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

Pain Assessment Issues in Children with CP

Little research exists concerning pain assessment in children with CP. Developmental differences such as cognition and ability to communicate significantly influence children's perception of and response to pain (McGrath, 1990). Motor, cognitive, and communication impairments complicate the task of appropriate pain assessment and should be considered when choosing instruments to evaluate pain. If a child with CP is unable to effectively use a self-report tool, overt responses to pain can be noted using observational rating or behavioral scales. Because pain and anxiety are difficult to separate in the clinical setting, the term "behavioral distress" is often used to capture the verbal, behavioral, and physiological indications of the inseparable elements of pain and anxiety (Katz, Kellerman, & Siegel, 1980; McGrath, 1990).

Pediatric pain assessment tools intended to measure overt behavioral distress are the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS; McGrath et al., 1985), the Observational Scale of Behavioral Distress (OSBD; Jay, Ozolins, Elliott, & Caldwell, 1983), and the Procedural Rating Scale-revised (Katz et al., 1980). Most of these scales have been developed for the assessment of acute pain in typically developing children. Increased attention has been paid to development of observational pain scales for persons with cognitive impairments and communication deficits (Breau, McGrath, Camfield, Rosmus, & Finley, 2000; Fanurik, Koh, Harrison, Conrad, & Tomerlin, 1998). Recently, Collignon and Giusiano (2001) developed a 10-item behavioral observation scale with demonstrated sensitivity and reliability when used with children with severe CP (Cronbach's (alpha) was 0.93 for internal scale coherence; Cohen's (k) ranged from 0.39 to 0.75 for between-expert consensus and 0.47 to 0.74 for consensus between the scale and the expert panel; sensitivity = 0.76-0.88 and specificity = 0.73-0.88). Items include observable behaviors such as crying, painful expression, protective responses, and moaning. Clinicians and researchers should be aware of these advancements and sensitive to the unique issues concerning pain assessment in children with CP.

Despite increasing interest and empirical evidence related to pain assessment and management in children with CP, questions remain unanswered, especially with respect to the occurrence and effect of ongoing painful experiences. Although literature concerning adults with CP suggests that pain is a common secondary condition for persons with CP and often begins in childhood (Schwartz et al., 1999; Turk et al., 1997), little is known about the pain experiences of children with CP from the child's perspective. Future research should explore not only the temporal descriptors and physiological markers of pain in children with CP (e.g., intensity, frequency, duration, muscle activity, heart rate), but also the functional effect of pain on children with CP in terms of activities of daily living, community participation, quality of life, socialization, active participation in rehabilitative activities, and psychological ramifications. Research concerning the potential differences in pain perception for those with and without a physical disability such as CP also is warranted. It will be important to examine the utility, validity, and reliability of appropriate assessment tools for children of all ages with CP. Consideration needs to be given to the parents' or caregivers' perspectives on the magnitude, scope, and management of their child's pain in order to better understand a child's global experience of pain, as well as implications for family life. Finally, the availability and efficacy of appropriate treatments, both pharmacological and nonpharmacological, should be investigated.


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