| Description |
Musculoskeletal pain from:
- Spasticity leading to bony deformations, contractures, and joint stress (18,77).
- Scoliosis (77).
- Congenital dislocations (18).
- Wheelchair use.
- Hip subluxation (65).
Other pain from:
- Gastro-esophageal reflux (65).
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| Location of Pain |
- Most common sites are low back, hip, leg, and knee. Other reported sites include foot / ankle pain, hand and wrist, elbow, neck, shoulder, arm and upper back pain (17,19,42,65,77).
- Less common sites included head, abdomen and pelvis, buttocks (19).
- Postoperative pain from any number of surgical procedures a person with CP may face (65).
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| Aggravating Factors |
- Fatigue.
- Stress.
- Greater severity of impairment.
- Presence of gastrostomy tube.
- Gastrointestinal problems in children with CP.
- Higher fat stores in children with CP.
- Catastrophizing.
- CP-related pain may be under-evaluated and under-treated (9,12,18,26,42).
- Depression (65).
- Overexertion (77).
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| Alleviating Factors and Treatment Options |
Pharmacological:
- Intrathecal baclofen and possibly botulinum toxin may reduce spasticity and pain in children and adults with CP (18,65,91).
- Acetaminophen (42).
- Ibuprofen (42).
- Codeine (42).
Non-pharmacological:
For musculoskeletal pain arising from wheelchair use, the following options may help:
- Change environment to place frequently viewed objects (TV, computer screen, phone) to appropriate height from wheelchair to minimize neck pain (50).
- Consider a wheelchair with a higher (or adjustable) seat height and ability to tilt back or recline trunk to minimize neck pain (50).
- Whenever possible, have friends, family and clinicians sit rather than stand while conversing with a wheelchair user (50).
- Whenever possible, have wheelchair seat and transfer destination heights equal to minimize upper extremity effort required (66).
- Exercise balanced with resting (42).
- Stretching (42).
- Transcutaneous electrical nerve stimulation (TENS) (42).
- More often used cognitive strategies like task persistence, diverting attention, coping self-statements, reinterpreting pain sensations, praying, and hoping (18).
- Lesser-used physical strategies like postural guarding, increasing activity, and resting (18).
- There are a reasonably wide variety of pain treatments that may provide short-term pain relief but has minimal effect on average pain ratings over a two-year span. Of note, despite self-reported helpfulness of many pain treatments, only a small proportion of people with CP used them (18,42).
Surgical:
- Selective dorsal root rhizotomy (to reduce spasticity and improve gait). It may also decrease the need for future orthopedic operations (65,13).
- Soft tissue releases to relieve contractures (65).
- Arthrodesis (77).
- Total joint arthroplasty (5).
- For any surgical option, keep in mind that postoperative pain will be created and need to be managed (13).
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| Specific Exercise Guidelines to Manage Pain |
Little has been studied or noted in regard to exercise and musculoskeletal pain relief in CP. More study is needed to understand what type of exercise is safe and most beneficial (40,77).
General Guidelines
- When caregivers perceived more benefits of exercise, the adults with CP in their care were more likely to exercise. Educating caregivers on the benefits of exercise, how to customize a program to individual needs, and how to monitor activity to ensure enjoyment and safety (40).
- Caregivers in nursing homes tend to be less positive about exercise than in non-nursing home environments (40).
Aerobic Exercise / Flexibility Training
- Frequency recommendations vary from 2- or 3-times weekly cardiovascular endurance combined with resistance training (2x weekly vs. 3x may increase compliance).
- Although aerobic and flexibility exercises are important to overall health, there was no data available in this literature search relating to pain relief benefits.
Strength Training:
- Strength training has not been shown to increase spasticity or contractures, or decrease range of motion (ROM) in people with CP as previously believed. There is some evidence that strength training may even increase ROM, especially in the lower limbs (16).
- Frequency recommendations vary from once or twice daily strengthening/stretching shoulder exercises to 2- or 3-times weekly combined cardiovascular endurance and resistance training (2x weekly vs. 3x may increase compliance).
- For musculoskeletal pain arising from wheelchair use the following strength training strategies may help:
- Stretch anterior shoulder musculature including pectoralis and bicep muscles; strengthen posterior shoulder musculature and maintain range of motion in shoulder especially groups which control external rotations, and adduction. Watch for and address any strength deficiencies or imbalances (11,66).
- Stretch scapularic protractors; strengthen scapularic retractors (11,66).
- Rowing exercises or backward wheeling can strengthen scapularic retractors (25,66).
- Wall pulley exercises, free weights, exercise bands, wheelchair friendly weight machine with or without wrist straps can all work well in devising a resistance training program for persons in a wheelchair (11,39).
- Exercise program must be ongoing to provide long-term pain management. As adherence declines, musculoskeletal pain increases (15,39).
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