CME Objectives: Upon completion of this article, the reader should be able to: (1) Cite current limitations in the literature regarding the assessment of stress and pain after treatment in children with CP; (2) Describe potential measures of stress and pain in children with CP undergoing treatment interventions; (3) Anticipate stress and pain in children with CP undergoing therapeutic interventions and implement appropriate treatment.
Level: Advanced Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)i. Physicians should only claim credit commensurate with the extent of their participation in the activity. Authors: Xiaoke Zhao, PhD Mengying Chen, PhD Senjie Du, MD Hongying Li, MD Xiaonan Li, MD, PhD
Cerebral Palsy
CME ARTICLE
.
2015 SERIES
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NUMBER 3
Evaluation of Stress and Pain in Young Children with Cerebral Palsy During Early Developmental Intervention Programs A Descriptive Study ABSTRACT Zhao X, Chen M, Du S, Li H, Li X: Evaluation of stress and pain in young children with cerebral palsy during early developmental intervention programs: a descriptive study. Am J Phys Med Rehabil 2015;94:169Y179.
Objective: The aim of this study was to use the Face, Legs, Activity, Cry, Consolability Scale; salivary cortisol levels; and withdrawal reflex thresholds to assess pain, stress, and pain sensitivity in young children with cerebral palsy during early developmental intervention programs.
Affiliations:
Design: A total of 40 children with cerebral palsy (age range, 1Y4 yrs) par-
From the Rehabilitation Department (XZ, SD, HL) and Department of Healthcare (MC, XL), Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China.
Correspondence: All correspondence and requests for reprints should be addressed to: Xiaonan Li, MD, PhD, Department of Healthcare, Nanjing Children’s Hospital Affiliated to Nanjing Medical University, 72 Guangzhou Rd, Nanjing 210008, China.
ticipated in the early intervention programs, which included neurodevelopmental treatment, neuromuscular electrical stimulation, occupational therapy, head acupuncture, and Chinese traditional manipulation five times per week for 3 wks. The Face, Legs, Activity, Cry, Consolability Scale was applied during the course of each treatment, and salivary cortisol samples were obtained from each child 10 mins before and 10 mins after each treatment. Withdrawal reflex thresholds were assessed via mechanical stimulation of the foot with von Frey hairs.
Results: All treatment programs caused some degree of pain. In descending
0894-9115/15/9403-0169 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
order, the extents of the pain caused by each treatment were head acupuncture, neurodevelopmental treatment, neuromuscular electrical stimulation, Chinese traditional manipulation, and occupational therapy. There were statistically significant increases in salivary cortisol levels after the head acupuncture (P G 0.001), neurodevelopmental treatment (P G 0.001), neuromuscular electrical stimulation (P G 0.001), and Chinese traditional manipulation (P G 0.001) treatments. No significant changes were found in the withdrawal reflex thresholds during the study (P 9 0.05).
DOI: 10.1097/PHM.0000000000000252
Conclusions: The results of this study demonstrate that early developmental intervention programs cause pain and stress in young children with cerebral palsy. Key Words:
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Cerebral Palsy, Pain, Stress, Treatment
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Disclosures: Supported by the Youth Foundation of the National Natural Science Foundation of China (No. 81202222), the Nanjing Medical Science and Technique Development Foundation (No. QRX11207), and the Scientific Development Fund of Nanjing Medical University (No. 2012NJMU066). Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
C
erebral palsy (CP) is thought to be the most common cause of severe cognitive and motor problems in childhood,1 and early developmental interventions aim to reduce these disabilities within the first several years of life early in the course of CP.2 Common therapeutic interventions include neurodevelopmental treatment (NDT), neuromuscular electrical stimulation (NMES), and occupational therapy (OT). Specifically in China, traditional Chinese medicines, such as head acupuncture (HA) and Chinese traditional manipulation (CTM), are widely used as medical interventions for CP in children.3,4 Unlike the chronic pain that is associated with spasticity, contractures, and bony deformities that result from spasticity in adults with CP, children with CP primarily experience pain during the intervention programs. Kibele5 found that one of the most salient negative memories of childhood among adults with CP is the pain related to the stretching and bracing that occurred during physical therapy. More recently, a multicenter investigation of pain in young people with CP that was conducted by Parkinson and colleagues6 found that nearly half of young people who had received physiotherapy had experienced pain during therapy, and 6% reported severe or very severe pain. Pain is a secondary problem in children with CP that increases the negative effects of the disease both physically and mentally. Typically, children with pain express higher levels of anxiety and depression.7 Moreover, persistent pain is associated with a range of negative outcomes (e.g., reduced participation, psychologic distress, and lower quality-of-life) for individuals with disabilities including CP.8 Stress is commonly defined as the physiologic and psychologic reactions that mobilize an organism’s defense against external or internal threats (i.e., stressors). The stress reaction includes the activation of the hypothalamus-pituitary-adrenal axis and the subsequent release of cortisol.9 Salivary cortisol level is routinely considered to be a reliable and noninvasive
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measure of hypothalamus-pituitary-adrenal adaptation to stress.10 Although the important first step of identifying pain during therapy as a potential issue for children with CP occurred in recent years,6,11Y14 the few relevant studies are limited to memories and perceptions of pain; researchers have not described the degrees of pain or other characteristics of pain that are caused by intervention programs. Thus, the purpose of this study was to use salivary cortisol levels; the Face, Legs, Activity, Cry, Consolability Scale; and the withdrawal reflex thresholds (WRTs) to assess stress, pain, and pain sensitivity in young children with CP during early developmental intervention programs.
METHODS Participants The participants were recruited between February 2012 and December 2013 from the inpatient department of rehabilitation of the Nanjing Children’s Hospital, which is a tertiary care center affiliated with the Nanjing Medical University in southeast China. To be eligible for the study, the patients were required to meet the following criteria: (1) aged between 1 and 4 yrs, (2) diagnosed with CP, and (3) able to accept and comply with the treatment strategy. The exclusion criteria were as follows: (1) unstable seizures, (2) any surgery or botulinum toxin injections in the preceding 6 mos, (3) any other diseases associated with chronic pain, and (4) the presence of a major congenital abnormality that hindered cooperation. The parents or guardians of all participating children signed the informed consent, and this study was approved by the Medical Ethics Committee of Nanjing Medical University. The patients were divided into two groups based on the type of abnormal muscle tone, that is, a spastic group (n = 21, spastic CP classification) and a nonspastic group (n = 19; ataxic, dystonic, or choreoathetosic CP classification).
Clinical Management and Procedures For 3 wks, each child received a conventional therapy program consisting of NDT, NMES, OT, HA, and CTM once per day 5 days per week. During the first week, the first treatment of each day was randomized and different from the other days. A representative illustration is given in Figure 1.
Pain Assessment Self-report is the criterion standard of pain assessment. However, von Baeyer15 identified self-report
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FIGURE 1 A representative illustration of the schedule in the first week. as problematic in children, particularly children with cognitive impairments. The Face, Legs, Activity, Cry, Consolability Scale behavioral pain assessment scale was developed to quantify the pain behaviors of young children who cannot provide self-reports.16 This scale includes five indicators (face, legs, activity, crying, and consolability), and each item is ranked in severity on a scale from 0 to 2 based on behavioral descriptions to produce a total score between 0 and 10.16 This tool can be used with children ranging in age from 2 mos to 7 yrs17 and has been shown to have high levels of reliability and validity.18,19 The assessments were performed during the first treatment each day in the first week. One independent research assistant performed all assessments and data entry. The assistant sat in the next room behind a coated glass and was unobserved by the children.
Stress Assessment Saliva samples were collected from each child 10 mins before and 10 mins after the first treatment program at 7:50 a.m. and 9:00 a.m., respectively, on each of the initial five days. The first sample represents the child’s initial level of stress before the intervention program, and the second sample represents the child’s stress response to the intervention program. The baseline samples were obtained on the second nonprocedural weekend day at 7:50 a.m. and 9:00 a.m. (i.e., the same times at which samples were acquired on the procedural days). Because of poor cognition and cooperation, the chew technique typically used with the Salivette system of collecting salivary cortisol was not suitable for some of the children with CP. Therefore, an alternative collection method was adapted. The children were allowed to view videos on an iPad that showed close-up views of people eating delicious foods. When the child salivated as a result of conditioned reflexes, the cotton pad of the Salivette system was placed in the child’s mouth for a few seconds to absorb the saliva. Cortisol concentrations in the saliva were measured via electrochemiluminescence immunoassay using the Cobas Salivary Kit on an Elecsys 2010 www.ajpmr.com
immunoanalyser system (Roche, Germany) in the Biochemical Laboratory of Nanjing Children’s Hospital. All samples were assayed in duplicate. The laboratory reports indicated intra-assay coefficients of variation between 4.52% and 6.21% as well as interassay coefficients of variation between 6.78% and 8.57%.
Assessment of Pain Sensitivity Pain sensitivity was investigated using the WRTs induced by von Frey hairs mechanical stimulation of the foot. The range of force of the von Frey hairs and measurement procedure were similar to those described by Slater et al.20 Beginning with the smallest hair (0.096 g) and with the use of increasing force delivered by calibrated von Frey hairs, each hair was applied to the plantar surface of the foot five times at 60-sec intervals. Both sides of the body were measured and analyzed. The measurements were performed at baseline and 3 wks after intervention. The WRTs were defined as the stimulus intensity at which visible withdrawal movements of the limb away from the stimulus occurred in at least three of five occasions.
Statistical Analyses All analyses were performed with the SPSS software (version 19.0 for Windows). The KolmogorovSmirnov test was used to test the normality of the distribution, and all variables showed normal distribution. Cortisol levels and Face, Legs, Activity, Cry, Consolability Scale assessments were analyzed with repeated-measures one-way analyses of variance followed by Tukey tests, and independent t tests were used to examine the between-group differences. Paired t tests were applied to examine the baselinepostintervention differences in the cortisol levels and WRTs data. Significance was considered at P G 0.05.
RESULTS A total of 51 children were eligible to participate during the study period. Parents declined participation for seven children, and four children dropped out because of refusal to saliva collection. Evaluation of Stress and Pain in Children with CP
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TABLE 1 Demographic characteristics of the study participants Groups Parameter
Spastic Group
Nonspastic Group
All
P (t Test/W2)
28.67 (9.49)
25.74 (9.72)
27.28 (9.59)
0.34 0.35
13 8
10 9
23 17
7 10 4 0
9 7 2 1
16 17 6 1
21 V V V
V 5 12 2
21 5 12 2
Age, mos Sex Male Female GMFCS levels Level I Level II Level III Level IV CP subtype Spastic Ataxic Dystonic Choreoathetosic
0.50
V
GMFCS, Gross Motor Function Classification System.
Thus, 40 children were finally included in the analysis. As demonstrated in Table 1, the children were aged between 1 and 4 yrs, and most were distributed across Gross Motor Function Classification System levels IYIII.
Pain Assessment Nearly all children exhibited pain during the course of intervention. The greatest pain incidence was 100.00% for the HA, and the lowest incidence was 60.00% on the OT. In descending order, the magnitude of the pain induced by the five intervention programs was HA, NDT, NMES, CTM, and OT (Table 2). The extent of the pain experienced by the spastic group was higher than that by the nonspastic group, and this difference was statistically significant for the NDT (t = j3.500, P G 0.001).
were too small to analyze and resulted in data loss, only matched data were included in the statistical analysis. Two children were excluded from the analysis of the HA, one from the analysis of the NMES and one from the analysis of the OT. The mean cortisol levels obtained after the treatments were higher than those obtained on the baseline day at the same time. Significant posttreatment increases were observed for the HA (t = j15.364, P G 0.001), NDT (t = j12.488, P G 0.001), NMES (t = j11.640, P G 0.001), and CTM (t = j 4.878, P G 0.001) compared with pretreatment (Table 3). There were no statistically significant differences in the mean salivary cortisol values acquired before and after the treatment between the spastic group and the nonspastic group.
Pain Sensitivity Stress Responsiveness Because of several reasons, such as missed time points of collection as well as salivary samples that
After the intervention, there were no significant changes in pain sensitivity across all of the children. When the results were divided into the
TABLE 2 The pain assessments in different items Item HA NDT NMES CTM OT
Total (n = 40) A
7.08 (2.49) 5.10 (2.76)BF 3.98 (3.06)CFG 2.88 (1.98)DG 2.60 (2.57)EG
Spastic Group (n = 21)
Nonspastic Group (n = 19)
Incidence
7.24 (2.21) 6.38 (2.40)a 4.05 (2.92) 3.33 (2.08) 2.95 (2.66)
6.89 (2.81) 3.68 (2.47) 3.89 (3.28) 2.37 (1.77) 2.21 (2.49)
100.00% 92.50% 82.50% 72.50% 60.00%
The data are expressed as mean (SD). Capital letters indicate between-item comparison; means having different capital letters are significant (P G 0.05) and same letters are not significant. a Indicates differences between the two groups (P G 0.05).
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TABLE 3 The salivary cortisol levels before and after the intervention items and compared with baseline
Time
Intervention Items
Baseline (n = 40)
HA (n = 38) NDT (n = 40) NMES (n = 39) CTM (n = 40) OT (n = 39)
Before intervention 8.01 (0.79) 8.34 (0.81) 8.28 (0.69) After intervention 7.18 (0.76) 10.38 (1.26)a 9.47 (0.83)a Percentage of change j10.17 (7.00) 24.88 (10.14) 14.60 (8.06) P G0.001 G0.001 G0.001
8.29 (0.80) 9.34 (0.79)a 13.40 (9.04) G0.001
8.19 (0.79) 8.69 (0.78)a 6.62 (9.32) G0.001
8.21 (0.82) 8.28 (0.98)a 1.10 (8.47) = 0.483
The data are expressed as mean (SD). a Indicates significant difference between baseline and posttreatment with P G 0.001.
groups of spastic and nonspastic children, there were still no changes (Table 4).
DISCUSSION This is, to the authors’ knowledge, the first study that rated pain intensity and dealt with cortisol hormone during procedural interventions, and the findings from this study have important implications for delivering pain interventions when treating children with CP. The authors’ choice to use the first treatment of the day for the time point of pain assessment and saliva collection was based on two considerations. First, the children underwent a number of interventions each day, and the cumulative effect needed to be considered. Second, cortical levels exhibit a pattern of circadian fluctuations, so this choice of time point reduced the risk for confounding biases. Because of ethical restrictions, the circadian patterns of cortisol secretion, and the potential effects of time, this study evaluated pain and salivary cortisol specimens at the same time of the first treatment each day to maximally reduce interference between the various treatment programs and reduce bias. Cortisol is one of the major glucocorticoids that are produced by the adrenal cortex, and cortisol secretion increases when hypothalamus-pituitaryadrenal axis activity increases in response to psychologic stress. Thus, salivary cortisol has been identified as an objective biologic marker of stress responses.10 However, cortisol is responsive to a wide range of factors that should be considered when
collecting and measuring salivary cortisol in children. In this study, the specific strategies that were used to control for extraneous variables were described by Hanrahan et al.21 and included collecting samples at consistent times, the avoidance of food for 30 mins before sampling, and others. Although the reported efficacies of these treatments are not consistent,22Y25 acupuncture and massage are two techniques that are commonly used for the treatment of CP in China. The findings of this study indicated that HA, which involves the insertion of a needle into the injured tissue, led to the worst pain and that the pain caused by OT was relatively minor. This information should guide clinicians in prioritybased pain management. The participants in the spastic group experienced more pain after NDT. This is probably because, since the spastic group exhibited abnormally high muscle tone, children were prone to more passive stretching techniques and range-of-motion manipulations than the nonspastic group, and according to previous research, stretching and range of motion were frequently identified as painful procedures by both children and their families.11,26 At baseline, salivary cortisol decreased with time, which could be attributed to the effects of the circadian rhythm of cortisol secretion. On the HA, NDT, NMES, and CTM items, salivary cortisol increased after treatment, suggesting that, similar to intravenous insertion27 and acute injury,28 these intervention programs were also stressors that caused significant cortisol responses. Although the
TABLE 4 WRTs at Baseline and at 3 wks Time Baseline 3 wks P
Total (n = 40)
Spastic Group (n = 21)
Nonspastic Group (n = 19)
1.58 (0.86) 1.60 (0.83) 90.05
1.63 (0.98) 1.61 (0.97) 90.05
1.52 (0.71) 1.58 (0.66) 90.05
The data are expressed as mean (SD).
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salivary cortisol levels were slightly higher after OT, this difference was not statistically significant. OT training programs in young children with CP focus on fine motor skills such as hand movements, use of arms, and eye-hand coordination. In view of this technique highlighting the importance of children’s self-initiated activity, therapists often use a friendly approach to increase children’s motivation, which may explain the less pain and stress in OT. Stress and pain are different at the behavioral, cellular, and molecular levels, but these two responses are closely related and overlap to a large extent.29 This argument was corroborated by the present results, which indicated that the pain intensities caused by the intervention treatments were generally consistent with the increased levels of salivary cortisol. Moreover, salivary cortisol can be used as a biologic indicator of pain and stress during rehabilitation intervention. In the future, clinics might use this measure to determine whether pain interventions should be provided. The authors were unable to identify significant baseline-postintervention changes in pain sensitivity in this study. Therefore, the results imply that the pain intensities induced by intervention programs do not affect pain sensitivity. However, a collection of clinical and animal studies suggest that repetitive or prolonged pain during early development leads to long-term changes in neural circuitry and behavior.20,30 Further study is needed on the adverse effects of therapeutic pain. Although the present study fills some gaps in the understanding of the incidences and levels of pain during procedural interventions, the results should be considered with several limitations. First, the heterogeneity of the CP individuals limits the consistency of treatment parameters in terms of content, focus, and intensity within clinical practices, and different treatment parameters will induce varying incidences and degrees of pain. To some extent, the conclusions of this study need to be interpreted cautiously. Second, the pain assessments were performed during the entire time course of the procedural interventions, but the durations of pain varied for each treatment; thus, further studies should account for this dynamic factor.
ACKNOWLEDGMENTS
The authors thank the children and their parents, who generously participated in this study, and Yan Song for her contribution to data collection. REFERENCES 1. Surveillance of Cerebral Palsy in Europe (SCPE): Surveillance of cerebral palsy in Europe: A collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol 2000;42:816Y24 2. Spittle A, Orton J, Anderson P, et al: Early developmental intervention programmes post-hospital discharge to prevent motor and cognitive impairments in preterm infants. Cochrane Database Syst Rev 2012;12:CD005495 3. Liu L, Liu LG, Lu M, et al: Clinical observation on infantile cerebral palsy treated with quick meridian needling therapy plus scalp acupuncture. Zhongguo Zhen Jiu 2010;30:826Y9 4. Zhou XJ, Zheng K: Treatment of 140 cerebral palsied children with a combined method based on traditional Chinese medicine (TCM) and western medicine. J Zhejiang Univ Sci B 2005;6:57Y60 5. Kibele A: Occupational therapy’s role in improving the quality of life for persons with cerebral palsy. Am J Occup Ther 1989;43:371Y7 6. Parkinson KN, Dickinson HO, Arnaud C, et al: Pain in young people aged 13 to 17 years with cerebral palsy: Cross-sectional, multicentre European study. Arch Dis Child 2013;98:434Y40 7. Simons LE, Sieberg CB, Claar RL: Anxiety and impairment in a large sample of children and adolescents with chronic pain. Pain Res Manag 2012;17:93Y7 8. Ehde DM, Jensen MP, Engel JM, et al: Chronic pain secondary to disability: A review. Clin J Pain 2003; 19:3Y17
CONCLUSIONS
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intensity of pain of the spastic group was statistically greater than that of the nonspastic group during the NDT. 2. The rehabilitative intervention treatments caused varying degrees of stress in the CP children as indicated by the salivary cortisol levels, and the stress and pain levels were essentially basically consistent. 3. No statistically significant changes were identified in pain sensitivity after the early developmental intervention programs.
The following conclusions were reached in this study:
9. Doepel M, Soderling E, Ekberg EL, et al: Salivary cortisol and IgA levels in patients with myofascial pain treated with occlusal appliances in the short term. J Oral Rehabil 2009;36:210Y6
1. The majority of the children experienced pain during the entire course of the early developmental intervention programs. Moreover, the
10. Hellhammer DH, Wust S, Kudielka BM: Salivary cortisol as a biomarker in stress research. Psychoneuroendocrinology 2009;34:163Y71
Zhao et al.
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11. Hadden KL, von Baeyer CL: Pain in children with cerebral palsy: Common triggers and expressive behaviors. Pain 2002;99:281Y8
21. Hanrahan K, McCarthy AM, Kleiber C, et al: Strategies for salivary cortisol collection and analysis in research with children. Appl Nurs Res 2006;19:95Y101
12. Swiggum M, Hamilton ML, Gleeson P, et al: Pain in children with cerebral palsy: Implications for pediatric physical therapy. Pediatr Phys Ther 2010;22:86Y92
22. Yu HB, Liu YF, Wu LX: Acupuncture combined with music therapy for treatment of 30 cases of cerebral palsy. J Tradit Chin Med 2009;29:243Y8
13. Swiggum M, Hamilton ML, Gleeson P, et al: Pain assessment and management in children with neurologic impairment: A survey of pediatric physical therapists. Pediatr Phys Ther 2010;22:330Y5
23. Wang SQ, Liang WX, Huang GH, et al: Randomized controlled clinical trials for acupuncture treatment of spastic cerebral palsy children by bilateral horizontal puncturing from Yuzhen (BL 9) to Tianzhu (BL 10). Zhen Ci Yan Jiu 2011;36:215Y9
14. Parkinson KN, Gibson L, Dickinson HO, et al: Pain in children with cerebral palsy: A cross-sectional multicentre European study. Acta Paediatr 2010; 99:446Y51 15. von Baeyer CL: Children’s self-reports of pain intensity: Scale selection, limitations and interpretation. Pain Res Manag 2006;11:157Y62 16. Merkel SI, Voepel-Lewis T, Shayevitz JR, et al: The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293Y7 17. O’Rourke D: The measurement of pain in infants, children, and adolescents: From policy to practice. Phys Ther 2004;84:560Y70 18. Voepel-Lewis T, Zanotti J, Dammeyer JA, et al: Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care 2010;19:55Y61; quiz 2 19. Bai J, Hsu L, Tang Y, et al: Validation of the COMFORT Behavior scale and the FLACC scale for pain assessment in Chinese children after cardiac surgery. Pain Manag Nurs 2012;13:18Y26 20. Slater R, Cantarella A, Gallella S, et al: Cortical pain responses in human infants. J Neurosci 2006;26:3662Y6
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24. Macgregor R, Campbell R, Gladden MH, et al: Effects of massage on the mechanical behaviour of muscles in adolescents with spastic diplegia: A pilot study. Dev Med Child Neurol 2007;49:187Y91 25. Glew GM, Fan MY, Hagland S, et al: Survey of the use of massage for children with cerebral palsy. Int J Ther Massage Bodywork 2010;3:10Y5 26. Hadden KL, von Baeyer CL: Global and specific behavioral measures of pain in children with cerebral palsy. Clin J Pain 2005;21:140Y6 27. McCarthy AM, Hanrahan K, Kleiber C, et al: Normative salivary cortisol values and responsivity in children. Appl Nurs Res 2009;22:54Y62 28. Brown NJ, Kimble RM, Rodger S, et al: Biological markers of stress in pediatric acute burn injury. Burns 2014;40:887Y95 29. Kumar A, Goswami L, Goswami C: Importance of TRP channels in pain: Implications for stress. Front Biosci 2013;5:19Y38 30. Anand KJ: Pain, plasticity, and premature birth: A prescription for permanent suffering? Nat Med 2000; 6:971Y3
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CME Self-Assessment Exam Questions CME Article 2015 Series Number 3: Zhao et al. 1. Current limitations in the literature regarding the assessment of stress and pain after treatment in children with CP include: A. Few relevant studies B. Studies are limited to memories and perceptions of pain C. The degree and character of pain have not been assessed D. All of the above
4. In this study, stress response as measured by significant posttreatment increases in mean salivary cortisol levels occurred after which treatment? A. Head acupuncture (HA) B. Neurodevelopmental treatment (NDT) C. Neuromuscular electrical stimulation (NMES) D. All of the above
2. Which of the following treatments did not result in a significant increase in salivary cortisol levels? A. Neurodevelopmental therapy (NDT) B. Neuromuscular electrical stimulation (NMES) C. Occupational therapy (OT) D. Chinese traditional manipulation (CTM)
5. In this study, which is the most likely reason that the pain of spastic patients was statistically greater than that of nonspastic subjects during the neurodevelopmental treatment (NDT)? A. Passive stretching training B. Sit-to-stand training C. Strength training D. All of the above
3. In this study, the greatest pain incidence in children was noted after which treatment? A. Neurodevelopmental treatment (NDT) B. Head acupuncture (HA) C. Neuromuscular electrical stimulation (NMES) D. Occupational therapy (OT)
(Continued next page)
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Level: Advanced Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)i. Physicians should only claim credit commensurate with the extent of their participation in the activity. Authors: Xiaoke Zhao, PhD Mengying Chen, PhD Senjie Du, MD Hongying Li, MD Xiaonan Li, MD, PhD
Cerebral Palsy
CME ARTICLE
.
2015 SERIES
.
NUMBER 3
Evaluation of Stress and Pain in Young Children with Cerebral Palsy During Early Developmental Intervention Programs A Descriptive Study ABSTRACT Zhao X, Chen M, Du S, Li H, Li X: Evaluation of stress and pain in young children with cerebral palsy during early developmental intervention programs: a descriptive study. Am J Phys Med Rehabil 2015;94:169Y179.
Objective: The aim of this study was to use the Face, Legs, Activity, Cry, Consolability Scale; salivary cortisol levels; and withdrawal reflex thresholds to assess pain, stress, and pain sensitivity in young children with cerebral palsy during early developmental intervention programs.
Affiliations:
Design: A total of 40 children with cerebral palsy (age range, 1Y4 yrs) par-
From the Rehabilitation Department (XZ, SD, HL) and Department of Healthcare (MC, XL), Nanjing Children’s Hospital Affiliated to Nanjing Medical University, Nanjing, China.
Correspondence: All correspondence and requests for reprints should be addressed to: Xiaonan Li, MD, PhD, Department of Healthcare, Nanjing Children’s Hospital Affiliated to Nanjing Medical University, 72 Guangzhou Rd, Nanjing 210008, China.
ticipated in the early intervention programs, which included neurodevelopmental treatment, neuromuscular electrical stimulation, occupational therapy, head acupuncture, and Chinese traditional manipulation five times per week for 3 wks. The Face, Legs, Activity, Cry, Consolability Scale was applied during the course of each treatment, and salivary cortisol samples were obtained from each child 10 mins before and 10 mins after each treatment. Withdrawal reflex thresholds were assessed via mechanical stimulation of the foot with von Frey hairs.
Results: All treatment programs caused some degree of pain. In descending
0894-9115/15/9403-0169 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
order, the extents of the pain caused by each treatment were head acupuncture, neurodevelopmental treatment, neuromuscular electrical stimulation, Chinese traditional manipulation, and occupational therapy. There were statistically significant increases in salivary cortisol levels after the head acupuncture (P G 0.001), neurodevelopmental treatment (P G 0.001), neuromuscular electrical stimulation (P G 0.001), and Chinese traditional manipulation (P G 0.001) treatments. No significant changes were found in the withdrawal reflex thresholds during the study (P 9 0.05).
DOI: 10.1097/PHM.0000000000000252
Conclusions: The results of this study demonstrate that early developmental intervention programs cause pain and stress in young children with cerebral palsy. Key Words:
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Cerebral Palsy, Pain, Stress, Treatment
Evaluation of Stress and Pain in Children with CP Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Disclosures: Supported by the Youth Foundation of the National Natural Science Foundation of China (No. 81202222), the Nanjing Medical Science and Technique Development Foundation (No. QRX11207), and the Scientific Development Fund of Nanjing Medical University (No. 2012NJMU066). Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
C
erebral palsy (CP) is thought to be the most common cause of severe cognitive and motor problems in childhood,1 and early developmental interventions aim to reduce these disabilities within the first several years of life early in the course of CP.2 Common therapeutic interventions include neurodevelopmental treatment (NDT), neuromuscular electrical stimulation (NMES), and occupational therapy (OT). Specifically in China, traditional Chinese medicines, such as head acupuncture (HA) and Chinese traditional manipulation (CTM), are widely used as medical interventions for CP in children.3,4 Unlike the chronic pain that is associated with spasticity, contractures, and bony deformities that result from spasticity in adults with CP, children with CP primarily experience pain during the intervention programs. Kibele5 found that one of the most salient negative memories of childhood among adults with CP is the pain related to the stretching and bracing that occurred during physical therapy. More recently, a multicenter investigation of pain in young people with CP that was conducted by Parkinson and colleagues6 found that nearly half of young people who had received physiotherapy had experienced pain during therapy, and 6% reported severe or very severe pain. Pain is a secondary problem in children with CP that increases the negative effects of the disease both physically and mentally. Typically, children with pain express higher levels of anxiety and depression.7 Moreover, persistent pain is associated with a range of negative outcomes (e.g., reduced participation, psychologic distress, and lower quality-of-life) for individuals with disabilities including CP.8 Stress is commonly defined as the physiologic and psychologic reactions that mobilize an organism’s defense against external or internal threats (i.e., stressors). The stress reaction includes the activation of the hypothalamus-pituitary-adrenal axis and the subsequent release of cortisol.9 Salivary cortisol level is routinely considered to be a reliable and noninvasive
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measure of hypothalamus-pituitary-adrenal adaptation to stress.10 Although the important first step of identifying pain during therapy as a potential issue for children with CP occurred in recent years,6,11Y14 the few relevant studies are limited to memories and perceptions of pain; researchers have not described the degrees of pain or other characteristics of pain that are caused by intervention programs. Thus, the purpose of this study was to use salivary cortisol levels; the Face, Legs, Activity, Cry, Consolability Scale; and the withdrawal reflex thresholds (WRTs) to assess stress, pain, and pain sensitivity in young children with CP during early developmental intervention programs.
METHODS Participants The participants were recruited between February 2012 and December 2013 from the inpatient department of rehabilitation of the Nanjing Children’s Hospital, which is a tertiary care center affiliated with the Nanjing Medical University in southeast China. To be eligible for the study, the patients were required to meet the following criteria: (1) aged between 1 and 4 yrs, (2) diagnosed with CP, and (3) able to accept and comply with the treatment strategy. The exclusion criteria were as follows: (1) unstable seizures, (2) any surgery or botulinum toxin injections in the preceding 6 mos, (3) any other diseases associated with chronic pain, and (4) the presence of a major congenital abnormality that hindered cooperation. The parents or guardians of all participating children signed the informed consent, and this study was approved by the Medical Ethics Committee of Nanjing Medical University. The patients were divided into two groups based on the type of abnormal muscle tone, that is, a spastic group (n = 21, spastic CP classification) and a nonspastic group (n = 19; ataxic, dystonic, or choreoathetosic CP classification).
Clinical Management and Procedures For 3 wks, each child received a conventional therapy program consisting of NDT, NMES, OT, HA, and CTM once per day 5 days per week. During the first week, the first treatment of each day was randomized and different from the other days. A representative illustration is given in Figure 1.
Pain Assessment Self-report is the criterion standard of pain assessment. However, von Baeyer15 identified self-report
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FIGURE 1 A representative illustration of the schedule in the first week. as problematic in children, particularly children with cognitive impairments. The Face, Legs, Activity, Cry, Consolability Scale behavioral pain assessment scale was developed to quantify the pain behaviors of young children who cannot provide self-reports.16 This scale includes five indicators (face, legs, activity, crying, and consolability), and each item is ranked in severity on a scale from 0 to 2 based on behavioral descriptions to produce a total score between 0 and 10.16 This tool can be used with children ranging in age from 2 mos to 7 yrs17 and has been shown to have high levels of reliability and validity.18,19 The assessments were performed during the first treatment each day in the first week. One independent research assistant performed all assessments and data entry. The assistant sat in the next room behind a coated glass and was unobserved by the children.
Stress Assessment Saliva samples were collected from each child 10 mins before and 10 mins after the first treatment program at 7:50 a.m. and 9:00 a.m., respectively, on each of the initial five days. The first sample represents the child’s initial level of stress before the intervention program, and the second sample represents the child’s stress response to the intervention program. The baseline samples were obtained on the second nonprocedural weekend day at 7:50 a.m. and 9:00 a.m. (i.e., the same times at which samples were acquired on the procedural days). Because of poor cognition and cooperation, the chew technique typically used with the Salivette system of collecting salivary cortisol was not suitable for some of the children with CP. Therefore, an alternative collection method was adapted. The children were allowed to view videos on an iPad that showed close-up views of people eating delicious foods. When the child salivated as a result of conditioned reflexes, the cotton pad of the Salivette system was placed in the child’s mouth for a few seconds to absorb the saliva. Cortisol concentrations in the saliva were measured via electrochemiluminescence immunoassay using the Cobas Salivary Kit on an Elecsys 2010 www.ajpmr.com
immunoanalyser system (Roche, Germany) in the Biochemical Laboratory of Nanjing Children’s Hospital. All samples were assayed in duplicate. The laboratory reports indicated intra-assay coefficients of variation between 4.52% and 6.21% as well as interassay coefficients of variation between 6.78% and 8.57%.
Assessment of Pain Sensitivity Pain sensitivity was investigated using the WRTs induced by von Frey hairs mechanical stimulation of the foot. The range of force of the von Frey hairs and measurement procedure were similar to those described by Slater et al.20 Beginning with the smallest hair (0.096 g) and with the use of increasing force delivered by calibrated von Frey hairs, each hair was applied to the plantar surface of the foot five times at 60-sec intervals. Both sides of the body were measured and analyzed. The measurements were performed at baseline and 3 wks after intervention. The WRTs were defined as the stimulus intensity at which visible withdrawal movements of the limb away from the stimulus occurred in at least three of five occasions.
Statistical Analyses All analyses were performed with the SPSS software (version 19.0 for Windows). The KolmogorovSmirnov test was used to test the normality of the distribution, and all variables showed normal distribution. Cortisol levels and Face, Legs, Activity, Cry, Consolability Scale assessments were analyzed with repeated-measures one-way analyses of variance followed by Tukey tests, and independent t tests were used to examine the between-group differences. Paired t tests were applied to examine the baselinepostintervention differences in the cortisol levels and WRTs data. Significance was considered at P G 0.05.
RESULTS A total of 51 children were eligible to participate during the study period. Parents declined participation for seven children, and four children dropped out because of refusal to saliva collection. Evaluation of Stress and Pain in Children with CP
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TABLE 1 Demographic characteristics of the study participants Groups Parameter
Spastic Group
Nonspastic Group
All
P (t Test/W2)
28.67 (9.49)
25.74 (9.72)
27.28 (9.59)
0.34 0.35
13 8
10 9
23 17
7 10 4 0
9 7 2 1
16 17 6 1
21 V V V
V 5 12 2
21 5 12 2
Age, mos Sex Male Female GMFCS levels Level I Level II Level III Level IV CP subtype Spastic Ataxic Dystonic Choreoathetosic
0.50
V
GMFCS, Gross Motor Function Classification System.
Thus, 40 children were finally included in the analysis. As demonstrated in Table 1, the children were aged between 1 and 4 yrs, and most were distributed across Gross Motor Function Classification System levels IYIII.
Pain Assessment Nearly all children exhibited pain during the course of intervention. The greatest pain incidence was 100.00% for the HA, and the lowest incidence was 60.00% on the OT. In descending order, the magnitude of the pain induced by the five intervention programs was HA, NDT, NMES, CTM, and OT (Table 2). The extent of the pain experienced by the spastic group was higher than that by the nonspastic group, and this difference was statistically significant for the NDT (t = j3.500, P G 0.001).
were too small to analyze and resulted in data loss, only matched data were included in the statistical analysis. Two children were excluded from the analysis of the HA, one from the analysis of the NMES and one from the analysis of the OT. The mean cortisol levels obtained after the treatments were higher than those obtained on the baseline day at the same time. Significant posttreatment increases were observed for the HA (t = j15.364, P G 0.001), NDT (t = j12.488, P G 0.001), NMES (t = j11.640, P G 0.001), and CTM (t = j 4.878, P G 0.001) compared with pretreatment (Table 3). There were no statistically significant differences in the mean salivary cortisol values acquired before and after the treatment between the spastic group and the nonspastic group.
Pain Sensitivity Stress Responsiveness Because of several reasons, such as missed time points of collection as well as salivary samples that
After the intervention, there were no significant changes in pain sensitivity across all of the children. When the results were divided into the
TABLE 2 The pain assessments in different items Item HA NDT NMES CTM OT
Total (n = 40) A
7.08 (2.49) 5.10 (2.76)BF 3.98 (3.06)CFG 2.88 (1.98)DG 2.60 (2.57)EG
Spastic Group (n = 21)
Nonspastic Group (n = 19)
Incidence
7.24 (2.21) 6.38 (2.40)a 4.05 (2.92) 3.33 (2.08) 2.95 (2.66)
6.89 (2.81) 3.68 (2.47) 3.89 (3.28) 2.37 (1.77) 2.21 (2.49)
100.00% 92.50% 82.50% 72.50% 60.00%
The data are expressed as mean (SD). Capital letters indicate between-item comparison; means having different capital letters are significant (P G 0.05) and same letters are not significant. a Indicates differences between the two groups (P G 0.05).
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TABLE 3 The salivary cortisol levels before and after the intervention items and compared with baseline
Time
Intervention Items
Baseline (n = 40)
HA (n = 38) NDT (n = 40) NMES (n = 39) CTM (n = 40) OT (n = 39)
Before intervention 8.01 (0.79) 8.34 (0.81) 8.28 (0.69) After intervention 7.18 (0.76) 10.38 (1.26)a 9.47 (0.83)a Percentage of change j10.17 (7.00) 24.88 (10.14) 14.60 (8.06) P G0.001 G0.001 G0.001
8.29 (0.80) 9.34 (0.79)a 13.40 (9.04) G0.001
8.19 (0.79) 8.69 (0.78)a 6.62 (9.32) G0.001
8.21 (0.82) 8.28 (0.98)a 1.10 (8.47) = 0.483
The data are expressed as mean (SD). a Indicates significant difference between baseline and posttreatment with P G 0.001.
groups of spastic and nonspastic children, there were still no changes (Table 4).
DISCUSSION This is, to the authors’ knowledge, the first study that rated pain intensity and dealt with cortisol hormone during procedural interventions, and the findings from this study have important implications for delivering pain interventions when treating children with CP. The authors’ choice to use the first treatment of the day for the time point of pain assessment and saliva collection was based on two considerations. First, the children underwent a number of interventions each day, and the cumulative effect needed to be considered. Second, cortical levels exhibit a pattern of circadian fluctuations, so this choice of time point reduced the risk for confounding biases. Because of ethical restrictions, the circadian patterns of cortisol secretion, and the potential effects of time, this study evaluated pain and salivary cortisol specimens at the same time of the first treatment each day to maximally reduce interference between the various treatment programs and reduce bias. Cortisol is one of the major glucocorticoids that are produced by the adrenal cortex, and cortisol secretion increases when hypothalamus-pituitaryadrenal axis activity increases in response to psychologic stress. Thus, salivary cortisol has been identified as an objective biologic marker of stress responses.10 However, cortisol is responsive to a wide range of factors that should be considered when
collecting and measuring salivary cortisol in children. In this study, the specific strategies that were used to control for extraneous variables were described by Hanrahan et al.21 and included collecting samples at consistent times, the avoidance of food for 30 mins before sampling, and others. Although the reported efficacies of these treatments are not consistent,22Y25 acupuncture and massage are two techniques that are commonly used for the treatment of CP in China. The findings of this study indicated that HA, which involves the insertion of a needle into the injured tissue, led to the worst pain and that the pain caused by OT was relatively minor. This information should guide clinicians in prioritybased pain management. The participants in the spastic group experienced more pain after NDT. This is probably because, since the spastic group exhibited abnormally high muscle tone, children were prone to more passive stretching techniques and range-of-motion manipulations than the nonspastic group, and according to previous research, stretching and range of motion were frequently identified as painful procedures by both children and their families.11,26 At baseline, salivary cortisol decreased with time, which could be attributed to the effects of the circadian rhythm of cortisol secretion. On the HA, NDT, NMES, and CTM items, salivary cortisol increased after treatment, suggesting that, similar to intravenous insertion27 and acute injury,28 these intervention programs were also stressors that caused significant cortisol responses. Although the
TABLE 4 WRTs at Baseline and at 3 wks Time Baseline 3 wks P
Total (n = 40)
Spastic Group (n = 21)
Nonspastic Group (n = 19)
1.58 (0.86) 1.60 (0.83) 90.05
1.63 (0.98) 1.61 (0.97) 90.05
1.52 (0.71) 1.58 (0.66) 90.05
The data are expressed as mean (SD).
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salivary cortisol levels were slightly higher after OT, this difference was not statistically significant. OT training programs in young children with CP focus on fine motor skills such as hand movements, use of arms, and eye-hand coordination. In view of this technique highlighting the importance of children’s self-initiated activity, therapists often use a friendly approach to increase children’s motivation, which may explain the less pain and stress in OT. Stress and pain are different at the behavioral, cellular, and molecular levels, but these two responses are closely related and overlap to a large extent.29 This argument was corroborated by the present results, which indicated that the pain intensities caused by the intervention treatments were generally consistent with the increased levels of salivary cortisol. Moreover, salivary cortisol can be used as a biologic indicator of pain and stress during rehabilitation intervention. In the future, clinics might use this measure to determine whether pain interventions should be provided. The authors were unable to identify significant baseline-postintervention changes in pain sensitivity in this study. Therefore, the results imply that the pain intensities induced by intervention programs do not affect pain sensitivity. However, a collection of clinical and animal studies suggest that repetitive or prolonged pain during early development leads to long-term changes in neural circuitry and behavior.20,30 Further study is needed on the adverse effects of therapeutic pain. Although the present study fills some gaps in the understanding of the incidences and levels of pain during procedural interventions, the results should be considered with several limitations. First, the heterogeneity of the CP individuals limits the consistency of treatment parameters in terms of content, focus, and intensity within clinical practices, and different treatment parameters will induce varying incidences and degrees of pain. To some extent, the conclusions of this study need to be interpreted cautiously. Second, the pain assessments were performed during the entire time course of the procedural interventions, but the durations of pain varied for each treatment; thus, further studies should account for this dynamic factor.
ACKNOWLEDGMENTS
The authors thank the children and their parents, who generously participated in this study, and Yan Song for her contribution to data collection. REFERENCES 1. Surveillance of Cerebral Palsy in Europe (SCPE): Surveillance of cerebral palsy in Europe: A collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol 2000;42:816Y24 2. Spittle A, Orton J, Anderson P, et al: Early developmental intervention programmes post-hospital discharge to prevent motor and cognitive impairments in preterm infants. Cochrane Database Syst Rev 2012;12:CD005495 3. Liu L, Liu LG, Lu M, et al: Clinical observation on infantile cerebral palsy treated with quick meridian needling therapy plus scalp acupuncture. Zhongguo Zhen Jiu 2010;30:826Y9 4. Zhou XJ, Zheng K: Treatment of 140 cerebral palsied children with a combined method based on traditional Chinese medicine (TCM) and western medicine. J Zhejiang Univ Sci B 2005;6:57Y60 5. Kibele A: Occupational therapy’s role in improving the quality of life for persons with cerebral palsy. Am J Occup Ther 1989;43:371Y7 6. Parkinson KN, Dickinson HO, Arnaud C, et al: Pain in young people aged 13 to 17 years with cerebral palsy: Cross-sectional, multicentre European study. Arch Dis Child 2013;98:434Y40 7. Simons LE, Sieberg CB, Claar RL: Anxiety and impairment in a large sample of children and adolescents with chronic pain. Pain Res Manag 2012;17:93Y7 8. Ehde DM, Jensen MP, Engel JM, et al: Chronic pain secondary to disability: A review. Clin J Pain 2003; 19:3Y17
CONCLUSIONS
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intensity of pain of the spastic group was statistically greater than that of the nonspastic group during the NDT. 2. The rehabilitative intervention treatments caused varying degrees of stress in the CP children as indicated by the salivary cortisol levels, and the stress and pain levels were essentially basically consistent. 3. No statistically significant changes were identified in pain sensitivity after the early developmental intervention programs.
The following conclusions were reached in this study:
9. Doepel M, Soderling E, Ekberg EL, et al: Salivary cortisol and IgA levels in patients with myofascial pain treated with occlusal appliances in the short term. J Oral Rehabil 2009;36:210Y6
1. The majority of the children experienced pain during the entire course of the early developmental intervention programs. Moreover, the
10. Hellhammer DH, Wust S, Kudielka BM: Salivary cortisol as a biomarker in stress research. Psychoneuroendocrinology 2009;34:163Y71
Zhao et al.
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11. Hadden KL, von Baeyer CL: Pain in children with cerebral palsy: Common triggers and expressive behaviors. Pain 2002;99:281Y8
21. Hanrahan K, McCarthy AM, Kleiber C, et al: Strategies for salivary cortisol collection and analysis in research with children. Appl Nurs Res 2006;19:95Y101
12. Swiggum M, Hamilton ML, Gleeson P, et al: Pain in children with cerebral palsy: Implications for pediatric physical therapy. Pediatr Phys Ther 2010;22:86Y92
22. Yu HB, Liu YF, Wu LX: Acupuncture combined with music therapy for treatment of 30 cases of cerebral palsy. J Tradit Chin Med 2009;29:243Y8
13. Swiggum M, Hamilton ML, Gleeson P, et al: Pain assessment and management in children with neurologic impairment: A survey of pediatric physical therapists. Pediatr Phys Ther 2010;22:330Y5
23. Wang SQ, Liang WX, Huang GH, et al: Randomized controlled clinical trials for acupuncture treatment of spastic cerebral palsy children by bilateral horizontal puncturing from Yuzhen (BL 9) to Tianzhu (BL 10). Zhen Ci Yan Jiu 2011;36:215Y9
14. Parkinson KN, Gibson L, Dickinson HO, et al: Pain in children with cerebral palsy: A cross-sectional multicentre European study. Acta Paediatr 2010; 99:446Y51 15. von Baeyer CL: Children’s self-reports of pain intensity: Scale selection, limitations and interpretation. Pain Res Manag 2006;11:157Y62 16. Merkel SI, Voepel-Lewis T, Shayevitz JR, et al: The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23:293Y7 17. O’Rourke D: The measurement of pain in infants, children, and adolescents: From policy to practice. Phys Ther 2004;84:560Y70 18. Voepel-Lewis T, Zanotti J, Dammeyer JA, et al: Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. Am J Crit Care 2010;19:55Y61; quiz 2 19. Bai J, Hsu L, Tang Y, et al: Validation of the COMFORT Behavior scale and the FLACC scale for pain assessment in Chinese children after cardiac surgery. Pain Manag Nurs 2012;13:18Y26 20. Slater R, Cantarella A, Gallella S, et al: Cortical pain responses in human infants. J Neurosci 2006;26:3662Y6
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24. Macgregor R, Campbell R, Gladden MH, et al: Effects of massage on the mechanical behaviour of muscles in adolescents with spastic diplegia: A pilot study. Dev Med Child Neurol 2007;49:187Y91 25. Glew GM, Fan MY, Hagland S, et al: Survey of the use of massage for children with cerebral palsy. Int J Ther Massage Bodywork 2010;3:10Y5 26. Hadden KL, von Baeyer CL: Global and specific behavioral measures of pain in children with cerebral palsy. Clin J Pain 2005;21:140Y6 27. McCarthy AM, Hanrahan K, Kleiber C, et al: Normative salivary cortisol values and responsivity in children. Appl Nurs Res 2009;22:54Y62 28. Brown NJ, Kimble RM, Rodger S, et al: Biological markers of stress in pediatric acute burn injury. Burns 2014;40:887Y95 29. Kumar A, Goswami L, Goswami C: Importance of TRP channels in pain: Implications for stress. Front Biosci 2013;5:19Y38 30. Anand KJ: Pain, plasticity, and premature birth: A prescription for permanent suffering? Nat Med 2000; 6:971Y3
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T
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his is an adult learning experience and there is no requirement for obtaining a certain score. The objective is to have each participant learn from the total experience of studying the article, taking the exam, and being able to immediately receive feedback with the correct answers. For complete information, please see BInstructions for Obtaining Continuing Medical Education Credit[ at the front of this issue. Every question must be completed on the exam answering sheet to be eligible for CME credit. Leaving any item unanswered will make void the participant’s response. This CME activity must be completed and postmarked by December 31, 2016. The documentation received will be compiled throughout the calendar year, and once a year in January, participants will receive a certificate indicating CME credits earned for the prior year of work. This CME activity was planned and produced in accordance with the ACCME Essentials.
CME Self-Assessment Exam Questions CME Article 2015 Series Number 3: Zhao et al. 1. Current limitations in the literature regarding the assessment of stress and pain after treatment in children with CP include: A. Few relevant studies B. Studies are limited to memories and perceptions of pain C. The degree and character of pain have not been assessed D. All of the above
4. In this study, stress response as measured by significant posttreatment increases in mean salivary cortisol levels occurred after which treatment? A. Head acupuncture (HA) B. Neurodevelopmental treatment (NDT) C. Neuromuscular electrical stimulation (NMES) D. All of the above
2. Which of the following treatments did not result in a significant increase in salivary cortisol levels? A. Neurodevelopmental therapy (NDT) B. Neuromuscular electrical stimulation (NMES) C. Occupational therapy (OT) D. Chinese traditional manipulation (CTM)
5. In this study, which is the most likely reason that the pain of spastic patients was statistically greater than that of nonspastic subjects during the neurodevelopmental treatment (NDT)? A. Passive stretching training B. Sit-to-stand training C. Strength training D. All of the above
3. In this study, the greatest pain incidence in children was noted after which treatment? A. Neurodevelopmental treatment (NDT) B. Head acupuncture (HA) C. Neuromuscular electrical stimulation (NMES) D. Occupational therapy (OT)
(Continued next page)
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The activity enhanced my professional skills.
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The activity confirmed the effectiveness of previous skills.
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I learned new techniques or skills.
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I learned new diagnostic strategies.
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The activity was free of industry bias.
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I acquired new skills and competencies not listed aboveY please list here:
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These new skills will improve my work performance and professional competencies in the following areas: (Check all that apply):
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Provision of patient care Communication with patients and families Teaching and educational tasks Administrative duties Research endeavors Team and co-worker interactions
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Medical knowledge Practice-Based learning and improvement Interpersonal and communication skills Professionalism Systems-based practice Other please list here:
Please provide additional comments about the Activity and make any suggestions for improvement:
Please list any topics you would like to see presented in the future:
178
CME Self-Assessment Exam
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 3, March 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
CME ACTIVITY CERTIFICATION Please photocopy this form and complete the information required for each CME Activity. Journal Issue Month and Year CME Article Number
Volume Number CME Article Author’s Name
Issue Number
I, certify that I have met the criteria for CME credit by studying the designated materials, by responding to the self-assessment questions, by reviewing those parts of the article dealing with any question(s) answered incorrectly, and by referring to the supplemental materials listed in the references. This educational activity is designated for 11⁄2 category 1 CME credits. (maximum of 11⁄2 credits)
Indicate total credits claimed:
Date
Signature of Participant Are you a member of the AAP? 䡺 Yes
䡺 No
Do you have an individual subscription to the Journal? 䡺 Yes
䡺 No
If you are not an AAP member or a Journal subscriber, have you enclosed payment of $15 with your exam? 䡺 Yes 䡺 No Payment Options: 䡺 Check (Payable to AAP)
䡺 VISA
䡺 Mastercard
Exp. date
Card #
Amount $
Signature Please provide your name as it should appear on your certificate of credit and also provide your mailing address. Name
Position
Institution Street Address City, State, Zip Phone
Fax
Office Use
www.ajpmr.com
CME Self-Assessment Exam Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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