best predictors in individuals with TD. Speech ability was a predictor in both groups. In conclusion, the assessment of health attributes such as emotional health and speech may help design specific interventions for enhancing self-efficacy and adaptive pain coping skills.

Unique Pain Responses in Different Etiological Subgroups of Intellectual and Developmental Disabilities

We studied whether there exist variations in pain responses between different intellectual and developmental disability (IDD) etiologies. Self-reports and facial expressions (Facial Action Coding System = FACS) were recorded during experimental pressure stimuli and compared among 31 individuals with IDD-13 with cerebral palsy (CP), nine with Down syndrome (DS), nine with unspecified origin (UIDD)-and among 15 typically developing controls (TDCs). The CP and DS groups had higher pain ratings and FACS scores compared to the UIDD and TDC groups, and steeper stimulus-response functions. The DS group exhibited the most diverse facial expressions. There were variations in the foci of facial expressions between groups. It appears that different IDD etiologies display distinct pain responses.

The development of an iPad application for the pain assessment of individuals with developmental disabilities and complex communication needs

Aims: Develop a new pain assessment for youth with communication challenges. The Guard-Putzer Pain Assessment Domains (gPAD) mobile application (app) was designed and tested as a universally accessible way for youth, ages 7-12 years, with a developmental disability (DD) to express their pain experiences through self-report. Methods: A two-phase process developed the design for an app, created an interactive prototype, and tested its face validity and user interface. This work included a comprehensive scoping review of current assessments and pain apps as well as a survey to obtain descriptive data on the clinical practicality of the gPAD to guide the app design. Additionally, 15 therapists reviewed the gPAD assessment. Results: Thirteen respondents (87%) agreed to the statement that they would use the gPAD for this population. School-based practitioners seemed to highlight the most significant needs for the app. Conclusions: Advancement of this app could mainstream the assessment of pain in youth with DD, and other potential populations.

Autonomous nervous system regulation of pain in children with cerebral palsy

Aim: Children with cerebral palsy (CP) have increased pain sensitivity and recurrent pain episodes; however, pain is underreported in children with intellectual impairment. Cardiac autonomic regulation is imbalanced in chronic pain conditions and neurological disorders. This study aims at exploring the autonomous nervous system regulation of pain in children with CP compared with typically developing peers (TDP).Method: Heart rate variability (HRV) was recorded during 24 hours in 26 children with CP and 26 TDP, and examined offline at baseline (sleeping, seated rest) and during spontaneous pain events. Pain and fatigue, HRV indices (linear indices on time - IBI, SDNN, RMSSD - and frequency domains - high, low, and very low frequency - and non-linear indices - Hurst coefficient and multiscale entropy) were computed.Results: Children with CP showed comparable HRV during daily conditions and similar reductions after pain events than their TDP, regardless of their level of intellectual impairment. Interpretation: Children with CP have an intact autonomic regulation in acute pain events. HRV could be an accurate pain biomarker in children with CP and intellectual disability.What this paper adds: Autonomic regulation in acute pain is efficient in children with cerebral palsy.Heart rate variability indices can be reliable pain biomarkers in intellectual impairment.

Specific Behavioral Responses Rather Than Autonomic Responses Can Indicate and Quantify Acute Pain among Individuals with Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (IDD) are at a high risk of experiencing pain. Pain management requires assessment, a challenging mission considering the impaired communication skills in IDD. We analyzed subjective and objective responses following calibrated experimental stimuli to determine whether they can differentiate between painful and non-painful states, and adequately quantify pain among individuals with IDD. Eighteen adults with IDD and 21 healthy controls (HC) received experimental pressure stimuli (innocuous, mildly noxious, and moderately noxious). Facial expressions (analyzed with the Facial Action Coding System (FACS)) and autonomic function (heart rate, heart rate variability (HRV), pulse, and galvanic skin response (GSR)) were continuously monitored, and self-reports using a pyramid and a numeric scale were obtained. Significant stimulus-response relationships were observed for the FACS and pyramid scores (but not for the numeric scores), and specific action units could differentiate between the noxious levels among the IDD group. FACS scores of the IDD group were higher and steeper than those of HC. HRV was overall lower among the IDD group, and GSR increased during noxious stimulation in both groups. In conclusion, the facial expressions and self-reports seem to reliably detect and quantify pain among individuals with mild-moderate IDD; their enhanced responses may indicate increased pain sensitivity that requires careful clinical consideration.

No pain, no gain? Children with cerebral palsy and their experience with physiotherapy

OBJECTIVES

Recent studies have shown that physiotherapy can induce pain in children and young adults with cerebral palsy (CP). There is a lack of knowledge of children's pain experiences during therapy sessions and the specific causes of pain. The main objective of this study was to better understand the experience of children and young adults with CP during physiotherapy sessions and to analyse the coping strategies used by children and therapists.

METHODS

Qualitative study with focus groups. Eighteen children/young adults with CP who experienced pain during physiotherapy were interviewed, using focus groups as a source of data collection in a phenomenological perspective. Data collection and analysis were consecutive to ensure that the data saturation point was reached. The transcripts were coded manually using thematic analysis. First, interesting features of the verbatim were coded, then codes were collated into potential themes and then the themes were checked to ensure they worked in relation to the coded extracts. Multiple coding was performed by 3 different researchers, and results were merged at each step.

RESULTS

This study confirmed that among the 18 children interviewed (mean [SD] age 13.17 [4.02] years, 10 girls), physiotherapy, particularly stretching, induced pain. Participants reported that the experience of pain led to a dislike of physiotherapy, although some believed that the pain was necessary to show that the treatment was effective. The use of distraction techniques and the relationship with the physiotherapist were key elements associated with the perception and experience of pain.

CONCLUSIONS

This study confirmed that patients with CP experience pain during physiotherapy. Stretching seems to be the main source of pain. Beliefs and practices regarding the concept of pain show that physiotherapists need training in this field.

Determinants of satisfaction with motor rehabilitation in people with cerebral palsy: A national survey in France (ESPaCe)

BACKGROUND

User satisfaction is a key indicator of healthcare quality.

OBJECTIVE

We aimed to identify factors associated with satisfaction with motor rehabilitation (MR) in children and adults with cerebral palsy at a national level, using determinants related to patient characteristics, healthcare organisation and practice features.

METHODS

This study was part of ESPaCe, a national survey aimed at documenting the views of individuals with cerebral palsy and their families regarding MR services via a questionnaire, developed by a multidisciplinary group. The ESPaCe questionnaire included the Client Satisfaction Questionnaire (CSQ-8), whose total score was the primary outcome of this study. Survey participation was promoted nation-wide. The questionnaire could be completed by the person with cerebral palsy or their main carer. Analysis included the description of determinants across CSQ-8 quartiles and generalised linear modelling of the CSQ-8 score.

RESULTS

From June 2016 to June 2017, 1010 eligible participants (354 children, 145 adolescents and 511 adults) responded to the questionnaire, and 750 completed the CSQ-8. Univariate analysis suggested that multiple factors affected satisfaction with MR. On multivariate sequential adjustment, the factors that decreased satisfaction (all P<0.001) were being an adolescent, Gross Motor Function Classification System levels IV/V, frequent pain, receiving physiotherapy in private practice and poor access to a physiotherapist with specific CP training. Factors that increased satisfaction (all P<0.001) were presence of an MR coordinator, exchanges between healthcare professionals, provision of information regarding MR organisation, and goal setting and effective pain management by the physiotherapist. Organisation and practice features improved the predictive ability of patient characteristics (R²=0.40).

CONCLUSION

This study suggests that measures to improve the quality of healthcare for individuals with cerebral palsy should focus on improving pain management by the physiotherapist, establishing a therapeutic alliance, and greater provision of CP-specific practice education for healthcare professionals.

Factors associated with pain in adolescents with bilateral cerebral palsy

AIM

We explored factors associated with pain and its severity in a population cohort of young people with bilateral cerebral palsy, comparing parent/carer and young people self-reports.

METHOD

Of 278 survivors (mean age 16y 8mo, SD 1y 4mo, range 13y 8mo-19y 3mo) from the South Thames in the Study of Hips and Physical Experience cohort of 338 young people with bilateral cerebral palsy, 212 parents/carers and 153 young people completed questionnaires on the presence, severity, timing, site, associated factors, impact, and treatment of pain.

RESULTS

Seventy per cent of parents/carers reported pain within 3 months, 59% the previous week, and 50% the previous day with 56% reporting 'regularly experienced'. Of young people able to do so, 63% reported pain within 3 months, 50% the previous week, and 42% the previous day, with 48% reporting regular pain. There was strong agreement between the parent/carer and young people, reporting pain severity over the previous 3 months. Pain severity was associated with increased motor impairment and comorbidity, particularly constipation, spasticity, equipment use, and higher emotional score, but not sex, intellectual disability, speech, or maternal education. Multiple sites of musculoskeletal pain were reported in two-thirds of individuals. Pain was associated with voluntary movement in individuals with less motor impairment and with being moved in those with severe motor impairment. Greater pain severity had a negative effect on both physical and psychological quality of life.

INTERPRETATION

Increasing awareness of the comorbidities in cerebral palsy may aid effective treatment, reducing pain experienced by young people with cerebral palsy.

WHAT THIS STUDY ADDS

Regular moderate or severe pain is reported in young people with bilateral cerebral palsy (CP) in all Gross Motor Function Classification System levels. Pain is reported more frequently in young people who are non-ambulant. General ill health is strongly associated with severity of pain after controlling for severity of CP, especially constipation. Pain occurs most often in ambulant young people during voluntary activity and in those who are non-ambulant when being moved. There is strong agreement between parents/carers and young people about pain presence and severity.

Factors Associated with Parents' Adherence to Different Types of Exercises in Home Programs for Children with Disabilities

There is a lack of knowledge with regard to the adherence to different types of exercises prescribed for children with disabilities. The aim was to examine parents' adherence to prescriptions of different types of home exercises; to identify associated factors related to the parents, the children and the environment, and to assess the relative influence of the behaviour of health professionals. Parents (393) were recruited from 18 early intervention centres. A cross-sectional survey using a self-reported questionnaire was used to examine whether three types of exercises ("flexibility exercises", "neuromotor development training" and "body mechanics and postural stabilisation") were prescribed in their home programs; if the child had received exercises according to a prescription; and items related to the parents, child, environment, and health professionals. The adherence rates were different among the types of exercises. Parents with low perception of barriers and high self-efficacy had a higher adherence to neuromotor development training and postural stabilization, whereas parents with a high level of knowledge increased their odds of adherence to flexibility exercises. Health professionals' behaviour had a distinct influence on the adherence to different exercises. This study suggests the need to specifically consider the types of exercises prescribed in the management of adherence to home programs.

Parents and Physiotherapists Recognition of Non-Verbal Communication of Pain in Individuals with Cerebral Palsy

Pain assessment is difficult in individuals with cerebral palsy (CP). This is of particular relevance in children with communication difficulties, when non-verbal pain behaviors could be essential for appropriate pain recognition. Parents are considered good proxies in the recognition of pain in their children; however, health professionals also need a good understanding of their patients' pain experience. This study aims at analyzing the agreement between parents' and physiotherapists' assessments of verbal and non-verbal pain behaviors in individuals with CP. A written survey about pain characteristics and non-verbal pain expression of 96 persons with CP (45 classified as communicative, and 51 as non-communicative individuals) was performed. Parents and physiotherapists displayed a high agreement in their estimations of the presence of chronic pain, healthcare seeking, pain intensity and pain interference, as well as in non-verbal pain behaviors. Physiotherapists and parents can recognize pain behaviors in individuals with CP regardless of communication disabilities.

Physiological and Behavioral Responses to Calibrated Noxious Stimuli Among Individuals with Cerebral Palsy and Intellectual Disability

Objective

As individuals with intellectual disability (ID) due to cerebral palsy (CP) are at high risk of experiencing pain, measuring their pain is crucial for adequate treatment. While verbal reports are the gold standard in pain measurements, they may not be sufficient in ID. The aim was to detect behavioral/autonomic responses that may indicate the presence and intensity of pain in individuals with CP and ID, using calibrated stimuli, here for the first time.

Subjects

Thirteen adults with CP and ID (CPID), 15 healthy controls (HC), and 5 adults with CP with no ID (CPNID).

Methods

Subjects received pressure stimuli of various intensities. Self-reports (using a pyramid scale), facial expressions (retrospectively analyzed with Facial Action Coding System = FACS), and autonomic function (heart rate, heart rate variability, pulse, galvanic skin response) were analyzed.

Results

Self-reports and facial expressions but not the autonomic function exhibited stimulus-response relationship to pressure stimulation among all groups. The CPID group had increased pain ratings and facial expressions compared with controls. In addition, the increase in facial expressions along the increase in noxious stimulation was larger than in controls. Freezing in response to pain was frequent in CPID.

Conclusions

1) Individuals with CP and ID have increased responses to pain; 2) facial expressions and self-reports, but not autonomic variables can reliably indicate their pain intensity; 3) the pyramid scale is suitable for self-report in this population. Although facial expressions may replace verbal reports, increased facial expressions at rest among these individuals may mask pain, especially at lower intensities.