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Shearer HM, Verville L, Côté P, Hogg-Johnson S, Fehlings DL. Clinical course of pain intensity in individuals with cerebral palsy: A prognostic systematic review. Dev Med Child Neurol 2023; 65:24-37. [PMID: 35871758 DOI: 10.1111/dmcn.15358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/19/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Heather M Shearer
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.,Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
| | - Leslie Verville
- Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
| | - Pierre Côté
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
| | - Sheilah Hogg-Johnson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Research and Innovation, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - Darcy L Fehlings
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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2
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Bonfert M, Heinen F, Kaňovský P, Schroeder AS, Chambers HG, Dabrowski E, Geister TL, Hanschmann A, Althaus M, Banach M, Gaebler-Spira D. Spasticity-related pain in children/adolescents with cerebral palsy. Part 2 IncobotulinumtoxinA efficacy results from a pooled analysis. J Pediatr Rehabil Med 2022; 16:83-98. [PMID: 36057802 PMCID: PMC10116134 DOI: 10.3233/prm-220020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This pooled analysis of data from three Phase 3 studies investigated the effects of incobotulinumtoxinA on spasticity-related pain (SRP) in children/adolescents with uni-/bilateral cerebral palsy (CP). METHODS Children/adolescents (ambulant and non-ambulant) were evaluated for SRP on increasingly difficult activities/tasks 4 weeks after each of four incobotulinumtoxinA injection cycles (ICs) using the Questionnaire on Pain caused by Spasticity (QPS; six modules specific to lower limb [LL] or upper limb [UL] spasticity and respondent type [child/adolescent, interviewer, or parent/caregiver]). IncobotulinumtoxinA doses were personalized, with all doses pooled for analysis. RESULTS QPS key item responses were available from 331 and 155 children/adolescents with LL- and UL-spasticity, respectively, and 841/444 (LL/UL) of their parents/caregivers. IncobotulinumtoxinA efficacy was evident with the first IC. Efficacy was sustained and became more robust with further subsequent ICs. By Week 4 of the last (i.e. fourth) IC, 33.8-53.3% of children/adolescents reported complete SRP relief from their baseline pain for respective QPS items. Children/adolescents reported reductions in mean LL SRP intensity at levels that surpassed clinically meaningful thresholds. Similarly, parents/caregivers observed complete SRP relief and less frequent SRP with incobotulinumtoxinA. Similar results were found for UL SRP. CONCLUSION These findings indicate that incobotulinumtoxinA could bring considerable benefit to children/adolescents with spasticity by reducing SRP, even during strenuous activities.
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Affiliation(s)
- Michaela Bonfert
- Division of Paediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Florian Heinen
- Division of Paediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - A Sebastian Schroeder
- Division of Paediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | | | - Edward Dabrowski
- Beaumont Pediatric Physical Medicine & Rehabilitation -Royal Oak, Royal Oak, MI, USA
| | | | | | | | - Marta Banach
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Deborah Gaebler-Spira
- Shirley Ryan Ability Lab, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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Wong C, Westphall I, Michelsen JS. Measuring Effects on Pain and Quality of Life after Abobotulinum Toxin A Injections in Children with Cerebral Palsy. Toxins (Basel) 2022; 14:43. [PMID: 35051020 PMCID: PMC8781457 DOI: 10.3390/toxins14010043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 01/27/2023] Open
Abstract
Sixty-seven percent of children with cerebral palsy (CCP) experience pain. Pain is closely interrelated to diminished quality of life. Despite this, pain is an overlooked and undertreated clinical problem. The objective of this study was to examine the analgesic effect of a single lower extremity intramuscular injection of Abobotulinum toxin A/Dysport in CCP. Twenty-five CCP with at least moderate pain (r-FLACC ≥ 4) during passive range of motion were included. Localized pain and pain in everyday living were measured by r-FLACC and the Paediatric Pain Profile (PPP), respectively. Functional improvements were evaluated by the goal attainment scale (SMART GAS). Quality of life was evaluated by either the CPCHILD or the CP-QOL. The subjects were evaluated at baseline before injection, then after 4, 12, and 28 weeks. Twenty-two subjects had a significant mean and maximum localized pain reduction (p < 0.001) at four weeks post-treatment in 96% (21/22). The reduction was maintained at 12 (19/19) and 28 weeks (12/15). Daily pain evaluated by the PPP was significantly reduced and functional SMART GAS goals were significantly achieved from 4 to 28 weeks. Quality of life improved significantly at four weeks (CPCHILD). Significant functional gains and localized and daily pain reduction were seen from 4 to 28 weeks.
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Affiliation(s)
- Christian Wong
- Department of Orthopaedic Surgery, Copenhagen University Hospital, 2650 Hvidovre, Denmark
| | - Ian Westphall
- Department of Paediatrics, Copenhagen University Hospital, 2650 Hvidovre, Denmark
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Heinen F, Bonfert M, Kaňovský P, Schroeder AS, Chambers HG, Dabrowski E, Geister TL, Hanschmann A, Althaus M, Banach M, Gaebler-Spira D. Spasticity-related pain in children/adolescents with cerebral palsy. Part 1: Prevalence and clinical characteristics from a pooled analysis. J Pediatr Rehabil Med 2022; 15:129-143. [PMID: 35342060 PMCID: PMC9277671 DOI: 10.3233/prm-220011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE A large prospective database from three Phase 3 studies allowed the study of spasticity-related pain (SRP) in pediatric cerebral palsy (CP). METHODS Baseline (pretreatment) SRP data occurring during different activities in children/adolescents (aged 2-17 years, ambulant/nonambulant) with uni-/bilateral spastic CP was obtained using the Questionnaire on Pain caused by Spasticity (QPS; six modules specific to spasticity level [lower limb (LL) or upper limb (UL)] and type of respondent [child/adolescent, interviewer, or parent/caregiver]). RESULTS At baseline, 331 children/adolescents with LL- and 155 with UL-spasticity completed at least one key item of their modules; LL/UL QPS modules of parent/caregivers were at least partially completed (key items) by 841/444 parents/caregivers. SRP with at least one activity at baseline was self-reported in 81.9% /69.7% (LLs/ULs) of children/adolescents with spasticity. Parents/caregivers observed LL/UL SRP behaviors in 85.9% /77.7% of their children, with multiple body regions affected. SRP negatively affected the great majority of the children in various ways. Child/adolescent-reported mean SRP intensity and parent/caregiver-observed mean SRP behavior frequencies were higher for LLs than ULs, and the level of SRP increased with more physically demanding activities. CONCLUSION These data suggest SRP is more common and intense in pediatric CP than generally thought, emphasizing the need for effective, long-term pain management.
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Affiliation(s)
- Florian Heinen
- Division of Paediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Michaela Bonfert
- Division of Paediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, Olomouc, Czech Republic
| | - A Sebastian Schroeder
- Division of Paediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | | | - Edward Dabrowski
- Beaumont Pediatric Physical Medicine & Rehabilitation - Royal Oak, Royal Oak, MI, USA
| | | | | | | | - Marta Banach
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
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Long-term effect of botulinum toxin A on the hip and spine in cerebral palsy: A national retrospective cohort study in Taiwan. PLoS One 2021; 16:e0255143. [PMID: 34293010 PMCID: PMC8297884 DOI: 10.1371/journal.pone.0255143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 07/09/2021] [Indexed: 11/19/2022] Open
Abstract
Objectives To investigate the effect of botulinum toxin A (BTA) on the development of hip dislocation and scoliosis, surgical rates for hip and spine, and mortality in cerebral palsy (CP). Study design A cohort study was conducted using CP data from a Taiwan National Insurance Health Research Database. Diagnoses were defined using the International Classification of Diseases codes, 9th revision. Adjusted hazard ratios for outcomes were calculated using Cox regression analysis and adjusted for the following variables: BTA injection, sex, age, severities of CP, comorbidities, location, urbanization level, and level of care. Results A total of 1,405 CP children (670 female vs. 735 male), 281 in the BTA group and 1,124 in the controls, were followed-up for a mean of 5 years 4 months. There were no significant differences in the outcomes in both groups, in the incidence rates of hip dislocation and scoliosis, nor in the surgical rates for hip and spine surgery. Mortality rate in the BTA group was 0.49 times lower than that in the controls (p = 0.001). Moderate to severe types of CP had higher incidence rates of hip dislocation, scoliosis, hip surgery, spine surgery, and mortality. Conclusion Moderate to severe types of CP had poorer outcomes in all aspects, including a higher risk of hip dislocation, scoliosis, surgical rate for hip and spine, and mortality. Although BTA injection in children with CP proved to not significantly reduce hip dislocation and scoliosis, it is considered safe as an anti-spasticity treatment and may be beneficial for survival.
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Almina S, Karile Y, Audrone P, Indre B. Analgesic effect of botulinum toxin in children with cerebral palsy: A systematic review. Toxicon 2021; 199:60-67. [PMID: 34081932 DOI: 10.1016/j.toxicon.2021.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022]
Abstract
This review aims to determine the analgesic efficacy of botulinum toxin (BTX) for the management of pain in children with cerebral palsy (CP). During July and August 2020, a systematic literature search was performed using a mixture of subject headings and free text. The eligibility criteria for inclusion in the review were: (1) interventional studies, (2) participants: children aged 0-18 with CP, (3) participants were treated with BTX, (4) an outcome measure of pain or satisfaction with pain management, and (5) published in an English-language peer-reviewed journal. Eleven studies met the eligibility criteria; nine studies explored analgesic effects of BTX for hypertonia related pain and two for postoperative pain. The studies were of level II to level IV evidence. We identified one high-quality study, which provides level II evidence, and two observational studies that supported BTX therapy for muscle hypertonia related pain in non-ambulant children with CP (GMFCS levels IV and V). For children in GMFCS levels I to III, the evidence for the analgesic effects of BTX was contradictory possibly due to the heterogeneity of the studies and/or weak study design. Mixed evidence for the use of BTX to reduce pain after hip surgery was found likely due to differences in the surgical method, injection protocols, and outcome measures.
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Affiliation(s)
- Stramkauskaite Almina
- Department of Children's Rehabilitation, Lithuanian University of Health Sciences, Lithuania.
| | - Ylaite Karile
- Department of Children's Rehabilitation, Lithuanian University of Health Sciences, Lithuania.
| | - Prasauskiene Audrone
- Department of Children's Rehabilitation, Lithuanian University of Health Sciences, Lithuania.
| | - Bakaniene Indre
- Department of Children's Rehabilitation, Lithuanian University of Health Sciences, Lithuania.
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Musculoskeletal Pain Outcomes Pre- and Post Intrathecal Baclofen Pump Implant in Children With Cerebral Palsy: A Prospective Cohort Study. Arch Rehabil Res Clin Transl 2021; 2:100049. [PMID: 33543076 PMCID: PMC7853392 DOI: 10.1016/j.arrct.2020.100049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To characterize musculoskeletal pain intensity, duration, frequency, and interference with activities of daily living in children with cerebral palsy (CP) before and after intrathecal baclofen pump placement. Design Prospective cohort study. Setting Children's tertiary hospital. Participants Participants were children with CP (N=32; 53% male; mean age, 9.9y; age range, 4-17y). The majority of participants had a CP diagnosis of quadriplegia (76%) and relied on wheeled mobility (91%). Interventions Assessments were completed pre- and post intrathecal baclofen pump implant. Main Outcome Measures Because of considerable patient heterogeneity, both pain measures (Brief Pain Inventory, Dalhousie Pain Interview) were completed by proxy (parent) report at the time of the procedure and approximately 6 months after intrathecal baclofen (ITB) pump placement. Results Prior to implant, 31% of participants were living with constant pain, which reduced to 6% post ITB implant (P<.001). Based on Wilcoxon signed rank tests, pain duration significantly decreased post ITB pump implant (P<.01). Conclusions This prospective analysis supports the anecdotal and retrospective evidence that musculoskeletal pain decreases in CP following ITB pump implant. The greatest effect appears to be on the duration of pain experience. Pain did not decrease for all individuals, and it would be worth further investigation to better understand the relation between patient characteristics and pain outcomes.
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8
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Ostojic K, Paget SP, Morrow AM. Management of pain in children and adolescents with cerebral palsy: a systematic review. Dev Med Child Neurol 2019; 61:315-321. [PMID: 30378122 DOI: 10.1111/dmcn.14088] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 01/11/2023]
Abstract
AIM To determine the efficacy of interventions for the management of pain in children and adolescents with cerebral palsy (CP). METHOD Electronic databases were searched from the earliest date possible to April 2018 using a mixture of subject headings and free text. Inclusion criteria comprised of studies with (1) diagnosis of CP, (2) under the age of 18 years, (3) intervention for the management of pain, (4) outcome measure of pain, and (5) studies published in English-language peer-reviewed journals. RESULTS Fifty-seven studies met the eligibility criteria. Pain related to (n=number of studies): hypertonia (n=17), spastic hip disease (n=13), procedures for the management of CP (n=7), postoperative (n=18), and other (n=2). Most of the studies were of level III to level V evidence. INTERPRETATION There is level II evidence to support intrathecal baclofen therapy for pain secondary to hypertonia in spastic and spastic-dyskinetic CP, and non-pharmacological interventions for procedural pain and pharmacological interventions for postoperative pain. Most studies were restricted by retrospective design and limited use of validated outcome measures. Future research is needed to explore multidisciplinary interventions for chronic pain and pain secondary to dystonia. Clinicians and researchers would benefit from a standardized approach to pain assessment. WHAT THIS PAPER ADDS The strongest evidence exists for pharmacological treatments for postoperative pain in children and adolescents with cerebral palsy (CP). There is moderate evidence for the efficacy of intrathecal baclofen for pain related to hypertonia in predominately spastic CP. There is a lack of standardization in the assessment of pain. There is limited evidence for multimodal and non-pharmacological strategies in paediatric CP.
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Affiliation(s)
- Katarina Ostojic
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia.,Kids Rehab, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Cerebral Palsy Alliance, The University of Sydney, Sydney, New South Wales, Australia
| | - Simon P Paget
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia.,Kids Rehab, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Angela M Morrow
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia.,Kids Rehab, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
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Psychometric properties of the brief pain inventory modified for proxy report of pain interference in children with cerebral palsy with and without cognitive impairment. Pain Rep 2018; 3:e666. [PMID: 30123858 PMCID: PMC6085142 DOI: 10.1097/pr9.0000000000000666] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/14/2018] [Accepted: 05/30/2018] [Indexed: 11/27/2022] Open
Abstract
Introduction Cerebral palsy (CP) is the most common cause of physical disability in children and is often associated with secondary musculoskeletal pain. Cerebral palsy is a heterogeneous condition with wide variability in motor and cognitive capacities. Although pain scales exist, there remains a need for a validated chronic pain assessment tool with high clinical utility for use across such a heterogeneous patient population with and without cognitive impairment. Objectives The purpose of this study was an initial assessment of several psychometric properties of the 12-item modified brief pain inventory (BPI) pain interference subscale as a proxy-report tool in a heterogeneous sample of children with CP with and without cognitive impairment. Methods Participants (n = 167; 47% male; mean age = 9.1 years) had pain assessments completed through caregiver report in clinic before spasticity treatment (for a subgroup, the modified BPI was repeated after procedure). To measure concurrent validity, we obtained pain intensity ratings (Numeric Rating Scale of pain) and pain intensity, duration, and frequency scores (Dalhousie Pain Interview). Results Modified BPI scores were internally consistent (Cronbach α = 0.96) and correlated significantly with Numeric Rating Scale intensity scores (rs = 0.67, P < 0.001), Dalhousie Pain Interview pain intensity (rs = 0.65, P < 0.001), pain frequency (rs = 0.56, P = 0.02), and pain duration scores (rs = 0.42, P = 0.006). Modified BPI scores also significantly decreased after spasticity treatment (pretest [scored 0-10; 3.27 ± 2.84], posttest [2.27 ± 2.68]; t (26) = 2.14, 95% confidence interval [0.04-1.95], P = 0.04). Conclusion Overall, the modified BPI produced scores with strong internal consistency and that had concurrent validity as a proxy-report tool for children with CP.
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Analgesic Effects of Botulinum Toxin in Children with CP. Toxins (Basel) 2018; 10:toxins10040162. [PMID: 29671771 PMCID: PMC5923328 DOI: 10.3390/toxins10040162] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 11/17/2022] Open
Abstract
Experiencing pain is the greatest contributor to a reduced quality of life in children with cerebral palsy (CP). The presence of pain is quite common (~60%) and increases with age. This leads to missed school days, less participation, and reduced ambulation. Despite these alarming consequences, strategies to relieve the pain are absent and poorly studied. Moreover, it is difficult to evaluate pain in this group of children, especially in cases of children with cognitive deficits, and tools for pain evaluation are often inadequate. Botulinum toxin has been shown to alleviate pain in a variety of disorders and could potentially have an analgesic effect in children with CP as well. Even though most of the studies presented here show promising results, many also have limitations in their methodology as it is unlikely to capture all dimensions of pain in this heterogeneous group using only one assessment tool. In this review, we present a new way of examining the analgesic effect of botulinum toxin in children with CP using a variety of pain scores.
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Hauer J, Houtrow AJ, Feudtner C, Klein S, Klick J, Linebarger J, Norwood KW, Adams RC, Brei TJ, Davidson LF, Davis BE, Friedman SL, Hyman SL, Kuo DZ, Noritz GH, Yin L, Murphy NA. Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System. Pediatrics 2017; 139:peds.2017-1002. [PMID: 28562301 DOI: 10.1542/peds.2017-1002] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.
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Affiliation(s)
- Julie Hauer
- Complex Care Service, Division of General Pediatrics, Boston Children’s Hospital, Assistant Professor, Harvard Medical School, Boston Massachusetts
- Seven Hills Pediatric Center, Groton, Massachusetts; and
| | - Amy J. Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pediatric Rehabilitation Medicine, Rehabilitation Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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12
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Wininger M, Craelius W, Settle J, Robinson S, Isaac B, Maloni H, Moradi M, Newby NA, Wallin M. Biomechanical analysis of spasticity treatment in patients with multiple sclerosis. Ther Adv Neurol Disord 2015; 8:203-11. [PMID: 26668586 DOI: 10.1177/1756285615601390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES New metrics for clinical spasticity are needed to assess motor performance, since scales such as the Ashworth and Tardieu are unreliable. Here, we assessed outcomes of baclofen treatment in patients with multiple sclerosis (MS) using biomechanical analysis of voluntary movements. METHODS Patients with MS and symptomatic limb spasticity were recruited for a pre-post baclofen titration study, along with age-matched healthy controls. Oral baclofen was titrated to optimize spasticity symptoms in all MS cases over 4 weeks. Clinical assessments included the Modified Ashworth Scale (MAS), Tardieu Scale (TS); elbow kinematics were measured via the Transient Acceleration Measurement Interface (TAMI); performance was measured as the score at 4 weeks minus the baseline score in all measures. Movement proficiency within TAMI was quantified through a scale-free smoothness measure, according to the regional excursion deviation (RED) from a constant-velocity approximant. RESULTS Twelve patients with MS [age: 47.8 ± 9.8 years; women: 4; disease duration: 20 ± 10 years; disease-modifying therapy use: 7; Expanded Disability Status Scale (EDSS): 6.8 ± 1.4] and eight age-matched healthy controls were evaluated concurrently (mean age: 49.5 ± 13.1 years; women = 3). In MS cases, no significant improvement in arm spasticity was observed with main effects: MAS: -41.6 ± 72.6 (p = 0.09); EDSS: -1.6 ± 10.4% (p = 0.49); and TS: -8.3 ± 2.1% (p = 0.32), -24.9 ± 63.6% (p = 0.42), and -30.7 ± 79.9% (p = 0.06), at slow, moderate, and fast speeds, respectively. However, voluntary motion smoothness, as measured by TAMI: RED, decreased significantly: 0.62 ± 0.08 versus 0.54 ± 0.09, p < 0.001, indicating significant increase in movement smoothness post treatment. CONCLUSION A simple biomechanical analysis of voluntary movements revealed a significant reduction of spasticity after 30 days of baclofen therapy in patients with MS that was not detected by clinical assessments.
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Affiliation(s)
- Michael Wininger
- Prosthetics & Orthotics Program, University of Hartford, 200 Bloomfield Avenue, West Hartford, CT 06117, USA
| | - William Craelius
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
| | - Jill Settle
- Department of Veterans Affairs Medical Center - Washington, DC and VA Multiple Sclerosis Center of Excellence - East, USA
| | - Stephanie Robinson
- Department of Veterans Affairs Medical Center - Washington, DC and VA Multiple Sclerosis Center of Excellence - East, USA
| | - Bobbi Isaac
- Department of Veterans Affairs Medical Center - Washington, DC and VA Multiple Sclerosis Center of Excellence - East, USA
| | - Heidi Maloni
- Department of Veterans Affairs Medical Center - Washington, DC and VA Multiple Sclerosis Center of Excellence - East, USA
| | - Minoosh Moradi
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
| | | | - Mitchell Wallin
- Department of Veterans Affairs Medical Center - Washington, DC and VA Multiple Sclerosis Center of Excellence - East, USA
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Symons FJ, ElGhazi I, Reilly BG, Barney CC, Hanson L, Panoskaltsis-Mortari A, Armitage IM, Wilcox GL. Can biomarkers differentiate pain and no pain subgroups of nonverbal children with cerebral palsy? A preliminary investigation based on noninvasive saliva sampling. PAIN MEDICINE 2014; 16:249-56. [PMID: 25234580 DOI: 10.1111/pme.12545] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Assessing and treating pain in nonverbal children with developmental disabilities are a clinical challenge. Current assessment approaches rely on clinical impression and behavioral rating scales completed by proxy report. Given the growing health relevance of the salivary metabolome, we undertook a translational-oriented feasibility study using proton nuclear magnetic resonance (NMR) spectroscopy and neuropeptide/cytokine/hormone detection to compare a set of salivary biomarkers relevant to nociception. DESIGN Within-group observational design. SETTING Tertiary pediatric rehabilitation hospital. SUBJECTS Ten nonverbal pediatric patients with cerebral palsy with and without pain. METHODS Unstimulated (passively collected) saliva was collected using oral swabs followed by perchloric acid extraction and analyzed on a Bruker Avance 700 MHz NMR spectrometer. We also measured salivary levels of several cytokines, chemokines, hormones, and neuropeptides. RESULTS Partial least squares discriminant analysis showed separation of those children with/without pain for a number of different biomarkers. The majority of the salivary metabolite, neuropeptide, cytokine, and hormone levels were higher in children with pain vs no pain. CONCLUSIONS The ease of collection and noninvasive manner in which the samples were collected and analyzed support the possibility of the regular predictive use of this novel biomarker-monitoring method in clinical practice.
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Affiliation(s)
- Frank J Symons
- Department of Educational Psychology, University of Minnesota, Minneapolis, Minnesota; Center for Neurobehavioral Development, University of Minnesota, Minneapolis, Minnesota
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Lower limb functioning and its impact on quality of life in ambulatory children with cerebral palsy. Eur J Paediatr Neurol 2013; 17:561-7. [PMID: 23755939 DOI: 10.1016/j.ejpn.2013.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 03/07/2013] [Accepted: 04/13/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Children with cerebral palsy (CP) are confronted on a daily basis with their motor problems affecting gait, which might impact on their quality of life (QOL). AIM The goal of this study was to evaluate the impact of gross motor and gait function on QOL in ambulatory children with CP attending regular school. METHODS A condition-specific questionnaire (CP QOL-Child), including a parent/proxy and child self-report, was used to assess the relation between patient characteristics, lower limb impairments and functioning, and the different aspects of the child's QOL. Data on therapy management, lower limb impairments, and gross motor and gait function was collected for 81 children with CP (10.5 ± 3.0 years). CP QOL-Child questionnaires were completed by a parent/proxy for all 81 children and by 39 of the children over 9 years. RESULTS The mean self-reported QOL score (78.2 ± 9.6) was significantly higher than the mean parent/proxy reported score (73.9 ± 10.2). Lower limb spasticity and higher frequency of BTX-A injections correlated with worse scores for the pain and impact of disability domain. Results further showed the adverse impact of the severity of gait pathology on QOL perception for the parents/proxy and the child self-report. Gait speed was an important factor for the parents/proxy, though correlated less with self-perceived QOL for the children. CONCLUSIONS Children and parents identified similar factors that adversely affect QOL, whereby the amount of gait pathology was shown to play a crucial role. Only gait speed seemed to be of higher importance for the parents compared to the children.
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Thorley M, Donaghey S, Edwards P, Copeland L, Kentish M, McLennan K, Lindsley J, Gascoigne-Pees L, Sakzewski L, Boyd RN. Evaluation of the effects of botulinum toxin A injections when used to improve ease of care and comfort in children with cerebral palsy whom are non-ambulant: a double blind randomized controlled trial. BMC Pediatr 2012; 12:120. [PMID: 22873758 PMCID: PMC3472230 DOI: 10.1186/1471-2431-12-120] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 07/28/2012] [Indexed: 12/18/2022] Open
Abstract
Background Children with cerebral palsy (CP) whom are non-ambulant are at risk of reduced quality of life and poor health status. Severe spasticity leads to discomfort and pain. Carer burden for families is significant. This study aims to determine whether intramuscular injections of botulinum toxin A (BoNT-A) combined with a regime of standard therapy has a positive effect on care and comfort for children with CP whom are non-ambulant (GMFCS IV/V), compared with standard therapy alone (cycle I), and whether repeated injections with the same regime of adjunctive therapy results in greater benefits compared with a single injecting episode (cycle II). The regime of therapy will include serial casting, splinting and/or provision of orthoses, as indicated, combined with four sessions of goal directed occupational therapy or physiotherapy. Method/design This study is a double blind randomized controlled trial. Forty participants will be recruited. In cycle I, participants will be randomized to either a treatment group who will receive BoNT-A injections into selected upper and/or lower limb muscles, or a control group who will undergo sham injections. Both groups will receive occupational therapy and /or physiotherapy following injections. Groups will be assessed at baseline then compared at 4 and 16 weeks following injections or sham control. Parents, treating clinicians and assessors will be masked to group allocation. In cycle II, all participants will undergo intramuscular BoNT-A injections to selected upper and/or lower limb muscles, followed by therapy. The primary outcome measure will be change in parent ratings in identified areas of concern for their child’s care and comfort, using the Canadian Occupational Performance Measure (COPM). Secondary measures will include the Care and Comfort Hypertonicity Scale (ease of care), the Cerebral Palsy Quality of Life Questionnaire (CP QoL–Child) (quality of life), the Caregiver Priorities and Child Health Index of Life with Disabilities Questionnaire (CPCHILD©) (health status) and the Paediatric Pain Profile (PPP) (pain). Adverse events will be carefully monitored by a clinician masked to group allocation. Discussion This paper outlines the theoretical basis, study hypotheses and outcome measures for a trial of BoNT-A injections and therapy for children with non-ambulant CP. Trial registration Australia New Zealand Clinical Trials Registry:N12609000360213
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Affiliation(s)
- Megan Thorley
- Queensland Cerebral Palsy Health Service, Royal Children Hospital, Brisbane, Australia.
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Abstract
Palliative care has always been a part of the care of children. It includes any intervention that focuses on relieving suffering, slowing the progression of disease, and improving quality of life at any stage of disease. In addition, for even the child with the most unpredictable disease, there are predictable times in this child's life when the child, family, and care team will be suffering in ways that can be mitigated by specific interventions. Rather than defining pediatric palliative care in terms of a patient base, severity of disease, or even a general philosophy of care, palliative care can best be understood as a specific set of tasks directed at mitigating suffering. By understanding these tasks; learning to identify predictable times and settings of suffering; and learning to collaborate with multidisciplinary specialists, use communication skills, and identify clinical resources, the pediatrician can more effectively support children with life-threatening illnesses and their families. In this article, we define palliative care as a focus of care integrated in all phases of life and as a set of interventions aimed at easing suffering associated with life-threatening conditions. We detail an approach to these interventions and discuss how they can be implemented by the pediatrician with the support of specialists in hospice and palliative medicine. We discuss common and predictable times of suffering when these interventions become effective ways to treat suffering and improve quality of life. Finally, we discuss those situations that pediatricians most commonly and intensely interface with palliative care-the care of the child with complex, chronic conditions and severe neurologic impairment (SNI).
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Affiliation(s)
- Jeffrey C Klick
- The University of Pennsylvania School of Medicine, Pediatric Hospice and Palliative Medicine, Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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