Foot and lower leg pain in children and adults with cerebral palsy: a population-based register study on 5,122 individuals

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Abstract

Background

Pain is common in individuals with cerebral palsy (CP) and the most reported pain site is the foot/lower leg. We analyzed the prevalence of pain in the foot/lower leg and the associations with age, sex, gross motor function, and clinical findings in individuals with CP.

Method

This was a cross-sectional register-study, based on data reported to the Swedish Cerebral Palsy Follow-up Program (CPUP). All participants in CPUP, four years-of-age or older, were included. Pearson chi-square tests and logistic regression were used to analyze the prevalence and degree of pain in the foot/lower leg.

Results

In total, 5,122 individuals were included from the CPUP database: 58% were males and 66% were under 18 years-of-age. Overall, 1,077 (21%) reported pain in the foot/lower leg. The odds ratios (ORs) of pain were higher in females (OR 1.31, 95% confidence interval (CI) 1.13–1.53), individuals who could ambulate (Gross Motor Function Classification System Level I (OR 1.84, CI 1.32–2.57) and II (OR 2.01, CI 1.46–2.79) compared to level V), and in individuals with decreased range of motion of the ankle (dorsiflexion 1–10 degrees (OR 1.43, CI 1.13–1.83) and ≤ 0 degrees (OR 1.46, CI 1.10–1.93) compared to ≥ 20 degrees). With increasing age the OR of pain increased (OR 1.02, CI 1.01–1.03) as well as the reported pain intensity ( p < 0.001).

Conclusions

Pain in the foot and lower leg appears to be a significant problem in individuals with CP, particularly in those who walk. As with pain in general in this population, both pain intensity and frequency increase with age. The odds of pain in the foot and lower leg were increased in individuals with limited dorsiflexion of the ankle. Given the cross-sectional design causality cannot be inferred and it is unknown if pain causes decreased range of motion of the ankle or if decreased range of motion causes pain. Further research is needed on causal pathways and importantly on prevention.

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Most cited references 34

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Sex differences in pain: a brief review of clinical and experimental findings.

R Fillingim, Laura E Bartley (2013)

Recent years have witnessed substantially increased research regarding sex differences in pain. The expansive body of literature in this area clearly suggests that men and women differ in their responses to pain, with increased pain sensitivity and risk for clinical pain commonly being observed among women. Also, differences in responsivity to pharmacological and non-pharmacological pain interventions have been observed; however, these effects are not always consistent and appear dependent on treatment type and characteristics of both the pain and the provider. Although the specific aetiological basis underlying these sex differences is unknown, it seems inevitable that multiple biological and psychosocial processes are contributing factors. For instance, emerging evidence suggests that genotype and endogenous opioid functioning play a causal role in these disparities, and considerable literature implicates sex hormones as factors influencing pain sensitivity. However, the specific modulatory effect of sex hormones on pain among men and women requires further exploration. Psychosocial processes such as pain coping and early-life exposure to stress may also explain sex differences in pain, in addition to stereotypical gender roles that may contribute to differences in pain expression. Therefore, this review will provide a brief overview of the extant literature examining sex-related differences in clinical and experimental pain, and highlights several biopsychosocial mechanisms implicated in these male-female differences. The future directions of this field of research are discussed with an emphasis aimed towards further elucidation of mechanisms which may inform future efforts to develop sex-specific treatments.

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Sex, gender, and pain: a review of recent clinical and experimental findings.

Roger Fillingim, Christopher King, Margarete Ribeiro-Dasilva … (2009)

Sex-related influences on pain and analgesia have become a topic of tremendous scientific and clinical interest, especially in the last 10 to 15 years. Members of our research group published reviews of this literature more than a decade ago, and the intervening time period has witnessed robust growth in research regarding sex, gender, and pain. Therefore, it seems timely to revisit this literature. Abundant evidence from recent epidemiologic studies clearly demonstrates that women are at substantially greater risk for many clinical pain conditions, and there is some suggestion that postoperative and procedural pain may be more severe among women than men. Consistent with our previous reviews, current human findings regarding sex differences in experimental pain indicate greater pain sensitivity among females compared with males for most pain modalities, including more recently implemented clinically relevant pain models such as temporal summation of pain and intramuscular injection of algesic substances. The evidence regarding sex differences in laboratory measures of endogenous pain modulation is mixed, as are findings from studies using functional brain imaging to ascertain sex differences in pain-related cerebral activation. Also inconsistent are findings regarding sex differences in responses to pharmacologic and non-pharmacologic pain treatments. The article concludes with a discussion of potential biopsychosocial mechanisms that may underlie sex differences in pain, and considerations for future research are discussed. This article reviews the recent literature regarding sex, gender, and pain. The growing body of evidence that has accumulated in the past 10 to 15 years continues to indicate substantial sex differences in clinical and experimental pain responses, and some evidence suggests that pain treatment responses may differ for women versus men.

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The epidemiology of cerebral palsy: incidence, impairments and risk factors.

Else Odding, Marij Roebroeck, Hendrik J. Stam (2006)

Describing the epidemiology of cerebral palsy (CP), its impairments and risk factors. Literature review 1965-2004. Search terms: Cerebral palsy, incidence, prevalence, impairments, risk factors. In the last 40 years the prevalence of CP has risen to well above 2.0 per 1000 life births. In this time span the proportion of low-birthweight infants rose, the proportion of diplegia decreased, while the proportion of hemiplegia increased. CP is more prevalent in more deprived socio-economic populations. The majority of people with CP have the spastic syndrome of which the diplegic group is the smallest. Dependent on the subgroup of CP, 25-80% have additional impairments. A large proportion has some kind of cognitive impairment; the prevalence varies with the type of CP and especially increases when epilepsy is present. Epilepsy is present in 20-40%; it is most common among the hemi- and tetraplegics. Sensibility of the hands is impaired in about half. Chronic pain is reported by more than a quarter of the adults. Up to 80% have at least some impairment of speech. Low visual acuity is reported in almost three-quarters of all children. Half of all children have gastrointestinal and feeding problems. Stunted growth occurs in a quarter, while under- or overweight problems are present in half of the children. Almost 70% of people with spastic CP have abnormal brain CT findings; abnormal cranial ultrasounds is most strongly associated with hemiplegia, normal cranial ultrasounds with diplegia. The most important risk factors for CP are low birthweight, intrauterine infections and multiple gestation.

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Author and article information

Contributors

Ebba Jarlman: ebba.jarlman@med.lu.se

Journal

Journal ID (nlm-ta): BMC Musculoskelet Disord

Journal ID (iso-abbrev): BMC Musculoskelet Disord

Title: BMC Musculoskeletal Disorders

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2474

Publication date (Electronic): 18 May 2024

Publication date PMC-release: 18 May 2024

Publication date Collection: 2024

Volume: 25

Electronic Location Identifier: 391

Affiliations

[1 ]Department of Clinical Sciences, Orthopedics, Lund University, ( https://ror.org/012a77v79) Lund, Sweden

[2 ]GRID grid.413823.f, ISNI 0000 0004 0624 046X, Department of Orthopedics, , Helsingborg Hospital, ; Helsingborg, Sweden

Article

Publisher ID: 7486

DOI: 10.1186/s12891-024-07486-y

PMC ID: 11102238

PubMed ID: 38762469

SO-VID: 9f605571-4bd8-4d5f-bcc1-bec4a314681c

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 14 August 2023

Date accepted : 2 May 2024

Funding

Funded by: Lund University

Open Access :

Open access funding provided by Lund University.

Custom metadata

ScienceOpen disciplines: Orthopedics

Keywords: cerebral palsy,pain,pain intensity,lower extremities

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ScienceOpen disciplines: Orthopedics

Keywords: cerebral palsy, pain, pain intensity, lower extremities

Foot and lower leg pain in children and adults with cerebral palsy: a population-based register study on 5,122 individuals

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Most cited references 34

Sex differences in pain: a brief review of clinical and experimental findings.

Sex, gender, and pain: a review of recent clinical and experimental findings.

The epidemiology of cerebral palsy: incidence, impairments and risk factors.

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