A new reminder that pain hurts

The body of research regarding pain in children with cerebral palsy (CP) is small, but growing. The most recent study, by Ramstad et al.,1 highlights both the prevalence and impact of pain in this population. They found that over 67% of children reported recurrent pain and that mean pain intensity was greater than 5 on a 0 to 10 visual analogue scale. These data suggest that pain is common and that it can be severe. Given the nature of the pain children reported in their study, it is not surprising that it interfered with their daily lives, adding to the burden of their physical and intellectual impairments. Other studies have also examined the effects of pain on children with cerebral palsy through parent report or by questioning children directly. Houlihan et al.2 asked the parents of 198 children with CP aged 5 to 18 years to complete questionnaires. Their results indicated that pain was significantly related to the number of days children missed school and stayed in bed. In another study, Engel et al.3 interviewed 20 children with CP aged 6 to 17 years. Fourteen children reported bothersome pain in one or more body locations in the 3 months before the study and nine of these reported that pain was a problem for them. The children indicated that the greatest impact of pain was on physically demanding activities such as mobility, while less interference was reported for less demanding activities such as eating. They also found that pain caused problems with sleep. When Tervo et al.4 interviewed the parents of 77 children aged 3 to 17 years, they found similar results. Sixty-one percent reported that their child had pain in the past week and 33% reported that the pain interfered with normal activities including mobility, self-care, and participation in physical education. Finally, Varni et al.5 found that, based on both the self-report and parent-report of 77 children with CP, pain was related to all aspects of health-related quality of life, including physical and psychosocial health, emotional, social and school functioning, daily activities, school activities, movement and balance, fatigue, eating activities, and speech and communication. The results reported by Ramstad et al. concur with these previous studies. For the children studied here, pain not only had an impact on general activity, walking and sleep, but also was made worse by walking, running or being immobile. This suggests that children may avoid these activities, further reducing function. Thus, these new results add to the evidence that pain has a real impact on children with CP that has the potential to reduce function across multiple areas of their lives, reduce quality of life, and probably prevents children from reaching their full potential. Sadly, our knowledge that pain has a negative impact on children with CP is not new. In 1965, Reynell6 published a seminal study in this journal. Her observations of 50 children with CP after surgery constitute the first objective report of pain interfering with function in this group. The fact that studies today, 45 years later, are still finding negative effects of pain on children with CP speaks to the fact that either our attitudes towards pain or our practices in managing pain have not changed substantially in over four decades. Most pain related to CP can be treated effectively with well-tuned multi-disciplinary care. Thus, a great deal of the pain that these children experience can be managed with good care. For that reason, it is commendable that Ramstad et al. have once again reminded us that pain is common, severe, and influential in the lives of children with CP and that our efforts to relieve this unnecessary suffering must not stop.

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