There is limited evidence supporting the current therapies used to manage pain in children and adolescents with cerebral palsy, according to a recent study.
Further research to explore multidisciplinary interventions for chronic pain and pain secondary to dystonia — involuntary muscle contractions — along with a standardized approach to pain assessment are necessary, the study said.
Pain is common among young people with cerebral palsy, with some studies reporting a prevalence as high as 75%. Pain status for these children has been shown to remain consistent (45%) or worsen (34%) between clinical visits.
Pain management in young people with cerebral palsy can be complex; pain can occur for many reasons, including muscle spasms, constipation and gastroesophageal reflux, but also because of the effect of certain cerebral palsy treatments, such as intramuscular botulinum neurotoxin A (BoNT-A) injections.
Impaired communication in this patient population can make it challenging to identify the presence and location of pain.
Current strategies to manage pain in young cerebral palsy patients lack research evidence supporting their use. To date, only two studies have addressed this issue, and both may be missing information, researchers noted.
Now, a team of Australian researchers has assessed the effectiveness of interventions on pain outcome measures in children and adolescents with cerebral palsy.
The team conducted a literature search in seven online databases, from the earliest date available to April 2018. Studies were included if they met these criteria: diagnosis of cerebral palsy, under age 18, intervention for the management of pain, outcome measure of pain, and studies published in English-language peer-reviewed journals.
Of the 223 studies identified in all databases, 57 were selected and categorized into five groups based on clinical factors: pain related to hypertonia — a condition characterized by muscle hardening — (17 studies), pain related to spastic hip disease — a condition that alters hip structure — (13 studies), procedural pain related to interventions for the management of cerebral palsy (seven studies), postoperative pain (18 studies) and other pain (two studies).
The studies were also divided according to the strength of their results, in a ranking system called level of evidence (LoE). The levels that make up the ranking vary among countries and, in this study, they range from level 1 (at least one properly designed randomized clinical trial) to level 5 (opinions of respected authorities, based on descriptive studies, clinical experience or reports of expert committees).
No studies were found on level 1, while 17, 5, 31 and 4 studies were found on levels 2, 3, 4, and 5, respectively. Quality assessment found two strong-quality studies, 12 moderate studies and eight weak studies.
The team found limited high-quality evidence supporting current pain management strategies.
The strongest evidence exists for pharmacological treatments for postoperative pain in children and adolescents with cerebral palsy.
There is moderate evidence for the efficacy of intrathecal (injection in the spinal cord) baclofen treatment for pain related to hypertonia in predominantly spastic (the most common type) and spastic-dyskinetic (associated with involuntary movements) cerebral palsy. Baclofen, a gamma-aminobutyric acid agonist, is a cost-effective muscle relaxer that also treats muscle spasms.
Researchers also found moderate evidence of non-pharmacological interventions for procedural pain interventions, including BoNT-A injections, acupuncture and venipuncture (typically used as analgesics).
These results emphasize the need for further research exploring multidisciplinary interventions for pain management. Moreover, researchers believe that clinicians would benefit from a standardized approach to pain assessment.
“Despite the growing research on pain in pediatric cerebral palsy, there is limited high-quality evidence to support current pain management. Children with chronic pain and pain secondary to dystonia critically require more attention,” researchers said.
“Established multidisciplinary approaches to pain management in other patient groups should be investigated, with a holistic understanding of the pain experience in the young person with cerebral palsy. Future research would benefit from prospective design with standardization in the measurement of pain,” they concluded.