Pain assessment in cerebral palsy: a systematic review of measurement properties and evaluation using the COSMIN checklist

Chronic pain in children and young people with cerebral palsy: a narrative review of challenges, advances, and future directions

BACKGROUND

Cerebral palsy (CP), the most common physical disability of childhood, is often accompanied by a range of comorbidities including pain. Pain is highly prevalent in children and young people with CP, yet has been poorly understood, inaccurately assessed, and inadequately managed in this vulnerable population. This narrative review presents recent research advances for understanding and managing pain in children and young people with CP, focusing on chronic pain, and highlights future research directions.

MAIN BODY

Pain prevalence rates in CP vary due to different methodologies of studies. Recent systematic reviews report up to 85% of children experience pain; higher in older children, females, and those with dyskinesia and greater motor impairment. Research examining the lived experience perspectives of children and their families demonstrate that even those with mild motor impairments have pain, children want to self-report pain where possible to feel heard and believed, and management approaches should be individualized. Notably, many children with cognitive and communication impairments can self-report their pain if adjustments are provided and they are given a chance. Past inadequacies of pain assessment in CP relate to a focus on pain intensity and frequency with little focus on pain interference and coping, a lack of tools appropriate for the CP population, and an assumption that many children with cognitive and/or communication limitations are unable to self-report. Recent systematic reviews have identified the most reliable and valid assessment tools for assessing chronic pain. Many were not developed for people with CP and, in their current form, are not appropriate for the spectrum of physical, communication, and cognitive limitations seen. Recently, consensus and co-design in partnership with people with lived experience and clinicians have identified tools appropriate for use in CP considering the biopsychosocial framework. Modifications to tools are underway to ensure feasibility and applicability for the spectrum of abilities seen.

CONCLUSION

Recent research advances have improved our understanding of the prevalence, characteristics and lived experience of chronic pain, and refined assessment methods in children and young people with CP. However, the very limited evidence for effective and novel management of chronic pain in this population is where research should now focus.

A good night's sleep: pain trajectories and sleep disturbance in children with cerebral palsy

STUDY OBJECTIVES

Sleep quality is important during childhood and adolescence. Given the high prevalence of pain in children/youth with cerebral palsy, we aimed to measure the association between short-term pain trajectories and sleep disturbance in these individuals.

METHODS

We accrued the cohort between November 2019 and October 2020 and recruited children/youth who (1) were 8-18 years old; (2) had cerebral palsy with any Gross Motor Function Classification System level; and (3) could self-report pain and sleep disturbance. We collected self-reported baseline and weekly follow-up data using electronic questionnaires completed every week for 5 weeks. Sleep disturbance at 5 weeks was the primary outcome (pediatric Patient-Reported Outcomes Measurement Information System short form, v1.0-4a). We used general linear regression to assess the association between pain intensity trajectory group and sleep disturbance controlling for confounders.

RESULTS

A total of 190 individuals were eligible; 102 were enrolled and 89 were included in our final analysis. Pain trajectory groups had estimated crude mean sleep disturbance scores at 5 weeks ranging from 56.0 (95% confidence interval, 51.8, 60.8) to 61.8 (55.7, 67.9). Compared to those with stable, no/very mild pain, those in the stable, high-pain group had the greatest sleep disturbance (adjusted β = 5.7; 95% confidence interval, 1.2, 10.2).

CONCLUSIONS

Irrespective of pain trajectory, children and youth with cerebral palsy reported sleep disturbances. Those with a stable, high pain intensity in the previous 5 weeks reported the greatest sleep disturbance. The results highlight the importance of considering pain trajectories and their impact on sleep in children with cerebral palsy.

CITATION

Shearer HM, Côté P, Hogg-Johnson S, Fehlings DL. A good night's sleep: pain trajectories and sleep disturbance in children with cerebral palsy. J Clin Sleep Med. 2024;20(5):719-726.

Reliability of the Gait Outcomes Assessment List questionnaire

AIM

To report the test-retest reliability of the parent version of the Gait Outcomes Assessment List (GOAL) questionnaire for item, domain, total score, and goal importance in children with cerebral palsy (CP) functioning in Gross Motor Function Classification System (GMFCS) levels I to III.

METHOD

The GOAL questionnaire was completed twice, 3 to 31 days apart, in a prospective cohort study of 112 caregivers of children aged 4 to 17 years with CP (40% unilateral; GMFCS level I = 53; II = 35; III = 24; 76 males). All had an outpatient visit over a 1-year period. The standard error of measurement (SEM), minimum detectable change, and agreement were calculated for all responses, including goal importance.

RESULTS

The SEM for the total score was 3.1 points for the cohort (GMFCS level I = 2.3, GMFCS level II = 3.8, GMFCS level III = 3.6). The standardized domain and item scores were less reliable than the total score and varied according to GMFCS level. The gait function and mobility domain exhibited the best reliability for the cohort (SEM = 4.4), whereas the use of braces and mobility aids domain exhibited the lowest (SEM = 11.9). Goal importance was reliable (cohort average agreement 73%).

INTERPRETATION

The parent version of GOAL has acceptable levels of test-retest reliability for most domains and items. Caution is advised when interpreting the least reliable scores. Essential information necessary for accurate interpretation is provided.

WHAT THIS PAPER ADDS

The standard error of measurement (SEM) of the Gait Outcomes Assessment List (GOAL) total score was approximately 3 points. The SEM of the GOAL domain score ranged from 4 to 12 points. The use of braces and mobility aids domain had the lowest reliability score. Item-level reliability varied according to domain and Gross Motor Function Classification System level. Caregivers reliably identified item importance with approximately 73% agreement.

Evaluation of Measurement Properties of Supportive Environment Assessment Scales for Dementia Special Care Units: A COSMIN Systematic Review

OBJECTIVES

To identify, critically appraise, compare, and summarize the measurement properties of existing instruments that assess the supportive environment of dementia special care units (DSCUs).

DESIGN

Systematic review of measurement properties consistent with Consensus-based standards for the selection of health measurement instruments (COSMIN) guidelines.

SETTINGS AND PARTICIPANTS

PubMed, Embase, Web of Science, CINAHL, CNKI, Wanfang, VIP, and SinoMed were searched from inception to July 21, 2023. Studies that (1) measured the supportive environment for DSCUs using any type of assessment instrument and (2) evaluated 1 or more psychometric properties of a DSCU's supportive environment assessment instruments were included.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias.

RESULTS

Fourteen studies were identified that reported the psychometric properties of 8 assessment instruments. The Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH) exhibited relatively better results on methodological risk of bias and quality of the psychometric properties. None of the instruments reported the evaluations on hypothesis testing, cross-cultural validity/measurement invariance, measurement error, or responsiveness. Based on the summary of 32 dimensions from 8 assessment instruments, this review established 7 functional constructs for the supportive environment for DSCUs: safety maintenance, space design, external resources, sensory stimulation, humanistic care, residual function development, and professional care. In addition, this study also initially developed a conceptual framework for the supportive environment of DSCUs.

CONCLUSION AND IMPLICATIONS

TESS-NH received the rating of "best methodological quality" and outperformed other weakly recommended scales. Further studies should pay attention to developing or revalidating scales for assessing the supportive environment of DSCUs in large multicenter samples following the COSMIN methodology. Furthermore, the conceptual framework for the DSCU supportive environment will provide a theoretical reference for facilitating their hierarchical establishment and governance within diverse long-term care facilities by state authorities.

Arabic Patient-Reported Measures of Activity and Participation for Children: A Systematic Review of Psychometric Properties

AIM

To systematically review measurement properties of Arabic patient-reported outcome measures (PROMs) that assess activity and participation in children with and without health conditions.

METHOD

Four databases were searched. Arabic PROMs with focus on activity and/or participation constructs were selected. Data on measurement properties were extracted and the methodological quality of the studies was assessed by COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) risk of bias checklist.

RESULT

Of the total 149 articles screened, only 10 studies involving 10 measures that assessed activity and/or participation in children with or without health conditions were included. The focus of all PROMs is primarily on the activity of daily living at home and/or school, but dimensions of measurement differed across PROMs. None of the PROMs demonstrated sufficient properties for all psychometrics. The most studied psychometric property was internal consistency, whereas the least studied psychometric property was structural validity. Responsiveness was not investigated in any of the studies included.

CONCLUSIONS

Despite the presence of Arabic PROMs on activity and participation for children, none of the reviewed measures satisfied all psychometric properties. Clinicians and researchers are encouraged to carefully select PROMs that are psychometrically sound and appropriate for the construct being measured.

Chronic pain interference assessment tools for children and adults who are unable to self-report: A systematic review of psychometric properties

AIM

To identify and evaluate psychometric properties of assessment tools for assessing pain interference in children, adolescents, and adults with chronic pain and the inability to self-report.

METHOD

The protocol was registered with PROSPERO (CRD42022310102). A search was run in MEDLINE, Embase, and PsycInfo (29th March 2022) to identify articles reporting psychometric properties of pain interference assessment tools for children, adolescents, and adults with chronic pain and the inability to objectively self-report pain. Retrieved studies were reviewed by two authors (MGS, LCF) and study quality was assessed using COSMIN.

RESULTS

Psychometric properties of 10 pain interference tools were assessed from 33 studies. The Paediatric Pain Profile (PPP) had low-quality evidence for content validity and internal consistency with children and adolescents who are unable to self-report. No tools for adults had evidence for content validity and internal consistency. No tool had evidence for all nine psychometric properties.

INTERPRETATION

The PPP is recommended for pain interference assessment in children and adolescents with chronic pain and the inability to self-report. Few tools are available for adults. Three tools for children (Patient-Reported Outcome Measurement Information System Pediatric Proxy Pain Interference Scale; Bath Adolescent Pain Questionnaire for Parents; modified Brief Pain Inventory-Proxy [mBPI]) and three tools for adults (Doloplus-2; Patient-Reported Outcome Measurement Information System Pain Interference Scale-proxy; Brief Pain Inventory-proxy) are promising but require further investigation.

The Relationship between Pain and Spasticity and Tell-Tale Signs of Pain in Children with Cerebral Palsy

Pain and quality of life are closely interrelated in children with cerebral palsy (CCP). Even though 67% of CCP experience pain, it is overlooked and untreated. In this study, our purpose was two-fold: first, to examine the relationship between pain and spasticity by evaluating the effects of AbobotulinumtoxinA/Dysport (BoNT), and second, to describe the symptoms and location of pain in CCP. The subjects were 22 CCP in at least moderate pain. They were evaluated for spasticity by the modified Ashworth and Tardieu scale and for pain by the r-FLACC and the pediatric pain profile. After one injection of BoNT, the subjects were re-evaluated. We found a significant reduction in pain, but no significant relationship between the reduction of pain and spasticity. We found no association between the dose of BoNT and pain or spasticity. Pain in the lower extremity was located primarily in the hip region. The effect of ultrasound-guided intermuscular injections of BoNT suggests that pain in CCP has an extra-articular component. We found that pain in CCP manifests as specific tell-tale signs and problems in daily living. In conclusion, we found no relationship between pain and spasticity. Signs and manifestations of pain are described in detail. Lower extremity (hip) pain seems to have a soft tissue/extra-articular component.

Mapping the focus of research conducted with adults with cerebral palsy: an overview of systematic reviews

PURPOSE

To map research conducted with adults with cerebral palsy (CP) to the International Classification of Functioning, Disability and Health (ICF) to understand the array of research available, identify key clinical messages and inform future research.

MATERIALS AND METHODS

An overview of systematic reviews was conducted. Comprehensive searches (to December 2021) were conducted in PsycINFO, Web of Science, MEDLINE, CINAHL, Cochrane, JBI, and EMBASE. Eligible studies were systematic reviews that included primary studies of adults with CP. Included reviews were assessed for study quality and mapped to the ICF components and chapters. A narrative synthesis of commonly reported outcomes within the component/s and chapter/s was conducted.

RESULTS

All 24 included reviews were published since 2010. Thirteen focused on body functions: movement related functions and cardiovascular and respiratory systems. Although nine reviews focused on gait and mobility, considerable overlap of included studies limited the volume of evidence and variability in review quality limited generalisability of findings.

CONCLUSIONS

Research involving adults with CP is growing; however, this overview of reviews found a predominant focus on mobility and gait. Future research, informed by consumer priorities, is needed to address a broader range of key health and participation outcomes.Implications for rehabilitationFitness, mobility, and gait were the most common research topics found in these systematic reviews suggesting a narrow research focus in adults with CP.There are significant gaps in our knowledge to inform clinical messages for practice about broad long-term outcomes of CP and how best to support their activity performance and participation.There is very limited evidence with which to guide and support rehabilitation professionals working in this field.

Clinical course of pain intensity in individuals with cerebral palsy: A prognostic systematic review

AIM

To describe the clinical course of pain intensity in individuals with cerebral palsy (CP) resulting from usual care or specific interventions.

METHOD

We conducted an exploratory prognostic systematic review searching electronic databases from inception to 31st December 2021. Evidence from low and moderate risk-of-bias studies was synthesized.

RESULTS

We retrieved 2275 citations; 18 studies met the inclusion criteria and 10 were synthesized. The course of pain intensity in children with CP receiving usual care was stable over 15 weeks (χ² _[2]  = 1.8, p = 0.5). Children who received continuous intrathecal baclofen (CITB) reported significant pain intensity reduction (visual analogue scale [VAS] = -4.2 out of 10, 95% confidence interval [CI] = -6.3 to -2.1]) 6 months postinsertion but similar children receiving usual care had no significant change over 6 months (VAS = 1.3 out of 10, 95% CI = -1.3 to 3.6). Children receiving botulinum neurotoxin A (BoNT-A) injections had significant decreases in pain after 1 month (numeric rating scale = -6.5, 95% CI = -8.0 to -5.0). Adults with chronic pain receiving usual care reported stable pain intensity over time; pain intensity improved in ambulatory adults exercising and those treated surgically for cervical myelopathy.

INTERPRETATION

The course of pain intensity in individuals with CP is unclear. Evidence suggests that children and adults receiving usual care had stable pain intensity over the short or long term. Interventions (CITB and BoNT-A in children and exercise and surgical treatment for cervical myelopathy in adults) had pain intensity reduction. Larger study samples are needed to confirm these results.

WHAT THIS PAPER ADDS

Pain intensity was stable in children with cerebral palsy (CP) receiving usual care. Adults with CP and chronic pain receiving usual care had stable, persistent pain intensity. Children receiving continuous intrathecal baclofen via pump and botulinum neurotoxin A reported significantly lower pain intensities. Adults with chronic pain and dyskinetic CP and cervical myelopathy reported significantly lower pain intensity with exercise or cervical decompression. Limited high-quality evidence exists describing non-procedural pain changes in individuals with CP.