Prevalence of chronic pain and associated factors among children with cerebral palsy attending the Child Neurology and Rehabilitation clinics at Mulago National Referral Hospital

Abstract

Background: Cerebral palsy (CP) is the most common cause of physical disability in childhood occurring in 1,8–2,3 cases per 1000 children in developed countries, in Uganda the prevalence of cerebral palsy is 2,7 per 1000 children, it is caused by a non-progressive brain lesion developing in the fetus or early childhood. Due to physical impairment, between 65 to 78% of children with cerebral palsy report painful processes. Currently there is no data about how common pain is in children with cerebral palsy in Uganda. It is also unknown what factors predispose or are associated with the pain and what complications are associated with the pain.

Methods: This was a hospital based cross-sectional survey to determine the prevalence of chronic pain, the severity of pain, co-morbidities of pain and describe associated factors among children with cerebral palsy attending the child neurology clinic and the cerebral palsy rehabilitation clinics of Mulago hospital. We enrolled 224 children ages 2 to 12 years with cerebral palsy between November 2017 to May 2018 whose parents or caregivers had given consent. Detailed history and examination were done for each participant. Motor function was assessed using Gross Motor Function Classification (GMFCS), we assessed as well Manual Ability Classification System (MACS), Communication Function Classification System (CFCS), Eating and Drinking Ability Classification (EADACS). Pain was assessed using the revised Face, Legs, Activity, Consolability, Cry (FLACC) pain scale for Children age ranges 2 -12 years. The revised FLACC scale questionnaires for children with CP were filled to determine the pain and the severity of pain. This instrument has been recognized to be reproducible, valid and reliable in assessing pain in children with CP not able to self-report pain. It has been used in Africa as well, precisely in a study done by Shabana et al in Egypt for assessing pain in children with CP. Each of the 5 components, (F) face, (L) legs, (A) activity, (C) cry, (C) consolability is scored from 0-2, resulting in a total score between 0&10. Interpreting the score: 0 relaxed& comfortable, 1-3 mild discomfort, 4-6 moderate pain, and 7- 10 severe pain. Multivariate logistic regression model was used to describe factors associated with pain.

Results: A total of 224 participants were recruited. The prevalence of chronic pain was 64.3%. Majority of participants had moderate pain compare to severe pain. Epilepsy (60.9%), behavioral problem (63.2%), hearing impairment (66,7%), learning problem (67,6%), Dental caries (75%), Gastroesophageal reflux (75%), Sleep disorders (79.5%), vision impairment (80%), Malnutrition (90%) were comorbid conditions of chronic pain in children with CP. The factors independently associated with chronic pain among children with cerebral palsy were gross motor function classification Level 4&5 (P- value 0.009), Communication function classification level 4&5 (P- value 0.044), eating and drinking ability classification system level 4&5 (P- value 0.008), female participants (P-value 0.024) and care giver age of more than 30 years (P- value 0.035).

Conclusion: Chronic pain is common among children with cerebral palsy in Uganda. Severe disability in term of GMFC (level 4&5), CFCS (level 4&5), EADACS (level 4&5) were associated with chronic pain among children with cerebral palsy.