Prevalence, identification, and interference of pain in young children with cerebral palsy: a population-based study

Attainment of personal goals in the first year of intrathecal baclofen treatment in dyskinetic cerebral palsy: a prospective cohort study

PURPOSE

To assess attainment of individual treatment goals one year after intrathecal baclofen (ITB) pump implantation in individuals with dyskinetic cerebral palsy (CP).

MATERIALS AND METHODS

A multi-center prospective cohort study was conducted including 34 non-walking individuals with severe dyskinetic CP, classified as Gross Motor Function Classification System (GMFCS) IV/V, aged 4-24 years, 12 months after pump implantation. The main outcome measure was Goal Attainment Scaling (GAS). Predictors of GAS results were analyzed. Complications were registered systematically.

RESULTS

Seventy-one percent of individuals with dyskinetic CP fully achieved one or more treatment goals. One or more treatment goals were partially achieved in 97% of individuals. Two factors were found to be associated with attainment of goals: Dyskinesia Impairment Scale (DIS) score at baseline and the difference in pain score between baseline and follow-up. These two variables explain 30% of the variance in the outcome.

CONCLUSIONS

Intrathecal baclofen is effective in achieving individual treatment goals in children and young adults with dyskinetic CP after nine to 12 months of ITB treatment. A positive outcome on treatment goals is, for a small part, associated with higher severity of dystonia at baseline and with improvement of pain during treatment.

CLINICAL TRIAL REGISTRATION NUMBER

Dutch Trial Register, number NTR3642.Implications for rehabilitationIntrathecal baclofen treatment is effective in attainment of personal treatment goals, one year after pump implantation in patients with dyskinetic cerebral palsy.A positive outcome on treatment goals is, for a small part, related to higher severity of dystonia at the start and on improvement of pain during treatment.

Relationship between scoliosis, windswept hips and contractures with pain and asymmetries in sitting and supine in 2450 children with cerebral palsy

PURPOSE

This cross-sectional study of 2450 children with cerebral palsy aimed to analyse the prevalence and association of scoliosis, windswept hips, hip and knee contractures.

METHODS

Logistic regression was used to estimate associations with pain, postural asymmetries, and ability to change position for children at Gross Motor Function Classification System (GMFCS) levels I-V, aged 0-18 years.

RESULTS

Most children with a deformity or contracture had postural asymmetries in both sitting and supine positions; 10.5% had scoliosis, 8.7% windswept hips, 6.6% hip flexion and 19.2% knee contractures. Severe postural asymmetries increased the likelihood for scoliosis 9 times, for windswept hips 6 to 9 times, and for hip and knee flexion contractures 7 and 12 times respectively, adjusted for age, sex and GMFCS level. Hip flexion contractures and windswept hips increased the likelihood for pain by 1.5-1.6 times.

CONCLUSION

The likelihood of having scoliosis, windswept hips and flexion contractures in the hips and knees increased if the child had postural asymmetries, and for increased age and higher GMFCS levels. Efforts should focus on preventing postural asymmetries from occurring or progressing, and on increasing the child's ability to change position. Reducing postural asymmetries may also reduce the likelihood of pain.Implications for RehabilitationThe risk of having scoliosis, windswept hip deformity and flexion contractures in the hips and knees increased if the child had postural asymmetries in sitting or lying.Efforts should focus on preventing or reducing postural asymmetries, and on increasing the child's ability to change position.Reducing postural asymmetries may also reduce the risk of pain.

Chronic Pain in Young People With Cerebral Palsy: Activity Limitations and Coping Strategies

PURPOSE

To describe the effect of chronic pain on the activities of children and adolescents with cerebral palsy, to describe coping strategies, and to examine associations between effect of pain on activities, coping strategies, and level of pain.

METHODS

Using an online survey, 27, 8- to 18-year-olds with cerebral palsy and chronic pain or their parents reported pain intensity, distribution, activity limitations (using the Child Activity Limitations Interview-21), and coping strategies (using the Pediatric Pain Coping Inventory).

RESULTS

Pain intensity ranged from 3 to 10, and 89% reported pain in multiple areas, principally the lower limbs. Individuals reporting higher pain intensity had more activity limitations and were more likely to use catastrophizing coping strategies.

CONCLUSIONS

Coping strategies may be an important mediator between pain and its effect on activities in children with cerebral palsy. Individualized pain management should be based on routine pain assessment.

Exploring pain interference and self-perceived health status in children with osteogenesis imperfecta - a cross-sectional study

Background

Chronic pain may affect and interfere in children’s everyday life and can be present in children with Osteogenesis Imperfecta (OI). However, the knowledge is still sparse to what extent pain is present, how pain interfere in children’s everyday life and affect their self-perceived health status. The purpose of the study was therefore to explore presence of chronic pain, pain interference in daily life, and self-perceived health status in children with OI.

Methods

Children with OI, aged 6–18 years, were recruited consecutively to this cross-sectional study. Participants answered a standardised interview including five pre-structured questions, and the Numeric Pain Rating Scale (NPRS), the Pain Interference Index, and a questionnaire concerning self-perceived health status the Patient Reported Outcomes Measurement Information System Pediatric-25 Profile v1.1 (PROMIS-25).

Results

Twenty-eight children (median: 11 years, IQR 6) with OI type I, III, or IV participated. Pain was present in 27 of 28 children and interfered in their everyday life regardless of OI-type, sex, and age. The median NPRS for average pain intensity was 4 (IQR 2), the median for pain frequency was 2–3 times/week, and the median frequency of school absence due to pain was 2–3 times per month. The most common pain locations were back and feet. Pain in the feet was more frequently reported in children with type I (p = 0.032), and pain in the hip was more often reported in children ≥13 years (p = 0.011). The children were asked what they thought to be the cause of pain and the most frequent response was “walking long distances”. Self-perceived health status for mobility was lower than the general population, and lowest for children with type III (p = 0.016). Pain interference was associated with children’s self-perceived health status (r_s = 0.84, p < 0.001).

Conclusion

Almost all children experienced pain, which interfered in children’s everyday lives, affected participation in various activities and was associated with reduced self-perceived health status. If children avoid physical activities because of pain, it might cause a vicious circle of inactivity, which further decreases bone density and increase the risk of fractures. The results emphasize the importance to offer adequate pain reducing interventions.

Recurrent pain in adolescents with cerebral palsy: a longitudinal population-based study

AIM

To investigate the pain characteristics, pain interference with activities of daily living, and use of analgesics in adolescents with cerebral palsy (CP) and compare the results with previous findings.

METHOD

Sixty-seven adolescents (median age 14y 4mo, range 12y 2mo-17y, 28 females, 39 males) classified in Gross Motor Function Classification System (GMFCS) levels III to V, who participated in a CP surveillance programme, were assessed on pain measures twice, 5 years apart. Primary caregivers marked recurrent pain sites and graded pain interference with activities of daily living and sleep. Information on pain severity was obtained through two questions from the Child Health Questionnaire (CHQ) and were transformed into a pain score scaled from 0 to 100, where 100 represented no pain. The use of short-acting analgesics was recorded.

RESULTS

Over 5 years, the prevalence of recurrent pain, number of pain sites, pain intensity, and pain frequency all increased significantly. The most frequent pain sites were the hip/thigh in GMFCS level V and knee in GMFCS level III. The median CHQ pain score decreased from 60 to 40 (p<0.001). Pain interference with activities of daily living increased (p=0.011) but not for sleep. Twenty-eight of 54 participants with moderate or severe pain (CHQ pain score ≤60) received no short-acting analgesics.

INTERPRETATION

In adolescents with CP, pain increased over 5 years despite follow-up in a surveillance programme. For enhanced management of pain, we propose that an algorithm on pain should be included in surveillance programmes.

Lived experiences of pain in children and young people with cerebral palsy

AIM

To explore the lived experiences of pain in children and young people with cerebral palsy (CP).

METHOD

Participants were recruited from the Sydney Children's Hospitals Network and the New South Wales/Australian Capital Territory CP Registers. Inclusion criteria were as follows: CP; aged 9 to 17 years; current/past experience of pain; fluent in English; no greater than mild intellectual disability. Purposive sampling ensured representation across age, motor subtypes, and Gross Motor Function Classification System (GMFCS) levels. Semi-structured face-to-face interviews were conducted. Data were analysed following an interpretative phenomenological approach.

RESULTS

Ten participants (three male) were included (mean age 14y 5mo, SD 2y), GMFCS levels I (n=4), II (n=3), III (n=2), and IV (n=1). Analysis led to three superordinate themes: (1) Everybody's experience of pain is different; (2) When the pain is winning; (3) 'I know how to deal with it'. Pain contributors and locations varied between children. Pain intruded on school, physical activity, and psychosocial functioning. Children described personalized strategies used to deal with pain.

INTERPRETATION

In this study, children self-reported highly individualized pain experiences which interfered with their daily life and psychosocial well-being. There is a need for improvement in pain assessment and a personalized approach to pain management.

An exploratory study: The effects of sleep systems on sleep quality, pain and carer goals for non-ambulant children and young people with cerebral palsy

Introduction

Sleep systems are supports used in lying, forming part of 24 h posture management programmes, for children and adults with severe motor disorders. Improved posture reduces likelihood of secondary complications such as pain and poor sleep quality, thus improving quality of life. The study aims are to investigate the effect of sleep systems on sleep quality and quantity, pain for young people with Cerebral Palsy and outcomes for carers.

Methods

Baseline data were gathered for 1 month prior to sleep system provision. Comparative data with the sleep system in place, were gathered for 5 months. The sample comprised four children with Cerebral Palsy, GMFCS level V, average age of 11.5, who did not have a sleep system. Data on sleep quality and quantity was gathered using the Chailey Sleep Questionnaire and sleep diaries and pain levels using the Paediatric Pain Profile. GAS Light verbal outcome measure was used to measure carer goals.

Results

Descriptive statistics and paired sample t-tests were used, demonstrating pain levels remained static, improvements in sleep quality and quantity were found and carer goals achieved.

Conclusion

A small sample size and subjective data collection methods were used; further research is required to obtain more conclusive results.

Data linkage and pain medication in people with cerebral palsy: a cross-sectional study

AIM

To explore data linkage and pain medication as a proxy for pain, to assess differences in pain medication between the cerebral palsy (CP) and the general populations, and to identify factors associated with pain medication in CP.

METHOD

This cross-sectional study linked the Northern Ireland CP Register and two administrative health care databases for people resident in Northern Ireland born between 1981 and 2008. Pain medication as a proxy was validated by replicating analyses from the Study of Participation of Children with Cerebral Palsy Living in Europe (SPARCLE) studies. Logistic regression compared pain medication in the CP and general populations. Multi-level regression models assessed factors associated with pain medication in the CP cohort.

RESULTS

The sample size was 701 075, of whom 1430 (0.2%) were people with CP. There were 358 969 males and 340 677 females in the general population, and 810 males and 620 females in the CP population, with an age range of 4 to 31 years in both groups. The validation exercise produced results similar to the SPARCLE studies. More people with CP received pain medication (61% vs 50.9%) and had twice the odds of being prescribed opioid analgesics (odds ratio [OR]=2.81, 95% confidence interval [CI] 2.32-3.40). Among those with CP, the odds of being prescribed pain medication were higher for: females (OR=1.34, 95% CI 1.06-1.70), younger age (OR=1.60, 95% CI 1.02-2.51), Gross Motor Function Classification System level V (OR=2.60, 95% CI 1.52-4.47), seizures (OR=2.55, 95% CI 1.68-3.87), and higher deprivation score (OR=2.06, 95% CI 1.41-3.24).

INTERPRETATION

Pain medication is an effective proxy for pain. More people with CP were prescribed pain medication than the general population. Pain medication for people with CP is not only dependent on physiological and clinical characteristics, but also environmental factors. What this paper adds Data linkage using pain medication as a proxy for experiencing pain is a valid method. People with cerebral palsy (CP) are more likely to experience pain than the general population. People with CP have over twice the odds of receiving opioids compared to the general population. The odds of being prescribed pain medication were higher for females with CP. Prescription of pain medication among those with CP is not only dependent on clinical characteristics, but also environmental factors.

Paediatricians' Views on Pain in Children with Profound Intellectual and Multiple Disabilities

Pain is a frequent issue in children with profound intellectual and multiple disabilities (PIMD). Its identification and treatment can prove highly challenging for primary care physicians, mainly because of the children’s limited communication abilities. We used an online survey to explore paediatricians’ views regarding the experience and management of pain in children with PIMD and invited 480 professionals working in the canton of Vaud, Switzerland, to take part. We received 121 responses (participation rate 25.5%). A large majority of respondents provided care to children with PIMD. All paediatricians considered that these children feel pain at least as much as typically developing children. However, paediatricians had mixed views on their tolerance to pain. More than 90% held the view that their pain is under-assessed and undertreated. The principal barriers they reported to appropriate management were communication limitations with the child, difficulties in pain assessment, lack of knowledge about children with disabilities and lack of experience. Paediatricians have complex opinions regarding how children with PIMD experience pain and how to manage this problem. Professional education and training on the specificities of children with PIMD, including how to address their pain, seem necessary to foster paediatricians’ ability and confidence in approaching this complex issue.

Pain and Communication in Children with Cerebral Palsy: Influence on Parents' Perception of Family Impact and Healthcare Satisfaction

Cerebral palsy (CP) is an impacting chronic condition. Concomitant comorbidities such as pain and speech inability may further affect parents’ perception of the pathology impact in the family quality of life and the provided care. The objective of this cross-sectional descriptive correlational study was to compare parental reports on family impact and healthcare satisfaction in children with CP with and without chronic pain and with and without speech ability. Parents of 59 children with CP (age range = 4–18 years) completed several questions about pain and speech ability and two modules of the Pediatric Quality of Life Measurement Model: The PedsQLTM 2.0 Family Impact Module and the PedsQLTM Healthcare Satisfaction Generic Module. Our findings revealed that children’s pain slightly impacted family physical health, social health and worry. In children without pain, speech inability increased the perceived health impact. Parents’ healthcare satisfaction was barely affected by pain or speech inability, both increasing parents’ satisfaction in the professional technical skills and inclusion of family domains on the care plan. In conclusion, pain and speech inability in children with CP can impact family health but not healthcare satisfaction. Regular assessment and intervention in family health is essential for the design of family-centred programs for children with CP.

Postural asymmetries, pain, and ability to change position of children with cerebral palsy in sitting and supine: a cross-sectional study

PURPOSE

To examine any associations between postural asymmetries, postural ability, and pain for children with cerebral palsy in sitting and supine positions.

METHODS

A cross-sectional study of 2,735 children with cerebral palsy, 0-18 years old, reported into the Swedish CPUP registry. Postural asymmetries, postural ability, the gross motor function classification system levels I-V, sex, age and report of pain were used to determine any relationship between these variables.

RESULTS

Over half the children had postural asymmetries in sitting (n = 1,646; 60.2%) or supine (n = 1,467; 53.6%). These increased with age and as motor function decreased. Children were twice as likely to have pain if they had an asymmetric posture (OR 2.1-2.7), regardless of age, sex and motor function. Children unable to maintain or change position independently were at higher risk for postural asymmetries in both supine (OR 2.6-7.8) and sitting positions (OR 1.5-4.2).

CONCLUSIONS

An association was found between having an asymmetric posture and ability to change position in sitting and/or lying; and with pain. The results indicate the need to assess posture and provide interventions to address asymmetric posture and pain.Implications for rehabilitationPostural asymmetries are present in children with cerebral palsy at all levels of gross motor function.Postural asymmetries increase with age and are associated with pain.Assessment of posture should be included in surveillance programs to enable early detection and treatment.

Exploring sleep problems in young children with cerebral palsy - A population-based study

OBJECTIVE

To describe and explore sleep problems in a population-based cohort of young children with cerebral palsy (CP) in Stockholm, Sweden.

METHODS

All children with CP, aged 5-10 years, and living in the Northern Karolinska University Hospital's catchment area were invited to participate in a cross-sectional study. Medical records obtained in the previous two-year period were reviewed, and a pre-planned parental telephone interview that included five structured questions and the Insomnia Severity Index (ISI) was conducted.

RESULTS

In total, 118 children, with a mean age of 7.4 years (SD 1.5), were included. Bilateral CP was present in 45%, unilateral in 37%, dyskinetic in 15%, and ataxic CP in 3%. Parents of 81% of the children participated in the interview. They reported sleep problems in 41% of their children, and in 80% of these children, night-time sleep was negatively affected by pain. Differences between the ISI total score in relation to CP subtypes (p < 0.025) and levels in GMFCS-E&R (p < 0.001) were detected, with increasing sleep problems for children with dyskinetic CP and children in GMFCS-E&R V. Sleep problems affected by pain were associated to the total score at ISI (r_s = 0.83, p < 0.001, n = 95).

CONCLUSION

The results identified that sleep problems were present in more than 40% of children with CP. Sleep problems were more frequently and extensively present in children with dyskinetic CP and children in GMFCS-E&R level V. Sleep problems were associated with the presence of pain and, in particular, in the most severely affected children.