Qualitative development of the 'Questionnaire on Pain caused by Spasticity (QPS),' a pediatric patient-reported outcome for spasticity-related pain in cerebral palsy

Measurement properties and feasibility of chronic pain assessment tools for use with children and young people with cerebral palsy

PURPOSE

Chronic pain assessment tools exist for children, but may not be valid, reliable, and feasible for populations with functional, cognitive or communication limitations, for example, cerebral palsy (CP). This study aimed to (i) identify chronic pain assessment tools used with children and young people and rate their measurement properties; (ii) develop a CP specific feasibility rating tool to assess the feasibility of tools in CP; and (iii) categorise tools according to reporting method.

MATERIALS AND METHODS

Assessment tools were identified by literature review. Their measurement properties were rated using the COnsensus based standards for the Selection of health Measurement INstruments. The CP specific Feasibility Rating Tool was developed and used to rate the tools.

RESULTS

Fifty-seven chronic pain assessment tools were identified. Six have content validity for CP, four of these use proxy-report. Forty-two tools were considered feasible for people with CP; 24 self report and 18 observational/proxy-report. Only the Paediatric Pain Profile has content validity and feasibility for people with CP unable to self-report.

CONCLUSIONS

There are few valid, reliable and feasible tools to assess chronic pain in CP. Further research is required to modify tools to enable people with cognitive limitations and/or complex communication to self-report pain.

Clinical utility of a patient-reported outcome for assessing spasticity in a pediatric population

PurposeThis study aimed to (1) examine the construct validity of the Zorowitz spasticity patient-reported outcome (PRO) scale in pediatric populations and (2) examine the scale's responsiveness to change in children to determine its clinical utility in guiding treatment of pediatric spasticity.MethodsRetrospective analysis of data collected at a large academic pediatric hospital system, including 505 patients who received injections for spasticity from pediatric physiatrists, was performed. Zorowitz scores, spasticity (Modified Ashworth Scale) scores, and Gross Motor Function Classification System levels were extracted.ResultsBaseline Zorowitz score (median 19, interquartile range 13-25) was not related to functional level (r = -0.088, p = 0.20) nor muscle tone (r = 0.006, p = 0.95), but patients with follow-up data reported reduced impact of spasticity post-injection (p < 0.0001). Higher baseline Zorowitz score was related to a greater decrease in Zorowitz score after injection (r = -0.39, p < 0.00001). Injection location, sex, number of muscles injected, and botulinum toxin dose were not related to Zorowitz change score.ConclusionThe Zorowitz scale may be responsive to spasticity treatment in children. However, construct validity to existing clinical measures was not observed, suggesting either that a clinical gold standard does not exist, that the scale measures a construct not otherwise captured clinically, or that it has limited validity in children.

Integrated hip surveillance pathways for pain, function and quality of life in children with Cerebral Palsy: A systematic literature review

AIM

To determine the effectiveness of integrated hip surveillance pathways on pain, function and quality of life (QOL) in children with Cerebral Palsy (CP).

METHOD

A systematic literature review, designed, conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

INCLUSION CRITERIA

confirmed CP diagnosis, management under recognised international hip surveillance pathways, outcome measures of hip displacement plus at least one other relevant to pain, function or QOL.

RESULTS

100 articles were identified. 12 full text articles were screened, and four were included. Reduced range of movement was associated with hip pain in children with CP. Increasing age, Gross Motor Function Classification Score (GMFCS) and migration percentage (MP) were associated with increased hip pain. General health declined with increased age. Increased MP and GMFCS level were associated with interruption to activities of daily living.

INTERPRETATION

Outcomes relating to function and QOL are under-researched in the current integrated hip surveillance pathway evidence-base. Wider outcomes related to function and QOL need to be included to capture the wider impact on children who are at risk of hip dislocation.

WHAT THIS PAPER ADDS

Increased pain was associated with reduced joint range and increased migration percentage. Pain also increased with greater age and Gross Motor Function Classification Score. Early orthopaedic intervention for hip displacement may not successfully mitigate pain. Effectiveness of integrated pathways on function and quality of life is under-evidenced. Studies investigating integrated pathways and holistic outcomes are needed to inform practice.

Spasticity evaluation and management tools

Spasticity is a complex and often disabling symptom for patients with upper motor neuron syndromes. Although spasticity arises from neurological disease, it often cascades into muscle and soft tissue changes, which may exacerbate symptoms and further hamper function. Effective management therefore hinges on early recognition and treatment. To this end, the definition of spasticity has expanded over time to more accurately reflect the spectrum of symptoms experienced by persons with this disorder. Once identified, clinical and research quantitative assessments of spasticity are hindered by the uniqueness of presentations both for individuals and for specific neurological diagnoses. Objective measures in isolation often fail to reflect the complex functional impact of spasticity. Multiple tools exist to quantitatively or qualitatively assess the severity of spasticity, including clinician and patient-reported measures as well as electrodiagnostic, mechanical, and ultrasound measures. A combination of objective and patient-reported outcomes is likely required to better reflect the burden of spasticity symptoms in an individual. Therapeutic options exist for the treatment of spasticity along a broad spectrum from nonpharmacologic to interventional procedures. Treatment strategies may include exercise, physical agent modalities, oral medications, injections, pumps, and surgery. Optimal spasticity management most often requires a multimodal approach, combining pharmacological management with interventions that match the functional needs, goals, and preferences of the patient. Physicians and other healthcare providers who manage spasticity must be familiarized with the full array of spasticity interventions and must frequently reassess results of treatment to ensure the patient's goals of treatment are met.

Spasticity-related pain in children/adolescents with cerebral palsy. Part 2: IncobotulinumtoxinA efficacy results from a pooled analysis

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.

Spasticity-related pain in children/adolescents with cerebral palsy. Part 1: Prevalence and clinical characteristics from a pooled analysis

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.

IncobotulinumtoxinA for the treatment of lower-limb spasticity in children and adolescents with cerebral palsy: A phase 3 study

PURPOSE

Investigate the efficacy and safety of multipattern incobotulinumtoxinA injections in children/adolescents with lower-limb cerebral palsy (CP)-related spasticity.

METHODS

Phase 3 double-blind study in children/adolescents (Gross Motor Function Classification System - Expanded and Revised I-V) with unilateral or bilateral spastic CP and Ashworth Scale (AS) plantar flexor (PF) scores ⩾ 2 randomized (1:1:2) to incobotulinumtoxinA (4, 12, 16 U/kg, maximum 100, 300, 400 U, respectively) for two 12- to 36-week injection cycles. Two clinical patterns were treated. Pes equinus (bilateral or unilateral) was mandatory; if unilateral, treatment included flexed knee or adducted thigh.

ENDPOINTS

Primary: AS-PF change from baseline to 4 weeks; Coprimary: investigator-rated Global Impression of Change Scale (GICS)-PF at 4 weeks; Secondary: investigator's, patient's, and parent's/caregiver's GICS, Gross Motor Function Measure-66 (GMFM-66).

RESULTS

Among 311 patients, AS-PF and AS scores in all treated clinical patterns improved from baseline to 4-weeks post-injection and cumulatively across injection cycles. GICS-PF and GICS scores confirmed global spasticity improvements. GMFM-66 scores indicated better motor function. No significant differences between doses were evident. Treatment was well-tolerated, with no unexpected treatment-related adverse events or neutralising antibody development.

CONCLUSION

Children/adolescents with lower-limb spasticity experienced multipattern benefits from incobotulinumtoxinA, which was safe and well-tolerated in doses up to 16 U/kg, maximum 400 U.

IncobotulinumtoxinA Efficacy/Safety in Upper-Limb Spasticity in Pediatric Cerebral Palsy: Randomized Controlled Trial

BACKGROUND

This randomized phase 3 study with double-blind main period (MP) and open-label extension (OLEX; NCT02002884) assessed incobotulinumtoxinA safety and efficacy for pediatric upper-limb spasticity treatment in ambulant/nonambulant (Gross Motor Function Classification System [GMFCS] I-V) patients, with the option of combined upper- and lower-limb treatment.

METHODS

Patients were aged two to 17 years with unilateral or bilateral spastic cerebral palsy (CP) and Ashworth Scale (AS) score ≥2 in treatment-selected clinical patterns. In the MP, patients were randomized (2:1:1) to incobotulinumtoxinA 8, 6, or 2 U/kg body weight (maximum 200, 150, 50 U/upper limb), with optional lower-limb injections in one of five topographical distributions (total body dose ≤16 to 20 U/kg, maximum 400 to 500 U, depending on body weight and GMFCS level). In the OLEX, patients received three further treatment cycles, at the highest MP doses (8 U/kg/upper limb group). Outcomes included AS, Global Impression of Change Scale (GICS), and adverse events (AEs).

RESULTS

AS scores improved from baseline to week 4 in all MP dose groups (n = 350); patients in the incobotulinumtoxinA 8 U/kg group had significantly greater spasticity improvements versus the 2 U/kg group (least-squares mean [standard error] for upper-limb main clinical target pattern -1.15 [0.06] versus -0.93 [0.08]; P = 0.017). Investigator's, child/adolescent's, and parent/caregiver's GICS scores showed improvements in all groups. Treatment benefits were sustained over further treatment cycles. AE incidence did not increase with dose or repeated treatment across GMFCS levels.

CONCLUSIONS

Data provide evidence for sustained efficacy and safety of multipattern incobotulinumtoxinA treatment in children and adolescents with upper-limb spasticity.

Muscle-tendon unit in children with cerebral palsy

Muscle-tendon unit surgery for correction of deformities and movement dysfunction in children with cerebral palsy (CP) is fairly complicated. An understanding of basic muscle-tendon unit properties and their adaptation to both CP and surgery are important to develop advances in this field. In this review, we provide information to therapists, surgeons, and scientists regarding the short- and long-term adaptations of the muscle-tendon unit. Surgical releases, lengthening, and transpositions are discussed, as are some of the tissue, cellular, and molecular adaptations. What this paper adds Muscle strength, tone, and control must be considered in surgical interventions for cerebral palsy (CP). Muscle-tendon unit lengthening causes significant and lasting weakness requiring prolonged rehabilitation. Sarcomere length increases in CP muscle may be one of the underlying causes of muscle weakness. Muscle satellite cells are decreased and epigenetically modified in a way that may limit muscle growth in CP.

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

Purpose: This systematic literature review aims to analyse the methodological quality of instruments available to assess pain in Cerebral Palsy (CP), according to the COSMIN guidelines and checklist.Materials and methods: Electronic literature searches were conducted in PubMed, ScienceDirect, Web of Science, PEdro, Scielo, Scopus and Academic Search Complete (EBSCO host) for articles on measurement properties of self-report, proxy or observational instruments.Results: A total of 14 instruments were identified. Of these, 8 were self-report instruments, 4 were observational instruments and 2 could be used both as self-report or proxy-report. The quality of the manuscripts was inadequate or doubtful in 45.5%, adequate in 15.9% and very good in 38.6% of the cases. No instrument was assessed for all the properties recommended by COSMIN. The quality of the evidence for the measurement properties of the pain assessment instruments ranged from very low to moderate.Conclusions: There is scarce and low-quality evidence on the measurement properties of instruments used to assess pain in individuals with cerebral palsy. Further research is needed designed in line with the COSMIN recommendations.Implications for rehabilitationThere is scarce and low-quality evidence on the measurement properties of instruments used to assess pain in individuals with cerebral palsy;Clinicians need to carefully choose instruments to assess pain in individuals with cerebral palsy as there is insufficient evidence on the quality of instruments;Self-report pain intensity scales may be a useful instrument for a subgroup of individuals with cerebral palsy.

A Systematic Review of the Use and Quality of Qualitative Methods in Concept Elicitation for Measures with Children and Young People

BACKGROUND

Qualitative research is recommended in concept elicitation for patient-reported outcome measures to ensure item content validity, and those developing measures are encouraged to report qualitative methods in detail. However, in measure development for children and young people, direct research can be challenging due to problems with engagement and communication.

OBJECTIVES

The aim of this systematic review was to (i) explore the qualitative and adapted data collection techniques that research teams have used with children and young people to generate items in existing measures and (ii) assess the quality of qualitative reporting.

METHODS

Three electronic databases were searched with forward citation and reference list searching of key papers. Papers included in the review were empirical studies documenting qualitative concept elicitation with children and young people. Data on qualitative methods were extracted, and all studies were checked against a qualitative reporting checklist.

RESULTS

A total of 37 studies were included. The quality of reporting of qualitative approaches for item generation was low, with information missing on sampling, data analysis and the research team, all of which are key to facilitating judgements around measure content validity. Few papers reported adapting methods to be more suitable for children and young people, potentially missing opportunities to more meaningfully engage children in concept elicitation work.

CONCLUSIONS

Research teams should ensure that they are documenting detailed and transparent processes for concept elicitation. Guidelines are currently lacking in the development and reporting of item generation for children, with this being an important area for future research.

Development and preliminary testing of a culturally-friendly pain assessment tool for children (Crying Faces Pain Scale)

Having a universal tool for assessing pain in children is hamstrung by cultural sensitivity. This study aimed to develop and validate a culturally-friendly pain assessment tool (i.e. Crying Faces Pain Scale (CFPS)) among Nigerian Children. This study employed criterion-standard design. The study was in three phases, namely: (1) development of CFPS, (2) cross-validity and (3) validation of the CFPS. 70 children (39 (55.7%) males and 31 (44.3%) females) within the age range of 4-13 years who had post-surgical pain, orthopaedic pain, stomach pain or headache were involved in the validation phase. Psychometric properties and preferences for the CFPS compared with the Wong-Baker FACES Pain Rating Scale (FACES) were examined. Descriptive and inferential statistics were used to analyze the data. Alpha level was set at p<0.05. The median score of the CFPS was 4.60 compared to FACES median score of 4.49. There was weak correlation between FACES and CFPS (r=0.325; p=0.006). Preference score as a culturally friendly tool for CFPS and FACES was 6.07±1.23 and 3.67±1.09 respectively, based on a modified 0-10 numerical pain scale. Conclusions: The crying faces pain scale has fair psychometric properties for assessing pain in children. However, CFPS was preferred to FACES as a culturally friendly tool for assessing pain among Nigerian children. Implications: The CFPS is more culturally friendly and so might be better suited as a pain scale in Africa. However, due to its fair psychometric properties, further studies may be needed to improve upon this scale.

Evaluation of Psychometric and Linguistic Properties of the Italian Adolescent Pain Assessment Scales: A Systematic Review

INTRODUCTION

Adolescents' pain experiences are complex and multidimensional, and evaluating pain only from a sensory and affective point of view may be in many instances limiting and inadequate; this is the reason why it is of paramount importance to identify the tools which can better assess the pain experienced by young patients. A person-oriented approach is highly encouraged, as it may better investigate the cognitive and behavioral development typical of this age group. The aim of this review paper is to describe the available tools which are able to adequately assess pain intensity in adolescents, in particular those validated in Italian.

METHODS

We conducted a systematic review using four databases: CINAHL, PsycINFO, PubMed and Cochrane, and selected all the articles published between January 1970 and November 2017. We selected all the papers reporting the validation process of pain assessment tools specifically tailored for adolescent patients (age range 10-18 years) and based on psychometric and linguistic parameters, and focused especially on the tools available in Italian and able to measure acute and chronic pain.

RESULTS

The results of our investigation have revealed the existence of 40 eligible tools, 17 of which are monodimensional and the remaining 23 multidimensional, more specifically tailored to assess both acute and chronic pain. Some of the instruments (26) were self-reports while others were classified as behavioral (13) and/or mixed. Only one tool turned out to be suitable for fragile adolescents, while six adopted a person-oriented approach that better emphasized the cognitive and behavioral process typical of the adolescent population. None of them has ever been validated in Italian.

CONCLUSION

Valid and reliable psychometric tools specifically organized to provide a cultural and linguistic evaluation of the patient are indeed the most recommended instruments to assess the intensity of the pain experienced by the patient, as they may provide useful information to implement a health policy aimed at identifying the best assistance programs.

A systematic review of pediatric self-report symptom measures: Congruence with the theory of unpleasant symptoms

PURPOSE

Many children and adolescents experience unpleasant symptoms due to acute and chronic illnesses. Several symptom measures specific to children and adolescents are available to assess unpleasant symptoms. What is unclear is how well these measures assess all dimensions of the symptom experience. Using the Theory of Unpleasant Symptoms (TOUS) as a guide, the purpose of this systematic review of self-report symptom measures was to examine the comprehensiveness of current symptom measures designed to assess children's and adolescents' symptom experiences.

CONCLUSIONS

The TOUS did not guide the development of any of the measures studied; hence, exact parallels were not expected. Currently, no pediatric self-report symptom measures were found that assessed all dimensions of the symptom experience. Four measures captured three dimensions: intensity, timing, and distress. Only two measures assessed quality.

PRACTICE IMPLICATIONS

Practitioners need to be aware of the dimensions reflected in commonly used symptom measures. Augmentation of these measures is needed in order to assess the entire symptom experience in children and adolescents.

Initial psychometric validation of the questionnaire on pain caused by spasticity (QPS)

BACKGROUND

The Questionnaire on Pain caused by Spasticity (QPS) is a modular patient- and observer-reported outcome measure of spasticity-related pain (SRP) in children with cerebral palsy (CP). Originally developed for an English-speaking population, we conducted a psychometric validation of a recently developed Chinese language version of the QPS.

METHODS

This was a prospective, observational study involving 137 children/adolescents with CP and upper and/or lower limb spasticity and their parents at three sites in China. Six QPS modules were used, three each for upper and lower limb SRP assessment: a patient self-report module; an interviewer-administered module used by site staff based on the cognitive, communicative, and motor abilities of a patient; and a parent/caregiver module administered for all children as an observer-reported outcome to complement the patient-reported outcome. If no assessment by the patient was possible because of age or cognitive impairments, only the parent/caregiver module was completed. Two visits with a 3-week interval provided data to evaluate and establish administrative ease of use, scoring of the QPS (factor analyses, Rasch analyses), reliability (Cronbach's α, intraclass correlation coefficient), validity (correlations with quality of life [PedsQL™], motor impairment [Gross Motor Function Classification System, Gross Motor Function Measure-66, Manual Ability Classification System], and spasticity [Ashworth Scale, Modified Tardieu Scale]).

RESULTS

For most children, clinic staff reported no difficulties associated with general QPS use or deciding which module to use. Children (and parents) who reported more demanding activities also reported higher levels of associated SRP (or observed SRP behavior). Activity-related SRP items were combined for a total QPS score. Cronbach's α was low for child self-report, but was acceptable for interviewer-administered and parent reports on SRP. Test-retest reliability was high for all modules. Moderate-strong associations were frequently seen between QPS and quality of life, and were particularly strong in the child self-report group. Relatively weak associations were observed between QPS and motor impairment and spasticity.

CONCLUSIONS

This first study was successful in providing initial evidence for the psychometric properties. Clinic staff were able to administer the QPS modules easily, and both children and parents were able to complete the designated QPS appropriately.

Challenges of Developing an Observable Parent-Reported Measure: A Qualitative Study of Functional Impact of ADHD in Children

BACKGROUND

Informant-reported outcome measures, usually completed by parents, are often administered in pediatric clinical trials with the intention of collecting data to support claims in a medical product label. Recently, there has been an emphasis on limiting these measures to observable content, as recommended in the US Food and Drug Administration guidance on patient-reported outcomes. This qualitative study explores the concept of observability using the example of childhood attention deficit/hyperactivity disorder (ADHD).

METHODS

Concept elicitation interviews were conducted with children (aged 6-12 years) diagnosed with ADHD and parents of children with ADHD to identify concepts for a potential parent-reported measure of functional impact of childhood ADHD. The observability of each concept was considered.

RESULTS

Of the 30 parents (90% females; mean age = 42.0 years), 24 had a child who was also interviewed (87.5% males; mean age = 9.6 years). Areas of functional impact reported by parents and/or children included the following: 1) functioning within the home/family, 2) academic performance, 3) school behavior, 4) social functioning, 5) emotional functioning, and 6) decreased self-efficacy. Parents cited many examples of direct observation at home, but opportunities for observation of some important areas of impact (e.g., school behavior and peer relationships) were limited.

CONCLUSIONS

Findings illustrate the substantial functional impairment associated with childhood ADHD while highlighting the challenges of developing informant-reported outcome measures limited to observable content. Because ADHD has an impact on children's functioning in a wide range of contexts, a parent-report measure that includes only observable content may fail to capture important aspects of functional impairment. Approaches for addressing this observability challenge are discussed.

Ability of PROMIS Pediatric Measures to Detect Change in Children With Cerebral Palsy Undergoing Musculoskeletal Surgery

BACKGROUND

The Patient Reported Outcomes Measurement Information System (PROMIS) was developed to provide patient-reported outcome measures that are designed as being universally relevant across health conditions, low burden, and precise. A major problem for research and clinical practice in cerebral palsy (CP) is the void of outcomes instruments that are capable of evaluating the wide range of abilities and broad age spectrum inherent in this clinical population. Given the tremendous potential of PROMIS, the research questions for this study were "How do PROMIS pediatric computer adaptive tests and short forms detect change in children with CP following elective musculoskeletal surgery?" and "How do PROMIS instruments compare to the Pediatric Quality of Life Inventory Cerebral Palsy Module Version 3.0 (PedsQL CP), Pediatric Outcomes Data Collection Instrument (PODCI), the Timed Up and Go (TUG), and the Gross Motor Functional Measure (GMFM)."

METHODS

PROMIS Pediatric computer adaptive tests and short forms and the PedsQL, PODCI, TUG, and GMFM were administered before and after surgery. Effect size (ES) and standardized response mean (SRM) were calculated. Floor and ceiling effects were evaluated and, exposure rates for the PROMIS item banks were examined.

RESULTS

ES and SRM for all PROMIS Pediatric Measures were nonsignificant. PedsQL CP detected significant, positive change in mobility at 6 (ES=0.26; SRM=0.31) and 12 (ES=0.36; SRM=0.36) months; pain at 12 months (ES=0.29; SRM=0.34); and fatigue at 6 (ES=0.24; SRM=0.22) and 12 (ES=0.36; SRM=0.41) months. Significant negative changes were detected by the PODCI (ES=-0.20; SRM=-0.26), GMFM (ES=-0.13; SRM=-0.24), and TUG (ES=-0.29; SRM=-0.25). Ceiling effects were high. Exposure to an appropriate range of the PROMIS Mobility item bank was limited.

CONCLUSIONS

PROMIS measures were less able to detect change than other measures. PROMIS measures may be improved by tailoring start/stop rules or by adding items to include content appropriate for children with mobility impairments.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Associations between recurrent musculoskeletal pain and visits to the family doctor (GP) and specialist multi-professional team in 74 Norwegian youth with cerebral palsy

BACKGROUND

Musculoskeletal pain in cerebral palsy (CP) is common, but probably undertreated. The aim of the study was to explore if recurrent musculoskeletal pain (RMP) related to the CP condition was associated with visits to the family doctor [general practitioner (GP)] and specialist habilitation centre in youth with CP.

METHODS

Seventy-four youth with CP (mean age 16.5 years, 40 boys) from the same geographical area were assessed by clinical examination, semi-structured interview on pain (adolescent and parent together), the two questions on pain from the Child Health Questionnaire (parents only) and a structured interview on health care services. Gross Motor Function Classification System was level I 39%, level II 23%, level III 8% and levels IV and V 30%.

RESULTS

Thirty-five participants (47%) had visited their GP last year, and 49 (66%) had visited the specialist habilitation centre. The presence of RMP (n = 58; 78%) was not significantly associated with having visited the GP or the specialist habilitation centre. Still, in participants with RMP, increasing pain severity was associated with having visited the GP. Rest, massage, change of position and oral drugs were the most common measures taken to relieve RMP. Three adolescents with RMP did not take any measures to relieve pain.

CONCLUSION

Youth with RMP do take measures to relieve pain, but usually not in the direction of consulting the health care services available unless the pain is severe. Both youth with CP and their caregivers should be encouraged to discuss RMP with their professional network of care.

One Size Care Does Not Fit All Patients Undergoing a Spinal Fusion

PURPOSE

Spinal fusion (SF) surgery is a complex procedure that affects children with and without underlying disabilities. The purpose of this article was to describe the necessary steps when preparing a child, specifically with cerebral palsy (CP), and family for an SF, while also emphasizing the postoperative care during discharge planning.

DESIGN

Literature review on pediatric patients undergoing SF and those who have CP.

METHODS

Literature was searched using the CINAHL database, from 2009 to 2016. Key terms included spinal fusion, cerebral palsy, pediatrics, orthopedic surgery, team approach, management and developmental disability, or disability. Literature was reviewed to provide recommendations on caring for children undergoing an SF who also have CP as little literature supports exact care measures on this cohort of patients.

FINDINGS

Variations exist in the surgery type, specification, and approach, as well as history, growth, and developmental capabilities of the child and caregiver's expectations. Nurses must be aware of all of these factors to promote safe, effective, timely, and patient-centered care. In particular, patients with an underlying condition of CP may be more likely to experience complications that make understanding these processes essential to the surgery itself.

CONCLUSIONS

Although an SF may be a necessary surgery to correct a curve or spine deformity, there are many complications that a child with CP might encounter. The health care team must work closely with the child and the family to ensure that all treatment recommendations are met to minimize any unnecessary complications. Each surgery must focus specifically on meeting the child's and family's needs to ensure success while incorporating the health care team's approach.

CLINICAL RELEVANCE

Providing patient and family-centered care for children having an SF is essential to optimize outcomes and improve quality of life for patients and caregivers.

Extracorporeal shockwave therapy (ESWT) benefits in spastic children with cerebral palsy (CP)

INTRODUCTION

ESWT refers to the use of Shock Waves in medical practice. It was used as an important tool in spasticity management of children with CP. The aim of our study was to evaluate the effect of a 3 session of ESWT on spastic upper and lower limbs muscles in children with CP.

METHODS

Sixty-three children (37 boys and 26 girls), mean age 99.57±53.74 months, were included in the study. We used focused ESWT, applied in 3 sessions during the admission of each child, on the mainly affected muscles, using the same parameters on all patients (energy - 0.15 mJ/mm2, shot dose - 500 shocks/ session, frequency - 10 Hz). All patients were assessed two times: once, in admission (before any physical or ESWT appliance) and second, at discharge (after receiving the entire prescribed treatment), following: Modified Ashworth Scale (MAS), Gross Motor Function Classification System (GMFCS), Gross Motor Function Measure 66 (GMFM-66) and also a Questionnaire on Pain caused by spasticity (QPS).

RESULTS

We found a better and significant decrease of MAS level in the ESWT treated group, thus leading to a concomitant decrease of QPS score and also increase of GMFM-66 score.

CONCLUSION

ESWT, applied in 3 sessions, with 0.15 mJ/ mm2, using 500 shocks/ min and 10 Hz as frequency may decrease children spasticity level and pain caused by it and improve the gross motor function.