Motor function predicts parent-reported musculoskeletal pain in children with cerebral palsy

Assessment of somatosensory profiles by quantitative sensory testing in children and adolescents with and without cerebral palsy and chronic pain

OBJECTIVE

We investigated differences in somatosensory profiles (SSPs) assessed by quantitative sensory testing in children and adolescents with cerebral palsy (CCP) with and without chronic pain and compared these differences to those in a group of typically developed children and adolescents (TDC) with and without chronic pain.

METHOD

All included subjects were consecutively recruited from and tested at the same outpatient orthopedic clinic by the same investigator. The subjects had their reaction times tested. The SSP consisted of the following tests: warmth (WDT), cool (CDT), mechanical (MDT), and vibration (VDT) detection thresholds; heat (HPT), pressure (PPT), and mechanical (MPT) pain thresholds; wind-up ratio (WUR); dynamic mechanical allodynia (DMA) and cold pressor test (CPT) using a conditioned pain modulation (CPM) paradigm.

RESULTS

We included 25 CCP and 26 TDC. TDC without chronic pain served as controls. In TDC with chronic pain, WDT, HPT, HPT intensity, and PPT were higher than in controls. No differences in SSPs between CCP with and without chronic pain were observed. In CCP, the MDT, WDT, CDT, and HPT intensity were higher than in controls. CCP had longer reaction times than TDC. There were no differences regarding the remaining variables.

DISCUSSION

In CCP, the SSPs were independent of pain status and findings on MR images. In all CCP the SSPs resembled TDC with chronic pain, compared to TDC without chronic pain. This suggests that CCP do not have the normal neuroplastic adaptive processes that activate and elicit functional changes in the central and peripheral nervous systems.

Pain trajectories and well-being in children and young people with cerebral palsy: A cohort study

AIM

To identify 5-week pain intensity trajectories and their association with physical and psychological well-being in children/young people with cerebral palsy (CP).

METHOD

A cohort study was conducted with 101 Canadian children/young people with CP, of whom 49 were female, with an overall mean age of 12 years 11 months (SD 3 years 1 month), range of 8 to 18 years, and classified in any Gross Motor Function Classification System level. Self-reported pain intensity (Faces Pain Scale - Revised) was collected weekly for 5 weeks and physical and psychological well-being (KIDSCREEN-27) at baseline and 5 weeks. Statistical analyses included latent class growth and general linear models.

RESULTS

All Gross Motor Function Classification System levels were represented (I = 40.6%; II = 15.8%; III = 20.8%; IV = 13.9%; V = 8.9%). Five pain intensity trajectories were identified. Three trajectories had very low (35.4%), low (32.4%), or high (4.9%) mean stable pain. Two trajectories had moderate changing pain (16.8%) and high pain decreasing to moderate levels (10.5%) respectively. Trajectory participants with stable high pain had the lowest physical well-being (adjusted β = -10.01; 95% confidence interval [CI] = -19.37 to -0.66). Those in the three trajectories with the highest mean baseline pain intensity (>3 out of 10) had the lowest psychological well-being (adjusted β = -8.27, 95% CI = -14.84 to -1.70; β = -6.74, 95% CI = -12.43 to -1.05; β = -5.82, 95% CI = -15.34 to 3.71).

INTERPRETATION

Almost one-third of participants had moderate-to-high pain intensity trajectories. Membership in the higher pain intensity trajectories was associated with lower physical and psychological well-being.

WHAT THIS PAPER ADDS

Five distinct 5-week pain intensity trajectories were identified in children/young people with cerebral palsy. Thirty-two per cent of participants had moderate-to-high pain intensity trajectories. Participants in the trajectories with higher pain intensity reported lower physical and psychological well-being.

Presence and predictors of pain after orthopedic surgery and associated orthopedic outcomes in children with cerebral palsy

While children with cerebral palsy (CP) may undergo 8‐22 orthopedic surgeries in their lifetime, little is known about the associated pain. We aimed to assess the pain presence before and one year after lower extremity orthopedic surgery, predictors of pain presence at follow‐up, and the association between pain and orthopedic outcomes related to surgery. This retrospective study included 86 children with CP (M age = 10.0 years, SD = 3.2; range = 4.1‐17.3 years, Gross Motor Functional Classification System (GMFCS) level I‐III) who underwent orthopedic surgery and had completed questionnaires at gait analyses before (M = 2.7 months; range = 0.0‐5.7) and after surgery (M = 11.8 months; range = 9.0‐14.9). Pain presence, location, and Pediatric Outcomes Data Collection Instrument (PODCI) scores were documented before and after surgery at gait analyses. Pain prevalence was 60% at baseline and 56% at follow‐up. Significant predictors of pain presence at follow‐up included (1) pain presence at baseline (range of odds ratios [OR] across any/all locations = 3.22 to 15.54), (2) older age (range of OR for any pain, back, knee, and foot pain = 1.24‐1.26), (3) female sex (decreased OR for males for ankle pain = 0.12), (4) having hip surgery (decreased OR for foot pain = 0.20), and (5) lower GMFCS level (OR for foot pain = 0.41). Changes in PODCI Sports and Physical Function scores were associated with changes in hip and knee pain (P < .03); PODCI scores worsened for patients who had pain at both time points and improved for patients who had pain at baseline but not follow‐up. Pain was present for over half of the participants before and after orthopedic surgery. Pain presence at follow‐up was predicted by pain presence at baseline. Pain and functional outcomes were correlated at follow‐up. Prospective studies examining perioperative pain experience and factors predicting pain outcomes are warranted.

Pain burden in children with cerebral palsy (CPPain) survey: Study protocol

Pain is a significant health concern for children living with cerebral palsy (CP). There are no population‐level or large‐scale multi‐national datasets using common measures characterizing pain experience and interference (ie, pain burden) and management practices for children with CP. The aim of the CPPain survey is to generate a comprehensive understanding of pain burden and current management of pain to change clinical practice in CP. The CPPain survey is a comprehensive cross‐sectional study. Researchers plan to recruit approximately 1400 children with CP (primary participants) across several countries over 6‐12 months using multimodal recruitment strategies. Data will be collected from parents or guardians of children with CP (0‐17 years) and from children with CP (8‐17 years) who are able to self‐report. Siblings (12‐17 years) will be invited to participate as controls. The CPPain survey consists of previously validated and study‐specific questionnaires addressing demographic and diagnostic information, pain experience, pain management, pain interference, pain coping, activity and participation in everyday life, nutritional status, mental health, health‐related quality of life, and the effect of the COVID‐19 pandemic on pain and access to pain care. The survey will be distributed primarily online. Data will be analyzed using appropriate statistical methods for comparing groups. Stratification will be used to investigate subgroups, and analyses will be adjusted for appropriate sociodemographic variables. The Norwegian Regional Committee for Medical and Health Research Ethics and the Research Ethics Board at the University of Minnesota in USA have approved the study. Ethics approval in Canada, Sweden, and Finland is pending. In addition to dissemination through peer‐reviewed journals and conferences, findings will be communicated through the CPPain Web site (www.sthf.no/cppain), Web sites directed toward users or clinicians, social media, special interest groups, stakeholder engagement activities, articles in user organization journals, and presentations in public media.

Chronic pain among children with cerebral palsy attending a Ugandan tertiary hospital: a cross-sectional study

Background

Children with cerebral palsy (CP) frequently experience chronic pain. The burden and severity of such pain is often underestimated in relation to their other impairments. Recognition and awareness of this chronic pain among children with CP constitute the cornerstone for caretakers and clinicians to improve the quality of life of those children. This study aimed to determine the prevalence of chronic pain among children with CP, and the factors associated.

Methods

A cross-sectional study of children with CP, aged 2–12 years, attending the CP rehabilitation clinic and Pediatric Neurology Clinic at Mulago Hospital, Uganda from November 2017 to May 2018. A detailed history and clinical examination were performed and the co-morbidities were determined. CP was classified using the Gross Motor Function Classification System (GMFCS), Manual Ability Classification System, Communication Function Classification System (CFCS), and the Eating and Drinking Ability Classification System (EDACS) and documented with the level of impairment in the different domains. Pain was assessed by using the revised Face, Legs, Activity, Consolability, Cry pain scale.

Results

A total of 224 children with CP were enrolled. The prevalence of chronic pain was 64.3%. The majority had spastic bilateral CP (77.8%), moderate pain lasting over 6 months, and none of them was on long-term pain management. Epilepsy (60.9%), behavioral problem (63.2%), hearing impairment (66,7%), learning problem (67,6%), dental caries (75%), gastro-esophageal reflux (75%), sleep disorders (79.5%), vision impairment (80%), and malnutrition (90%) were co- morbid conditions of chronic pain in children with CP in this study. The factors independently associated with chronic pain among children with CP were the GMFCS level IV & V, CFCS level IV & V, EDACS level IV & V, female children, and caretaker aged more than 30 years.

Conclusions

Two-thirds of children with CP attending rehabilitation in this hospital had chronic pain. None was receiving pain management. Chronic pain was associated with the presence of multiple co-morbidities and more severe disability. Rehabilitation and care programs for children with CP should include assessment of pain in routine care and provide interventions for pain relief in children with CP even at an early age.

Musculoskeletal Pain Outcomes Pre- and Post Intrathecal Baclofen Pump Implant in Children With Cerebral Palsy: A Prospective Cohort Study

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.

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.

Caregiver-Reported Pain Management Practices for Individuals With Cerebral Palsy

Objective

To investigate types and intensity of pain experienced by individuals with cerebral palsy (CP) and common pain-relieving approaches used by caregivers.

Design

The approach was cross-sectional, using standardized interviews.

Setting

Individuals with CP were recruited from a specialty health care hospital.

Participants

Eighty-six individuals (N=86; mean age, 17.2 years; male, 58%) with CP and complex communication needs participated.

Interventions

Not applicable.

Main Outcome Measures

Pain type, mean pain intensity (MPI) (graded on a scale of 0=no pain to 10=worst possible pain), and mean pain relief (MPR) (graded on a scale of 0=intervention did not help at all to 10=intervention completely relieved pain) were assessed by caregiver report as part of the Dalhousie Pain Interview for each type of pain experienced in the previous 7 days.

Results

Caregivers reported that 58 participants (67%) had experienced pain in the previous 7 days. MPI was 7.7±1.8 when the pain was worst in the previous 7 days. The 2 most common types of pain included musculoskeletal pain (n=70) and gastrointestinal pain (n=11). The most frequent treatment to relieve musculoskeletal pain was changing positions (n=27, MPI=5.1±2.3, MPR=6.6±2.1), medication (n=25, MPI=7.4±1.6, MPR=5.3±1.9), and massage (n=19, MPI=6.7±1.9, MPR=5.2±1.7). To treat gastrointestinal pain, medication was typically used (n=4, MPI=4.8±1.4, MPR=5.5±1.0), although no treatment was just as common (n=4, MPI=4.5±2.3).

Conclusions

The results indicate that musculoskeletal pain is prevalent in individuals with CP, and changing physical positions and providing medication are strategies most used by caregivers.

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

OBJECTIVE

To explore the presence of pain, how pain was addressed by physicians and parents, and how pain affected everyday life in young children with cerebral palsy (CP).

METHODS

Children with CP, aged 5-10 years, participated in this cross-sectional study. Data were collected from medical records spanning a period of two years and by a standardized parental interview that included six structured questions and the Pain Interference Index.

RESULTS

A total of 118 children, with a mean age of 7.4 years (SD 1.5), participated in the study. The parents of 81% of these children were interviewed. Pain was reported in 52% of the children, and pain was present at all severity levels. The prescription of analgesics was documented in 25% of these children's medical records. Fifty-nine percent of the children with pain received analgesics from their parents. Pain restricted the children's everyday lives particularly concerning sleep, school work and being with friends.

CONCLUSIONS

Half of this group of young children with CP were reported to have pain. Pain restricted the children's everyday lives and seemed to be under-treated. If pain can be addressed early, the children's everyday lives are likely to be improved.Implications for rehabilitationThere is a need to early identify and treat pain in young children.Important to discuss pain with parents irrespectively of the child's age and severity level.Pain interference assessment gives valuable information.Early treatment of pain might improve children's everyday life.

Gait Assessment of Pain and Analgesics: Comparison of the DigiGait™ and CatWalk™ Gait Imaging Systems

Investigation of pain requires measurements of nociceptive sensitivity and other pain-related behaviors. Recent studies have indicated the superiority of gait analysis over traditional evaluations (e.g., skin sensitivity and sciatic function index [SFI]) in detecting subtle improvements and deteriorations in animal models. Here, pain-related gait parameters, whose criteria include (1) alteration in pain models, (2) correlation with nociceptive threshold, and (3) normalization by analgesics, were identified in representative models of neuropathic pain (spared nerve injury: coordination data) and inflammatory pain (intraplantar complete Freund’s adjuvant: both coordination and intensity data) in the DigiGait™ and CatWalk™ systems. DigiGait™ had advantages in fixed speed (controlled by treadmill) and dynamic SFI, while CatWalk™ excelled in intrinsic velocity, intensity data, and high-quality 3D images. Insights into the applicability of each system may provide guidance for selecting the appropriate gait imaging system for different animal models and optimization for future pain research.

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.

Pain and sleep quality in children with non-vascular Ehlers-Danlos syndromes

The objective of this study was to explore the factors contributing to quality of life in pediatric patients with non-vascular Ehlers-Danlos syndromes (EDS). Data were analyzed on 41 children with a diagnosis of non-vascular EDS from the de-identified data available from the National Institute on Aging (NIA) study of heritable disorders of connective tissue. Children under age 19 years were seen as part of a long-term evaluation project from 2003 to 2013 on a larger natural history of patients with heritable disorders of connective tissue. Data collected included medical history, physical examination findings, diagnostic study results, and responses on validated questionnaires. We reviewed a sub-cohort of children with a diagnosis of non-vascular EDS and explored pain severity and interference via the Brief Pain Inventory, and sleep quality via the Pittsburgh Sleep Quality Index. Pain severity had a strong correlation with pain interference, and both were similar to other disorders that include chronic pain reported in the literature. Sleep quality did not correlate with pain severity or interference, but all patients had poor sleep quality in comparison to historical controls. We conclude that pain and sleep are significant issues in the pediatric non-vascular EDS population, and future research may be directed toward these issues.

Psychometric properties of the brief pain inventory modified for proxy report of pain interference in children with cerebral palsy with and without cognitive impairment

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.

Analgesic Effects of Botulinum Toxin in Children with CP

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.

[Pain in children with neurological impairment: A review from the French Pediatric Neurology Society]

Management of pain is one of the major expectations of children with neurological impairment and their families. The medical literature is poor on this topic accounting for approximately 0.15 % of the publications on pain in general. The objective of the French Pediatric Neurology Society was to review the current knowledge on this topic. Bibliographic research was conducted with PubMed and RefDoc for publications between 1994 and 2014 in French or English. A total of 925 articles were retrieved and 92 were selected for review. Pain is common in this population: a 2-week survey indicated that pain occurs in 50-75 % of children. Pain negatively impacts the quality of life of children and their parents. Children with neurological impairment express their pain with pain expression patterns and specific patterns common to children (change of tone, abnormal movements, spasticity, paradoxical reactions, such as laughter, self-injury or vasomotor dysfunction). Some children with neurological impairment are able to use self-report pain scales. If not, observational measures should be used. Behavioral rating scales specifically designed for this population are more sensitive than others. Scales must be selected according to children's communication skills, type of pain, and the context. Sometimes behavioral changes are the only expression of pain: any change in sleep, tone, feeding, or mood must suggest pain in this population. Management of pain remains difficult. There are no specific guidelines. Procedural pain management guidelines and the usual analgesic drugs can be used in children with neurological impairment with specific concerns regarding tolerance and side effects. These children are particularly at risk for neuropathic pain. A multidisciplinary approach is helpful, involving physicians, nurses, physiotherapists, psychologists and parents.

Efficacy of photobiomodulation therapy on masseter thickness and oral health-related quality of life in children with spastic cerebral palsy

The study aimed to evaluate the efficacy of photobiomodulation therapy (PBMT) on bilateral masseter muscle thickness and amplitude of mouth opening in children with spastic cerebral palsy (CP), and the impact on their oral health-related quality of life (OHRQOL). Three groups were included: experimental CP group (EG: n = 26 with oral complaints), positive control CP group (PCG: n = 26 without complaints), and negative control group (NCG: n = 26 without CP). In the EG, the masseter muscles on both sides were irradiated with an infrared low-level Ga-Al-As laser (λ = 808 ± 3 nm, 120 mW) using a 3 J/cm² energy dose per site, with a 20 s exposure time per site (spot area: 4 mm²; irradiance: 3 W/cm²; energy delivery per point: 2.4 J) six times over six consecutive weeks. Masseter thickness, assessed through ultrasonography, and the amplitude of mouth opening were measured in the EG before and after six applications of PBMT and once in the PCG and NCG. The Parental-Caregiver Perception Questionnaire (P-CPQ) was used to evaluate OHRQOL. ANOVA, chi-square, t tests, and multilevel linear regression were used for statistical analysis. In the EG, the study results revealed average increments of 0.77 (0.08) millimeter in masseter thickness (P < 0.05) and 7.39 (0.58) millimeter for mouth opening (P < 0.05) and reduction in all P-CPQ domains (P < 0.001), except for social well-being. The six applications of PBMT increased masseter thickness and mouth opening amplitude and reduced the impact of spastic CP on OHRQOL.

Change in pain status in children with cerebral palsy

AIM

To identify factors associated with a change in pain over time in children with cerebral palsy (CP).

METHOD

Pain was assessed at two time-points by physicians and caregiver-rated Health Utilities Index 3 (HUI3) pain scores.

RESULTS

One hundred and forty-eight children out of 179 approached from outpatient clinics (83% response; 104 males, 44 females mean age 8y 8mo, range 3y-16y) across all Gross Motor Function Classification System (GMFCS) levels were included. Fifty-five percent had changes in caregiver-reported HUI3 pain. A backward stepwise multiple linear regression retained HUI3 pain score at visit 1 and GMFCS level (F_[2,144] =23.40, R² =0.35; p<0.001) as variables associated with a change in pain status (HUI3 pain at visit 1: β=0.61, p<0.001; GMFCS level: β=-0.17, p<0.015). The association between HUI3 pain at visit 1 and GMFCS level was significant (β=-0.15, p<0.036). There was an association between pain etiology and pain trajectory (F_[3,144] =5.39, p=0.002). Post-hoc testing revealed musculoskeletal pain had the greatest improvements compared with the no pain group (p=0.006).

INTERPRETATION

Children with CP with more severe initial pain and higher gross motor function have lower pain at follow-up indicating an improvement in pain status over time.

A case-controlled comparison of postoperative analgesic dosing between girls with Rett syndrome and girls with and without developmental disability undergoing spinal fusion surgery

BACKGROUND

Rett syndrome is associated with severe motor and communicative impairment making optimal postoperative pain management a challenge. There are case reports documenting reduced postoperative analgesic requirement in Rett syndrome.

AIM

The goal of this preliminary investigation was to compare postoperative analgesic management among a sample of girls with Rett syndrome compared to girls with and without developmental disability undergoing spinal fusion surgery.

METHOD

The medical records of eight girls with Rett syndrome (mean age = 13.2 years, sd = 1.9), eight girls with developmental disability (cerebral palsy; mean age = 13.1 years, sd = 2.0), and eight girls without developmental disability (adolescent idiopathic scoliosis; mean age = 13.4, sd = 1.8) were reviewed. Data related to demographics, medications, and route of drug administration were recorded.

RESULTS

Girls with Rett syndrome received significantly fewer morphine equivalent opioids postoperatively (M = 0.26 mg·kg^-1 ·day^-1 , sd = 0.10) compared to girls with adolescent idiopathic scoliosis (M = 0.47mg·kg^-1 ·day^-1 , sd = 0.13; 95% CI -0.34 to -0.08; P = 0.001) and girls with CP (M = 0.40 mg·kg^-1 per day, sd = 0.14; 95% CI -0.27 to -0.02; P = 0.01). Girls with Rett syndrome received significantly fewer opioid patient-controlled analgesic (PCA) bolus doses (given by proxy; M = 42.63, sd = 17.84) compared to girls with adolescent idiopathic scoliosis (M = 98.25, sd = 52.77; 95% CI -96.42 to -14.83; P = 0.01). There was also some evidence indicating girls with Rett syndrome received fewer bolus doses compared to girls with CP (M = 80.88, sd = 38.93; 95% CI -79.05 to 2.55; P = 0.06). On average, girls with Rett syndrome also received smaller total doses of acetaminophen, diazepam, and hydroxyzine.

CONCLUSION

This study highlights possible discrepancies in postoperative pain management specific to girls with Rett syndrome and suggests further investigation is warranted to determine best practice for postoperative analgesic management for this vulnerable patient population.

A Case-controlled Investigation of Pain Experience and Sensory Function in Neuronal Ceroid Lipofuscinosis

OBJECTIVES

This case-control study explored pain experience and expression among individuals with neuronal ceroid lipofuscinosis (NCL) through parental report, tactile sensory testing, and infrared thermography (IRT).

MATERIALS AND METHODS

Participants with NCL (n=8; M=14.8 y) and their unaffected siblings (n=8; M=23.5 y) were characterized in terms of pain response to a brief tactile sensory test (light touch, Von Frey monofilament). During sensory testing, behavioral expression was measured using the Battens Observational Pain Scale and infrared thermography (IRT) was used to quantify changes in skin/eye temperature.

RESULTS

Children with NCL experienced pain frequently and from multiple sources that negatively impacted their lives. Children with NCL were reactive to the sensory testing as indexed by significant increased IRT temperature change (P<0.001). Across combined sensory conditions, individuals with NCL were significantly more reactive (Battens Observational Pain Scale total score) to sensory testing compared with siblings (P<0.05). Similarly, IRT difference scores between sensory conditions revealed a significant increase in temperature for individuals with NCL compared with siblings (P<0.001).

DISCUSSION

Ongoing reported pain was a problem for the children with NCL in this sample. Increased pain expression during the repeated Von Frey filament suggests that the pathophysiology of the ongoing pain may be centrally mediated.

Parent-reported pain in non-verbal children and adolescents with cerebral palsy

AIM

This cross-sectional study aimed to determine the prevalence, frequency, and intensity of parent-reported pain among non-verbal children with cerebral palsy (CP) and explore associations with medical, demographic, and parental psychosocial factors.

METHOD

Participants were parents of non-verbal outpatients (aged 2-20y) with CP at University of Malaya Medical Centre, Kuala Lumpur and two community centres. Parents answered the Caregiver Priorities and Child Health Index of Life with Disabilities Questionnaire and a pro forma regarding parent-reported frequency and intensity of pain during the preceding 4 weeks. Parental psychosocial well-being was assessed via the Depression, Anxiety and Stress Scale and Multidimensional Scale of Perceived Social Support.

RESULTS

The response rate was 94%; 104 children (54 males, 50 females) were studied. The majority (51%) were in Gross Motor Function Classification System level V and 65% had spastic quadriplegia. Parents reported pain in 65%, intense pain in 17%, and daily pain in 28%. Intense and frequent pain was reported during physiotherapy. More intense pain was reported in older children (p=0.016) and those with spastic quadriplegia (p=0.020).

INTERPRETATION

Caregivers of non-verbal children with CP report a high frequency of pain. Pain intensity is associated with patient factors but not parental psychosocial factors.

Pain experience and expression in Rett syndrome: Subjective and objective measurement approaches

Rett syndrome (RTT) is associated with myriad debilitating health issues and significant motor and communicative impairments. Because of the former there is concern about the possibility of recurrent and chronic pain but because of the latter it remains difficult to determine what pain 'looks like' in RTT. This study investigated pain experience and expression using multiple complementary subjective and objective approaches among a clinical RTT sample. Following informed consent, 18 participants (all female) with RTT (mean age= 12.8 years, SD= 6.32) were characterized in terms of pain experience and interference, typical pain expression, and elicited pain behavior during a passive range of motion-like examination procedure. Parents completed the Dalhousie Pain Interview (DPI; pain type, frequency, duration, intensity), the Brief Pain Inventory (BPI; pain interference), and the Non-Communicating Children's Pain Checklist - Revised (NCCPC-R; typical pain expression). A Pain Examination Procedure (PEP) was conducted and scored using the Pain and Discomfort Scale (PADS). The majority of the sample (89%) were reported to experience pain in the previous week which presented as gastrointestinal (n=8), musculoskeletal (n=5), and seizure related pain (n=5) that was intense (scored 0-10; M= 5.67, SD= 3.09) and long in duration (M= 25.22 hours, SD= 53.52). Numerous pain-expressive behaviors were inventoried (e.g., vocal, facial, mood/interaction changes) when parents reported their child's typical pain behaviors and based on independent direct observation during a reliably coded pain exam. This study provides subjective and objective evidence that individuals with RTT experience recurring and chronic pain for which pain expression appears intact.