Pain in Children With Cerebral Palsy: A Review

Kimberly A. McKearnan; Gail M. Kieckhefer; Joyce M. Engel; Mark P. Jensen; Susan Labyak


J Neurosci Nurs. 2004;36(5) 

In This Article


Cerebral palsy (CP) is a diagnostic label representing a wide range of nonprogressive motor impairments that are identified at birth or in early childhood. A more specific definition identifies CP as " umbrella term covering a group of nonprogressive, but often changing, motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages of its development" (Mutch, Alberman, Hagberg, Kodama, & Perat, 1992, p. 547). In developed countries, CP is the leading cause of childhood physical disability, with more than 10,000 infants and children diagnosed each year with CP in the United States alone (Stanley, Blair, & Alberman, 2000; United Cerebral Palsy [UCP], 2002). While the specific etiology is often unknown, cerebral palsy is thought to be a result of congenital, hypoxic, ischemic, infectious, or traumatic injury or insult to the central nervous system (Dzienkowski, Smith, Dillow, & Yucha, 1996; UCP).

Although some persons with CP also present with sensory and cognitive impairments, the focus of classification is on motor deficits present in all persons with CP. The different presentations of CP vary in the literature and in clinical practice. Blair and Stanley (1985) developed a system with demonstrated reliability that delineates the categories as follows: (a) predominantly spastic, (b) predominantly athetoid, (c) predominantly dystonic, (d) ataxic, and (e) mixed.

Spastic CP is characterized by involuntary spontaneous movement and muscle contraction, in addition to hypertonia and rigidity (Dzienkowski et al., 1996). Spastic CP is the most common, accounting for up to 80% of those diagnosed with CP (Stanley et al., 2000). Uncontrolled, fragmented movements involving the extremities as well as facial and oral musculature are a distinguishing attribute of athetoid CP, which affects about 10%-20% of persons with CP. Slow, twisting, uncontrolled movements in the trunk and extremities are differentiating characteristics of dystonic CP, which results from malformation, insult, or injury to the extrapyrimidal portion of the brain (Nehring, 2000). Ataxic CP is typified by hypotonia in infancy followed by increasing tone, muscle instability, intention tremor and gait disturbances later in life (Dzienkowski et al., 1996; UCP, 2002). Mixed-type CP includes persons demonstrating characteristics or behaviors from two or more of the categories listed above.

Cerebral palsy is also described in topographical terms by the location of motor impairment (e.g., quadriplegic, diplegic, hemiplegic). The Swedish classification system utilizes both the movement disorder and topographical description to delineate type (Mutch et al., 1992). Further standardized classification of motor skills is often done using the Gross Motor Function Classification System (GMFCS), which is specifically designed for children with CP (Palisano et al., 1997). This scale evaluates gross motor skills in both the home and community as well as functional mobility and use of adaptive equipment.

Classification systems allow clinicians and researchers to explore commonalities and differences within and between classifications of persons with CP in terms of impairments, disabilities, handicaps, and secondary conditions such as pain. Regardless of CP classification, children with CP may encounter a variety of pain experiences. To understand the pain problems associated with CP, it is important to have a basic understanding of the nature of pain.

Pain may be defined as " unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" and is invariably subjective in nature (International Association for the Study of Pain [IASP], 2002; Merskey & Bogduk, 1994, p.210). There are two primary categorizations for pain: acute and chronic. Acute pain is most often caused by tissue damage or irritation related to injury, insult, surgery, or disease and lasts 6 months or less (Engel, 1988; Menefee & Katz, 2002). Chronic pain, or pain without apparent biological value persisting beyond the typical course of a disease or normal healing time for an injury (Turk & Melzack, 1992), is a frequent secondary problem associated with many disabilities including CP (Schwartz, Engel, & Jensen, 1999). Chronic pain may include persistent or ongoing pain as well as recurrent or episodic pain (American Pain Society [APS], 2002). Acute and chronic pain may be accompanied by physical manifestations related to the biological processes as well as short- and long-term emotional and psychosocial ramifications. Chronic pain can affect a person's mood, personality, and social relationships. Persons with chronic pain may also experience depression, sleep disturbance, fatigue, and decreased overall physical functioning (Ashburn & Staats, 1999; Zucconi & Bruni, 2001).

Pain assessment and management are receiving increasing attention and emphasis in healthcare provision. Pain is the fifth vital sign according to the APS (1995). In addition, the Joint Commission on Accreditation of Healthcare Organizations (2002) implemented new standards requiring healthcare professionals to be competent in pain assessment and management. To address the many factors influencing the experience of and adjustment to pain, a biopsychosocial model of pain has been developed. This model accounts for not only the fundamental biological factors related to pain but also psychosocial issues such as coping skills, familial response and support, and personal beliefs (Gatchel & Turk, 1999; Jensen, Turner, Romano, & Lawler, 1994; Novy, Nelson, Francis, & Turk, 1995).

The multifaceted nature and impact of pain including biological and psychosocial factors are evident in children (McGrath, 1990). Children may struggle to make sense of their pain experiences given their cognitive limitations, developing communication skills, inexperience with pain, and socio-environmental influences. Assessment and management of pain in children also is complicated by these factors (Gaffney & Dunne, 1986; McGrath). To fully understand and examine pain in children with CP, the various common medical and rehabilitative procedures or activities these children undergo (e.g., injections, range of motion exercises) must be taken into account, as well as the complex developmental, psychosocial, and environmental factors that influence their pain experiences.


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