Association of Chronic Pain With Participation in Motor Skill Activities in Children With Cerebral Palsy

This cross-sectional study examines the association between pain and activities requiring motor skill performance among a nationally representative sample of US children with cerebral palsy.


Introduction
Many children with cerebral palsy (CP) experience the secondary condition of pain, which is problematic because children with CP face barriers to participation in motor skill activities. 1,2 Motor performance in activities of daily living among children with CP is markedly lower than that among their age-matched peers. 3 Because of the potential effect of pain on children with CP, we sought to examine the association between pain and activities requiring motor skill performance (ie, difficulty dressing or bathing and participation in sport) among a nationally representative sample of US children with CP.

Methods
This cross-sectional study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for observational studies. 4 The Georgia Southern University institutional review board approved this study under exempt status and with a waiver of informed consent because data were publicly available and deidentified, in accordance with 45 CFR §46.
Data were extracted from the 2017 to 2018 National Survey of Children's Health, which is a parent-reported national survey of the health of children aged 0 to 17 years in the US. 5 We examined responses from 151 participants aged 6 to 17 years with a medical diagnosis of CP and 9177 typically developing children (TDC). Prevalence estimates were compared between children with CP and TDC using a χ 2 test. We used binary logistic regression models to examine associations among CP, pain, difficulty dressing or bathing, and participation in sport while controlling for age, sex, and race. Race was assessed as part of the national survey to address demographic variables related to child health and was identified by participants through survey responses. Statistical significance was set at P < .05, and all hypothesis tests were 2 sided. A multiple imputation method was adopted to handle missing data. We used SAS statistical software version 9.4 (SAS Institute) to analyze the data. Data analysis was performed from April 2020 to February 2021.

Discussion
As expected, difficulty dressing or bathing and low participation in sport were much more common among children with CP than among TDC. A novel finding of this study was that the issue was exacerbated by the presence of pain, which was present in approximately one-third of the children with CP. However, pain also limited participation in sport and was negatively associated with difficulty dressing or bathing among TDC. Although CP is a complicated disorder and the difficulties associated with dressing or bathing and participation in sport are associated with the poor motor control of children with CP, these findings suggest that pain is also a notable contributing factor. A similar study 6 found that 33% of parents reported that pain had a negative effect on normal activities, specifically among some functional activities similar to dressing or bathing. Because children with CP face many barriers to performing motor skill activities in various settings, 2 identification and treatment of pain may improve participation. Although the prevalence of pain is often assessed and monitored through surveillance, 1 clinicians should consider regularly enhanced approaches to identifying and screening for pain.
This study has limitations related to the parent-reported observational nature, and there are always potentially confounding variables. Further research is needed to examine additional confounders and the underlying causes of pain and their association with motor skill activities.