Pain, motor function and health-related quality of life in children with cerebral palsy as reported by their physiotherapists

Pain and self-pressure relief in adolescents with cerebral palsy

Adolescents with CP classified as Gross Motor Functional Classification System Level V attend school up to 8 h daily with limited ability to self-reposition. Despite pain reported within this population, perceived pain and self-pressure relief during prolonged classroom sitting is unknown. A case series design was used with a convenience sample of six students (13-18 years) with CP. Pain assessments were taken every 30 min for 5 h. Self-relief assessments using the SensiMATTM were recorded while students were in their wheelchairs. One student self-reported pain and three students proxy reported pain movements. All students had unrelieved pressure or did not self-relieve pressure for at least 1.5 consecutive hours. Four students increased their self-pressure relief movements after 3.5 h. This study provided preliminary data regarding perceived pain and self-pressure relief during prolonged sitting and demonstrated that the SensiMATTM can capture pressure relief movements in sitting of students with severe CP. Although there was no trend of reported pain, students may either be moving enough, as demonstrated by recorded pressure relief movements, to independently relieve pressure and pain, or current pain assessments may not be sensitive enough for those with the most severe disabilities.

Impact of mother's care burden, fatigue and child's functional level on quality of life in spastic cerebral palsy

BACKGROUND AND PURPOSE

Cerebral palsy (CP) may be considered one of the most common motor disabilities that require a lot of caregiving from mothers or caregivers; therefore, the mothers of children with CP face a lot of difficulties in their caregiving, which in turn may affect the child's quality of life (QOL). This work was conducted to evaluate the impact of the children's functional level in different types of spastic CP, mothers' care burden (CB), and fatigue on the child's QOL.

METHODS

One hundred thirty-eight children with different types of spastic CP (unilateral and bilateral) with different levels of the gross motor function classification system (GMFCS), with an age range of 6-12 years, and their mothers with ages ranged from 25 to 45 years, participated in this study. Mother CB, fatigue, and child QOL were measured and compared between different groups by using the Zarit burden Interview (ZBI), Chalder Fatigue Questionnaire (CFQ), and Pediatric Quality of Life Inventory (PedsQL) CP Module, respectively.

RESULTS

There were significant differences in all measured variables (ZBI, CFQ, GMFCS, and PedsQL) with p-value <0.001 among the different spastic groups (unilateral and bilateral CP). However, the results revealed a positive impact of the child's GMFCS, mother's CB, and fatigue level on the quality of the child's life, with a greater effect on those with quadriplegic type.

CONCLUSION

The mother's CB and fatigue should be considered in the rehabilitation of spastic CP children based on their GMFCS, as they have a negative impact on child QOL; therefore, helping the mother with her needs should not be ignored, especially in families with severely spastic CP children and low financial income.

Selective dorsal rhizotomy in non-ambulant children with cerebral palsy: a multi-center prospective study

PURPOSE

Assess the effects of selective dorsal rhizotomy (SDR) on motor function and quality of life in children with a Gross Motor Function Classification System (GMFCS) level of IV or V (non-ambulatory).

METHODS

This is a prospective, observational study in three tertiary neurosurgery units in England, UK, performing SDR on children aged 3-18 with spastic diplegic cerebral palsy, and a GMFCS level of IV or V, between 2012 and 2019. The primary outcome measure was the change in the 66-item Gross Motor Function Measure (GMFM-66) from baseline to 24 months after SDR, using a linear mixed effects model. Secondary outcomes included spasticity, bladder function, quality of life, and pain scores.

RESULTS

Between 2012 and 2019, 144 children who satisfied these inclusion criteria underwent SDR. The mean age was 8.2 years. Fifty-two percent were female. Mean GMFM-66 score was available in 77 patients (53.5%) and in 39 patients (27.1%) at 24 months after SDR. The mean increase between baseline and 24 months post-SDR was 2.4 units (95% CI 1.7-3.1, p < 0.001, annual change 1.2 units). Of the 67 patients with a GMFM-66 measurement available, a documented increase in gross motor function was seen in 77.6% (n = 52). Of 101 patients with spasticity data available, mean Ashworth scale decreased after surgery (2.74 to 0.30). Of patients' pain scores, 60.7% (n = 34) improved, and 96.4% (n = 56) of patients' pain scores remained the same or improved. Bladder function improved in 30.9% of patients.

CONCLUSIONS

SDR improved gross motor function and reduced pain in most patients at 24 months after surgery, although the improvement is less pronounced than in children with GMFCS levels II and III. SDR should be considered in non-ambulant patients.

Quality of life and its predicting factors for Tunisian children with cerebral palsy

Background

Cerebral palsy (CP) can cause motor, sensory, perceptual, cognitive, communication and behavioural disorders. The complexity of this condition justifies measuring the quality of life (QOL) of children with CP. This measurement depends on personal and socio-economic factors, hence the relevance of performing it in our cultural context of Tunisia.

Objectives

The objectives of this study were to assess the QOL of Tunisian children with CP and to identify predictive factors for QOL.

Method

A cross-sectional study using a self-administered questionnaire (the CP QOL-Child) was employed. It included 68 children with CP and their parents who consulted the outpatient clinics of Physical Medicine and Rehabilitation of the University Hospital of Sahloul Sousse.

Results

The QOL of children with CP was altered, and the mean total score for the CP QOL-Child was 59.3 (± 14). All domains were affected by this alteration. Six predictive factors for lowered QOL in children with CP were identified, namely age older than 6 years, swallowing disorders, more intense chronic pain, greater level of motor impairment, the use of botulinum toxin injection and the absence of verbal communication.

Conclusion

Intervention with children with CP must be mindful of their altered QOL. Five out of the six predictive factors of QOL are modifiable through a multidisciplinary approach within the framework of the International Classification of Functioning, Disability and Health (ICF).

Contribution

The multiplicity of the factors associated with QOL revealed by this study incites clinicians to adopt the ICF approach by displaying its practical implications on the efficiency of the medical intervention.

Parent-report health-related quality of life in school-aged children with cerebral palsy: A cross-sectional study

Quality of life is both a goal and an outcome in Cerebral Palsy (CP) rehabilitation. Children with CP may show impaired health-related quality of life (HRQoL) compared to their typical peers. Parents' perceptions of HRQoL of their children could help rehabilitation professionals to identify areas for intervention aiming to improve health and wellbeing. This study aims to compare the proxy HRQoL of Portuguese school-aged children with CP and the general population, and to analyze child and family correlation. Differences were examined using European normative data for children from 8 to 18 years. Correlation and regression analysis examined the association between child and family variables in the CP group with statistically significant low scores. Sixty-eight parents of children and adolescents with CP (12.5 ± 2.91 years) answered the KIDSCREEN-52 parent version. We identified clinically significantly lower HRQoL in four out of ten HRQoL domains (Physical well-being, Autonomy, Moods & Emotions, and Bullying) than the norm peers. Correlations were found between the number of siblings and Autonomy (r = .315), meaning that having more siblings was associated with greater autonomy, and between mobility and Moods & Emotions (r = -.261), where children with impaired mobility shown low scores as perceived by their parents. Age, sex, mobility and cognitive impairment explained 32% of Physical well-being scores (p < .001). Mobility and cognitive impairment explained 16% of Bullying scores (p = .001). Although the family and child variables identified in this study are non-modifiable, they can help in the identification and early intervention aimed at improving HRQoL. Rehabilitation professionals should assess parent perceptions, extending the HRQoL assessment to children who can report and other informants, aiming at fostering wellbeing in children and adolescents with CP.

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.

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.

Is sleep duration associated with self-reported overall health, screen time, and nighttime texting among adolescents?

Objectives

We aimed to investigate whether sleep duration is associated with self-reported overall health, screen time, and nighttime texting among Swedish adolescents.

Methods

This was a cross-sectional survey of students (n = 1518) aged 13 to 15 years (50.7% girls) in southern Sweden.

Results

Fewer than 8 hours sleep duration before a school day was reported by 31% of students. The median time spent watching television and/or at the computer was 3 hours, and 43% of students reported texting at night one or more times per week. Sleeping fewer than 8 hours was significantly associated with poorer self-reported overall health, often being tired at school, increased screen time, and a habit of nighttime texting.

Conclusions

Short sleep duration (<8 hours) was associated with poor self-reported health, increased screen time, and nighttime texting among respondents. These results provide information for parents, educators, and school health professionals to encourage young people to adopt healthy screen habits and sleep hygiene.

Bullying and Pain in School-Aged Children and Adolescents: A Cross-Sectional Study

Bullying is defined as repeated and unwanted aggressive behavior involving a power imbalance and hurt children and adolescents’ socioemotional functioning. The aim is to investigate associations between pain (headache, stomach pain, backache, and neck/shoulder pain) and bullying among school-aged children and adolescents. This cross-sectional school-based survey comes from the Icelandic data set in the international research network Health Behaviour in School-Aged Children. The study population included all Icelandic students in Grades 6, 8, and 10 (ages 11, 13, and 15 years, respectively; participation rate, 84%; n = 10,626). An anonymous standardized questionnaire was distributed and completed by students in their classrooms. About every 8 in 10 bullied students reported weekly pain (79%), compared with little over half of nonbullied students (57%). The prevalence of pain was significantly higher among bullied students compared with their nonbullied peers. Being a bullying victim was associated with an increased frequency of experiencing headaches, stomachaches, and back pain, in addition to neck or shoulder pain. It is important for mental health nurses and health professionals to ask about pain when meeting with children and adolescents as well as to inquire about their peer relationships.

The relationship between motor abilities and quality of life in children with severe multiple disabilities

BACKGROUND

This study aimed to determine the relationship between motor abilities and quality of life in children with severe multiple disabilities.

METHODS

In this cross-sectional study, motor abilities of 29 children (mean age 9.8 years; 45% girls) with severe multiple disabilities [IQ < 25; Gross Motor Function Motor Classification System level V] were measured with the MOtor eVAluation in Kids with Intellectual and Complex disabilities (Movakic) questionnaire (completed by the child's physical therapist). Quality of life was measured with the Quality of Life-Profound Multiple Disabilities (QoL-PMD) questionnaire (completed by the child's parents).

RESULTS

A significantly moderate to high correlation was found between the total scores on the Movakic and the QoL-PMD (r = 0.40, P = 0.03), indicating that higher scores in motor abilities are associated with a higher level of quality of life. Furthermore, significantly moderate to high correlations were found between the total score on the Movakic and the dimension Physical Well-Being, Development and Activities of the Qol-PMD. In multiple linear regression models, all significant bivariate relationships between the Movakic total scores and QoL-PMD dimensions remained significant after controlling for the Gross Motor Function Motor Classification System level.

CONCLUSIONS

In these children with severe multiple disabilities, motor abilities (as measured by Movakic) are moderately related to quality of life (as measured by the QoL-PMD).

Participation of children with disabilities in school: A realist systematic review of psychosocial and environmental factors

Background

In order to make informed decisions about how best to support children and young people with disabilities, effective strategies that facilitate active and meaningful participation in school are required. Clinical factors, diagnosis or impairments somewhat helpful in determining what should be provided in interventions. However, clinical factors alone will not offer a clear view of how to support participation. It is helpful then to look at wider psychosocial and environmental factors. The aim of this review was to synthesise evidence of psychosocial and environmental factors associated with school participation of 4–12 year old children with disabilities to inform the development of participation-fostering interventions.

Methods

A systematic search and synthesis using realist methods was conducted of published research. Papers had to include consideration of psychosocial and/or environment factors for school participation of children with disabilities. The review was completed in accordance with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) and Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Papers were identified via Boolean search of the electronic databases MEDLINE, CINAHL, PhycINFO and ERIC (January 2006-October 2018). Appraisal focussed on contributions in terms of whether the articles are appropriate for the review (relevance) and research quality (rigour). Data were analyzed using content and thematic analysis methods using a realist framework. A narrative synthesis of results was reported.

Results and implications

We identified 1828 papers in the initial search. Seventy two papers were included in the final synthesis. Synthesis of findings led to three overarching mechanisms representing psychosocial factors for children (1) identity (2) competence and (3) experience of mind and body. Environmental aspects (context) compromised five interrelated areas: (1) structures and organization, (2) peers, (3) adults, (4) space and (5) objects. Our synthesis provides insights on how professionals may organize efforts to improve children’s participation. Consideration of these findings will help to proactively deal with suboptimal participation outcomes. Development of theoretically determined assessments and interventions for management of school participation are now required.

Self-reported physical function is associated with walking speed in adults with cerebral palsy

PURPOSE

To understand the relationship of walking speed to self-reported pain, fatigue, and physical function in adults with CP.

METHODS

Design: Cross-sectional study.

SETTING

Accredited clinical motion analysis laboratory in a regional children's hospital.

PARTICIPANTS

72 ambulatory patients ⩾ 18 years of age, diagnosed with CP, who previously had ⩾ 1 prior instrumented gait analysis at our facility.

MAIN OUTCOME MEASURES

PROMIS-57 pain interference/intensity, physical function, and fatigue measures and walking speed.

RESULTS

Physical function was significantly lower than able-bodied normal values by 1-2 standard deviations (40.3 ± 8.5). Pain interference (51.4 ± 9.0) and fatigue (50.2 ± 9.2) were not significantly different when compared to able-bodied normal values. Only physical function was statistically correlated with walking speed (p< 0.001), while pain interference (p= 0.39), pain intensity (p= 0.36), and fatigue (p= 0.75) were not. Pain interference, pain intensity, and fatigue were not statistically significant factors in the multiple regression of walking speed. Fatigue could significantly predict physical function, pain interference, and pain scores (p= 0.032, p< 0.001, p< 0.01, respectively), however, fatigue did not directly predict walking speed (p= 0.747).

CONCLUSIONS

Self-reported physical function correlates with objectively measured walking speed in young adults with CP while patient-reported pain and fatigue did not, contrary to what would be predicted by the literature.

The paediatric version of Wisconsin gait scale, adaptation for children with hemiplegic cerebral palsy: a prospective observational study

Background

In clinical practice there is a need for a specific scale enabling detailed and multifactorial assessment of gait in children with spastic hemiplegic cerebral palsy. The practical value of the present study is linked with the attempts to find a new, affordable, easy-to-use tool for gait assessment in children with spastic hemiplegic cerebral palsy. The objective of the study is to evaluate the Wisconsin Gait Scale (WGS) in terms of its inter- and intra-rater reliability in observational assessment of walking in children with hemiplegic cerebral palsy.

Methods

The study was conducted in a group of 34 patients with hemiplegic cerebral palsy. At the first stage, the original version of the ordinal WGS was used. The WGS, consisting of four subscales, evaluates fourteen gait parameters which can be observed during consecutive gait phases. At the second stage, a modification was introduced in the kinematics description of the knee and weight shift, in relation to the original scale. The same video recordings were rescored using the new, paediatric version of the WGS. Three independent examiners performed the assessment twice. Inter and intra-observer reliability of the modified WGS were determined.

Results

The findings show very high inter- and intra-observer reliability of the modified WGS. This was reflected by a lack of systematically oriented differences between the repeated measurements, very high value of Spearman’s rank correlation coefficient 0.9 ≤ |R| < 1, very high value of ICC > 0.9, and low value of CV < 2.5% for the specific physical therapists.

Conclusions

The new, ordinal, paediatric version of WGS, proposed by the authors, seems to be useful as an additional tool that can be used in qualitative observational gait assessment of children with spastic hemiplegic cerebral palsy. Practical dimension of the study lies in the fact that it proposes a simple, easy-to-use tool for a global gait assessment in children with spastic hemiplegic cerebral palsy. However, further research is needed to validate the modified WGS by comparing it to other observational scales and objective 3-dimensional spatiotemporal and kinematic gait parameters.

Trial registration

anzctr.org.au, ID: ACTRN12617000436370. Registered 24 March 2017.

The Adaptation and Psychometric Properties of the Kid-KINDL(R) for Hospitalized Children in Chile

PURPOSE

The impact of hospitalization on a child's well-being leads one to consider the health-related quality of life (HRQoL) measure as a fundamental aspect of pediatric care. The aims of the study were to adapt the Spanish version of the Kid-KINDL® to hospitalized children in Chile, to obtain a reduced version of the instrument and to analyze the psychometric properties of the reduced version.

DESIGN AND METHODS

An expert committee and interviews were carried out for the cross-cultural adaptation process. An exploratory factor analysis was conducted to examine the validity of the construct and to select the items for the reduced version. Cronbach's alpha was used to estimate the internal consistency of the adapted version of the Kid-KINDL® and the reliability of each component. Convergent validity was based on correlations with a pain scale.

RESULTS

This adapted and shorter instrument, similar to the original version, comprises five components that include the principal dimensions of HRQoL. Evaluating the School dimension in hospitalized children was considered inappropriate in Chilean public hospitals. The study replicates the relationship found between a child with high pain and low reported HRQoL.

CONCLUSIONS

The hospitalization process impacted the children's perceptions of their HRQoL. The reduced version of the Kid-KINDL® was found to be a valid instrument for assessing children's HRQoL in hospital units.

PRACTICE IMPLICATIONS

Finding effective ways to measure HRQoL and ultimately mitigate barriers and foster resilience are important clinical and research priorities in the pursuit of HRQoL for hospitalized children and their families.

Quantitative sensory testing profiles in children, adolescents and young adults (6-20 years) with cerebral palsy: Hints for a neuropathic genesis of pain syndromes

INTRODUCTION

Many patients with cerebral palsy (CP) suffer chronic pain as one of the most limiting factors in their quality of life. In CP patients, pain mechanisms are not well understood, and pain therapy remains a challenge. Quantitative sensory testing (QST) might provide unique information about the functional status of the somatosensory system and therefore better guide pain treatment.

OBJECTIVES

To understand better the underlying pain mechanisms in pediatric CP patients, we aimed to assess clinical and pain parameters, as well as QST profiles, which were matched to the patients' cerebral imaging pathology.

PATIENTS AND METHODS

Thirty CP patients aged 6-20 years old (mean age 12 years) without intellectual impairment underwent standardized assessments of QST. Cerebral imaging was reassessed. QST results were compared to age- and sex-matched controls (multiple linear regression; Fisher's exact test; linear correlation analysis).

RESULTS

CP patients were less sensitive to all mechanical and thermal stimuli than healthy controls but more sensitive to all mechanical pain stimuli (each p < 0.001). Fifty percent of CP patients showed a combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia; 67% of CP patients had periventricular leukomalacia (PVL), which was correlated with mechanic (r = 0.661; p < 0.001) and thermal (r = 0.624; p = 0.001) hypoesthesia.

CONCLUSION

The combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia in our CP patients implicates lemniscal and extralemniscal neuron dysfunction in the thalamus region, likely due to PVL. We suspect that extralemniscal tracts are involved in the original of pain in our CP patients, as in adults.

[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.

Predictors of parent-reported quality of life of adolescents with cerebral palsy: A longitudinal study

AIM

Parent-reporting is needed to examine Quality of Life (QoL) of children with cerebral palsy (CP) across all severities. This study examines whether QoL changes between childhood and adolescence, and what predicts adolescent QoL.

METHOD

SPARCLE is a European cohort study of children with CP, randomly sampled from population databases. Of 818 8-12-year-olds joining the study, 594 (73%) were revisited as 13-17-year-olds. The subject of this report is the 551 (316 boys, 235 girls) where the same parent reported QoL on both occasions using KIDSCREEN-52 (transformed Rasch scale, mean 50, SD 10 per domain). Associations were assessed using linear regression.

RESULTS

Between childhood and adolescence, average QoL reduced in six domains (1.3-3.8 points, p<0.01) and was stable in three (Physical wellbeing, Autonomy, Social acceptance). Socio-demographic factors had little predictive value. Childhood QoL was a strong predictor of all domains of adolescent QoL. Severe impairments of motor function, IQ or communication predicted higher adolescent QoL on some domains; except that severe motor impairment predicted lower adolescent QoL on the Autonomy domain. More psychological problems and higher parenting stress in childhood and their worsening by adolescence predicted lower QoL in five and eight domains respectively; contemporaneous pain in seven domains. The final model explained 30%-40% of variance in QoL, depending on domain.

INTERPRETATION

In general, impairment severity and socio-demographic factors were not predictors of lower adolescent QoL. However, pain, psychological problems and parenting stress were predictors of lower adolescent QoL in most domains. These are modifiable factors and addressing them may improve adolescent QoL.

Longitudinal changes in health-related quality of life in preschool children with cerebral palsy of different levels of motor severity

BACKGROUND

When setting goals for cerebral palsy (CP) interventions, health-related quality of life (HRQoL) is an important outcome.

AIMS

To compare longitudinal changes in HRQoL in children with CP of different levels of motor severity.

METHODS AND PROCEDURES

Seventy-three children with CP were collected and classified into three groups based on Gross Motor Function Classification System (GMFCS) levels. HRQoL was assessed by parent's proxy of the TNO-AZL Preschool Quality of Life (TAPQOL) at baseline and 6 months later.

OUTCOMES AND RESULTS

Children with GMFCS level V had a lower total TAPQOL score and scores in all domains than those with level I-IV (p<0.01), except for the non-motor subdomain of physical functioning at follow-up. With regards to longitudinal changes, the children with GMFCS level V had greater improvements in physical (p=0.016) and cognitive functioning (p=0.042), but greater deterioration in emotional functioning (p=0.008) than those with levels I-II at 6 months of follow-up.

CONCLUSIONS AND IMPLICATIONS

Motor severity was associated with TAPQOL scores in all domains and changes in some domains in children with CP. Clinicians should early identify children at risk of a poor HRQoL and plan timely treatment strategies to enhance the HRQoL of children with CP.

Pain in children and adolescents with cerebral palsy: a population-based registry study

Aim

We assessed prevalence and location of pain in a total population of children and adolescents with cerebral palsy (CP) based on the Gross Motor Function Classification System (GMFCS), age and gender.

Methods

This cross‐sectional study was based on the last assessment of children aged 1–14 years in the combined Swedish follow‐up programme and national quality register programme for CP. All were born 2001–2012 and reported to the registry in 2013–2014. Logistic regression was used to regress age, gender and the GMFCS level on the presence of pain. We also assessed pain sites among GMFCS groups.

Results

We included 2777 children (57% boys) at a median age of 7 years; 32.4% reported pain, with significantly more girls than boys experiencing pain and significantly more children at GMFCS levels III and V than GMFCS I. Pain frequency increased with age and differences among GMFCS levels were found in the lower extremities and abdomen. Pain in the abdomen and hips was most frequent at GMFCS V, knee pain at level III and foot pain at level I.

Conclusion

Our results showed that although a lower prevalence than in many other studies, pain constituted a significant problem in children and adolescents with CP.

Do environmental barriers affect the parent-reported quality of life of children and adolescents with cerebral palsy?

Physical, social, and attitudinal environment may affect the quality of life (QoL) of children and adolescents with cerebral palsy (CP). Participants in this study included parents of 206 children and adolescents with CP (55.8% males) aged 8-18 years (M=11.96, SD=3). Distribution according to the Gross Motor Function Classification System (GMFCS) was 24.3% level I, 18% level II, 18% level III, 12.6% level IV, and 27.2 level V. Environmental barriers were assessed with the Spanish version of the European Child Environment Questionnaire (ECEQ), and QoL was assessed with the KIDSCREEN parents' version. The results of the correlation analysis revealed that GMFCS level, IQ, and type of schooling are significantly correlated with QoL. Barriers were also associated with QoL. A series of hierarchical regression analyses indicated that, after controlling for the effect of child and parent's variables, barriers at home and at school significantly contribute to QoL. These findings underscore the importance of providing interventions to produce environmental changes that contribute to the improvement of QoL.