Influence of gait analysis on decision-marketing for lower extremity surgery

Low bone density’s association with severe pain in children with cerebral palsy

C M HOULIHAN MD, M J GURKA PHD, M N KUPERMINC MD,
R D STEVENSON MD

  1. 1. University of Virginia, Charlottesville, VA, USA

Objectives: To determine the impact of bone mineral density (BMD) and nutritional health on pain in children with cerebral palsy (CP).

Design: Prospective, cross-sectional cohort.

Participants: Eighty-one children (age 6-18y) with CP (Gross Motor Function Classification System [GMFCS] levels I-V).

Method: Anthropometric measurements included triceps skinfolds. BMD measurements of the distal lateral femur (DF) obtained in regions 1, 2, and 3 (R1, R2, R3) on a Hologic Discovery bone densitometer using published techniques. Caregivers/children completed the Child Health Questionnaire (CHQ) and the Pediatric Pain Profile (PPP) to assess pain. Z-scores were calculated using normative values on age and sex.

Results: Of 81 children, 33% were at GMFCS Level I, 11% were Level II, 14% were Level III, 15% were Level IV, and 27% were Level V. Children were grouped by less severe (GMFCS levels I-II) and more severe (GMFCS levels III-V) motor impairnment. Mean age was 11 years; 59% were male. Mean DF z-scores for R1, R2, R3 were -1.73, -1.35, and -1.2 respectively.
In assessing pain by the CHQ, 33% reported daily/almost daily pain and 36% had pain z-scores <-1.65; whereas only 5% of the general population is expected to have z-scores <-1.65. There was no sex difference in reported pain. Thirty-two percent of children reported having severe pain on a good day using the PPP. When evaluating most troublesome pain (MTP), 70% reported severe pain. Comparing severity, 77% of children at GMFCS levels III to V and 60% at GMFCS levels I and II reported severe MTP (no significant difference between groups).

Children with more severe motor impairnment had significant lowere BMD z-scores than those with less severe motor impairnment (p<0.05). Comapring bone density to pain, those with severe MTP had lower BMD z-scores than those whose pain was less severe. Adjusting for age and sex via logistic regression, mean BMD z-score for the DF was significantly associated with severe pain. A 1-point decrease in BMD z-score resulted in about twice the odds of severe MTP (p<0.05); there was no change when controlling for GMFCS. Increasing age was significantly associated with lower odds of severe pain. No difference was seen in reported pain with improved triceps z-score.

Conclusions: In children with CP, low BMD was strongly associated with reports of severe pain. Despite increasing awareness of pain in children with disabilities, ways to treat or reduce the causes of pain have not improved. Families continue to describe significant pain in their children across all GMFCS levels. Improved nutritional status did not influence reported pain.

 
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