Pain Assessment and Management in Children With Neurologic Impairment

Abstract

“How could I apply this information?” Pain, and in particular acute pain, in children has gained much attention during the last decennia. Currently, postsurgical pain and painful procedures are managed very differently. Pain management in children is a much-tailored procedure. It not only requires the careful consideration of the child's age and cognitive, communicative, physical, and psychological abilities, but it also requires the observation of the child's behavioral expressions, such as facial grimacing, sweating, withdrawals, and movements. Most of current literature deals with acute pain. Little is known about the pain that occurs during rehabilitative procedures. Reports indicate that one of the most salient negative memories of childhood in adults with neurologic impairment was the pain related to stretching and bracing by physical therapists. The authors performed a survey among practicing pediatric physical therapists to explore (1) the use of pain assessment tools and (2) the intervention strategies used to reduce pain during treatment of children with neurologic impairment. They found that more than 80% of the therapists reported using subjective measures to assess pain in this population. About 45% of the respondents used behavioral measures, whereas 40% used heart rate, oxygen saturation, and blood pressure as a physiological measure to assess pain. Next to these standardized measures, therapists also reported watching for irritability, crying, vocalizations, and facial grimacing. Distraction, procedural talk, and praise were most often used as a pain management strategy. For in-patients, referral to a child life specialist was suggested. The authors conclude that it appears that physical therapists rely on subjective observations to assess pain in children with neurologic impairments despite the availability of standardized behavioral assessments. They further conclude that a lack of awareness could explain this phenomenon. As an alternative explanation, they suggest that current behavioral tools are not conducive for use during real-time physical therapy sessions. “What should I be mindful about in applying this information?” The authors brought a relevant and clinically important problem to our attention. Too little is known about painful procedures in pediatric physical therapy practice. Many questions still need to be answered. What are painful procedures, are those evidence based, and, if not, can they be avoided? Also, when does the pain occur (during or after the procedure), and when does the pain wear off? Can procedures be changed so that they do not hurt? Is a pharmacologic cointervention possible? Finally, is hypnosis possible for those interventions? The study in question just touches a part of the problem. It is a first step in unraveling this question of pain in pediatric physical therapy. Unfortunately, the study is “underpowered” because of a very low response rate. More important, it is unclear whether the authors studied just children with cerebral palsy or children with a neurologic impairment and how this term was operationalized. Equally important to know is the way children were able to express themselves, as well as their underlying medical disorder. With this information, the authors could have analyzed pain behavior in subgroups of children. The merit, though, of this study is that it has brought an important and clinically relevant topic to our attention. Moreover, it clearly shows us that more studies are needed to be able to fully assess and manage pain due to painful procedures in pediatric physical therapy practice. Bart Bartels, PT, BSc, PCS Paul J. M. Helders, PT, PhD, MSc, PCS Faculty of Medicine, Division of Pediatrics, Utrecht University, Child Development and Exercise Center, University Children's Hospital and Medical Center, Utrecht, The Netherlands