Annals of Physical and Rehabilitation Medicine 59 (2016) 314–319

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Original article

Care-related pain and discomfort in children with motor disabilities

in rehabilitation centres
Jean-Sébastien Bourseul a,b,d,*, Sylvain Brochard a,b,d,e, Laetitia Houx a,b, Christelle Pons a,b,d,
Mélanie Bué b, Isabelle Manesse b, Juliette Ropars c,d, Dominique Guyader b,
Philippe Le Moine c,f, Amandine Dubois d,g
a
Physical and rehabilitation medicine department, CHRU de Brest, 2, avenue Foch, Brest, France
b
Pediatric rehabilitation center, Fondation Ildys, rue de Kérangall, Brest, France
c
Pediatric department, CHRU de Brest, 2, avenue Foch, Brest, France
d
Université de Bretagne Occidentale, 20, rue Duquesne, Brest, France
e
LaTIM INSERM UMR 1101, 2, avenue Foch, Brest, France
f
Pain evaluation and treatment center, CHRU de Brest, 2, avenue Foch, Brest, France
g
Psychological, cognitive and communication research centre, CRPCC - EA 1285, Rennes 2, France

A R T I C L E I N F O A B S T R A C T

Article history: Background: Pain is one of the symptoms reported most by children with motor disabilities particularly
Received 12 October 2015 during daily living activities in institutions and during rehabilitation. Despite the care and consideration
Accepted 9 April 2016 of professionals, a wide range of motor and cognitive disabilities, limited communication skills, the
presence of chronic pain and frequent care interventions place such children at high risk of experiencing
Keywords: induced pain.
Induced-pain Objectives: We aimed to identify care-related pain and discomfort in children with motor disabilities in
Motor disability
rehabilitation centres and the characteristics of children at risk of induced pain. A further aim was to
Rehabilitation
Children
evaluate the validity of a method for the continuous assessment of care-related pain.
Methods: Patients were recruited from 2 paediatric rehabilitation centres. The level of pain or discomfort
experienced during each daily care activity was evaluated for 5 days and 1 night by using the FLACC-r
scale and a visual analog scale (VAS) rated by the caregiver (VAS caregiver) and the patient (VAS patient).
Results: We included 32 children (mean age: 8.5  5 years, range: 1–15 years) with 1302 care activities
evaluated. Overall, 3.6% of the activities were rated as painful and 11% uncomfortable. The most frequent
painful activities were mouth care, transfers standing and dressing. The most frequent uncomfortable
activities were passive limb mobilisation, dressing and transfers. Children with neurological disorders were at
increased risk of induced pain.
Conclusions: Children with motor disabilities experienced pain during daily care activities. The
methodology we propose is valid and can be used in any type of institution for children with motor
disability to evaluate and reduce the frequency of care-related pain.
ß 2016 Elsevier Masson SAS. All rights reserved.

1. Introduction orthoses and botulinum toxin injections) in in- or outpatient

Certain genetic, congenital and acquired conditions cause
temporary or permanent motor disability in children. Motor
disability generally has a neurological (e.g., cerebral palsy, head
injury or brain tumour) or orthopaedic origin (e.g., scoliosis or
trauma). Children with motor disability frequently require care
and undergo long periods of rehabilitation (e.g., physiotherapy,
* Corresponding author. Tel.: +33 0 67 73 82 92.
E-mail address: jean-sebastien.bourseul@chu-brest.fr (J.-S. Bourseul).
rehabilitation facilities. They usually require help for activities of
daily living and have limited participation [1].
Pain is one of the symptoms reported most by children with
motor disabilities and their families [2,3]. It may be continuous or
provoked by movement, nursing care and other interventions.
Most studies of pain have investigated children with cerebral palsy
(CP), the main cause of motor disability in children (2.5/1000
births) [4]. Almost half (48%) of children with CP report pain, 35%
reporting moderate to severe pain [5], and pain is positively related
to the level of dependence [6]. Pain occurs particularly during
activities of daily living at home and in institutions (e.g., dressing,

http://dx.doi.org/10.1016/j.rehab.2016.04.009
1877-0657/ß 2016 Elsevier Masson SAS. All rights reserved.
 J.-S. Bourseul et al. / Annals of Physical and Rehabilitation Medicine 59 (2016) 314–319
getting out of bed, positioning in a wheelchair, prolonged sitting in
a wheel chair, washing) [7–11] and during rehabilitation [12–
16]. The few studies of children with other types of motor disability
[17,18] have reported similar results.
Children with motor disability undergoing a rehabilitation
program have regular contact with many medical and paramedical
professionals because of their loss of autonomy and dependence.
They tend to be frequently physically manipulated throughout the
day. Moreover, many children with motor disability due to a
neurological pathology also have sociocommunication and cogni-
tive disorders that limit the possibility of communicating about
pain. Children with moderate cognitive disability, who cannot
communicate orally, express pain in unusual ways (withdrawal,
aggressive behaviour, self-stimulatory behaviour and increased
spasticity) or sometimes paradoxical behaviour (smiling, lack of
facial expression and vocalisation) [17,18]. Therefore, signs of pain
are difficult to recognise.
Despite the care and consideration of professionals, the
combination of a wide range of motor and cognitive disabilities,
limited communication skills, the presence of chronic pain and
frequent care interventions place these children at high risk of
experiencing induced pain. However, the assessment and man-
agement of pain is challenging, and therefore pain is often under-
recognised and under-treated. We have no validated method for
the continuous measurement of care-related pain. ‘‘Continuous’’
measurement implies the assessment of all disciplines and care
activities that potentially induce pain within a rehabilitation
centre. The assessment must focus on the child’s life within the
centre. Similar studies have been performed in other instititutional
departments for vulnerable patients such as premature babies [19]
and older adults [20].
We aimed to assess the prevalence and intensity of care-related
pain and discomfort in children with motor disabilities undergoing
an in- or outpatient rehabilitation program. Secondary aims were
to identify the types of care activities that induce pain and
discomfort (including frequency and intensity) and the characte-
ristics of children at risk of induced pain. We further aimed to
assess the validity of our method for continuous assessment of
care-related pain.
2. Materials and methods
The study was approved by the local ethics committee (Comité
de protection des personnes Ouest I, France). Each child and the
family were informed of the continuous pain assessment and gave
their consent for participation.
2.1. Participants and establishments
Children were recruited from 2 paediatric rehabilitation centres
with a total of 37 inpatient beds and 18-day hospital places. The
centres admitted and followed children and teenagers with varied
neurological and orthopaedic pathologies, including both transi-
tory and permanent motor disability. The teams of both rehabili-
tation centres were aware of pain assessment and management
procedures before the beginning of the study (e.g., through
undergraduate training, transdisciplinary post-graduate training,
visual reminders posted in the nurse’s station and rehabilitation
rooms, pain committees integrated in the centres, auditing of
professional practices and identification of pain).
Participants were randomly drawn from children admitted to
either centre for at least 1 week (as in- or outpatients) with transitory
or permanent motor handicap. To facilitate and ensure the feasibility
of the study, a maximum of 3 children was simultaneously included
per centre. Since the frequency of care-induced pain was not known,
315
before beginning the study, we estimated including an arbitrary
number of at least 30 children.
2.2. Procedure
Data were collected over 5 consecutive days for both in- and
outpatients and during 1 night for inpatients by using a case report
form that the child carried everywhere in the department. All care
staffs were trained in data collection and pain evaluation and were
told which children had been included. The aim was to evaluate all
care activities that required physical contact with the child.
2.3. Data collection and measures
The case report form was used to collect relevant details
regarding the child, the nature of the care activity and the pain
assessment. Demographic data included age, gender and the type
of admission (in- or outpatient). Clinical and medical data included
the pathology, impairments of the upper or lower limbs, the type of
disability (transitory or permanent) and the level of dependence.
Level of dependence was measured by using the Programme de
médicalisation des systèmes d’information (PMSI) dependence
scale (French hospital activity database), which is based on
Diagnosis Related Groups [21]. This scale provides a broad
estimation of autonomy for 6 different activities: washing,
dressing, feeding, continence, behaviour and communication. Each
activity is rated as 1, independent, 2, needs supervision, 3, needs
partial assistance or 4, needs total assistance [22]. This score must
be considered purely indicative because the scale has not been
validated for use in this population.
Characteristics of care activities (Appendix A) included the day
and time, the type of activity, the duration in minutes, the
person(s) involved (with symbols; e.g., PT for physiotherapist) and
any specific measures used to prevent pain during the activity
from a predefined list (none, paracetamol, morphine, etc.). The
type of care activity was selected from a closed list of potentially
painful activities developed during 3 formal meetings and
intermediary exchanges involving professionals from all domains
(e.g., doctors, nurses, auxiliaries, child-care assistants, physio-
therapists, occupational therapists). The list was representative
and exhaustive for all care activities carried out in the centres. It
contained 30 activities involving nursing care (e.g., samples,
dressings, mouth care), daily living care (washing and dressing),
physiotherapy (e.g., mobilisation, walking), occupational therapy
(e.g., orthoses), speech and language therapy and adapted physical
activity (Appendix A). An activity not on the list could be reported
but had to be detailed.
A proxy measure of pain was recorded by the professional
involved, who used a behavioural pain scale, the French version of
the Face, Legs, Activity, Cry, Consolability-revised scale (FLACC-r)
[23,24] and a visual analog scale (VAS caregiver). The FLACC-r has
been validated in children who cannot communicate pain orally
[23–25]. It is based on 5 items: facial expression, leg movements,
activities, vocal expression and the consolable nature of the person.
Each item is rated from 0 to 2. A total score  4 was considered the
experience of pain and 1–3 discomfort. The scale is well correlated
with the VAS, the gold standard for evaluating pain in children who
can communicate [24]. It is reliable and easy to use for all
caregivers [25,26]. The VAS involves evaluating pain intensity on a
100-mm scale by the participant placing a cursor along its length
(0 = no pain, 100 = maximal pain). Many studies of children have
shown that this scale is valid as a proxy measure recorded by an
experienced person such as a caregiver [27]. The FLACC-r and the
VAS are complementary and provide an indication of the intensity
of pain experienced by the child in the most exhaustive and
objective manner possible.
316 J.-S. Bourseul et al. / Annals of Physical and Rehabilitation Medicine 59 (2016) 314–319
Self-reported pain was assessed in children > 6 years old if they
had sufficient cognitive and verbal capacity to use a VAS (VAS
patient) as previously described. This scale is considered the gold
standard in participants > 5 or 6 years old. Younger children tend
to use only the extremities of the scale [27,28].
2.4. Statistical analysis
Data are described with mean  SD or median (interquartile
range). We analyzed the number of times an activity caused pain or
discomfort among the total number of evaluations, the number of
times an activity caused pain or discomfort over the number of times
this activity was performed (the ‘‘rate of pain’’) and the pain intensity.
Validity of the assessment procedure was evaluated by using
Statistica v6.0 (StatSoft, Tulsa, OK, USA). Pearson’s correlation
coefficient was used to evaluate the concurrent validity between
the FLACC-r and the VAS caregiver and VAS patient. The level of
significance was fixed at P < 0.05.
3. Results
The study was performed over 19 weeks. All staff successfully
completed the case report form. There were few problems
regarding the data collection and entry. Staffs stated that they
could include the assessment of up to 3 children per week in their
daily workload.
No child or family refused to participate. All 33 children
included participated, but data for one with chronic pain were
excluded from the analysis because the repeated proxy measure-
ment and self-reports of pain exacerbated his pain. After this
experience, patients with chronic pain were not included.
We included 32 children (19 boys, mean age: 8.5  5 [range: 1–
15 years]) (Table 1); 19 children were inpatients and 13 outpatients.
Overall, 23 children had neurological pathologies (cerebral palsy,
severe epilepsy and encephalopathy) and 9 were admitted for
orthopaedic rehabilitation (lower-limb fractures, pelvic osteotomy
and knee ligamentoplasty). The mean number of care activities was
47.9  27.7 for children with neurological pathologies and
22.1  13 for those with orthopaedic pathologies. The median level
of dependence (on the PMSI scale) was 17/24; 22 children had
permanent disability.
3.1. Care-related pain and discomfort
In total, 1302 care activities were evaluated during the study
period: 47 (3.6%) were judged as painful (FLACC-r score  4) and
143 (11%) uncomfortable (FLACC-r score: 1–3). For 30 patients,
the baseline pain score was 0. Two other patients had a baseline
rating of 1 on one evaluation and 0 during a second evaluation.
Therefore, we considered that the baseline rating for the whole
group was 0.
3.2. Prevalence, rate and intensity of care related-pain and discomfort
The most frequent painful and uncomfortable activities (FLACC-
r score  4) were mouth care (15 times; median FLACC-r score = 4),
transfers, standing and dressing (4 times each; all medians = 6)
(Table 2). Among the 143 uncomfortable activities (FLACC-r: 1–3),
the 3 that were most often uncomfortable were passive mobilisa-
tion/stretching (21 times; median = 1), dressing/undressing
(15 times; median = 2) and transfers (13 times; median = 2).
The activities with the highest rating of pain were eye care (60%
of eye-care activities), gastrostomy care (25% of activities) and
mouth care (23.8% of activities) (Table 2). The most frequent
uncomfortable activities were chest physiotherapy (57% of
activities), samples and injections (55% of activities) and invasive
respiratory care (50% of activities).
The activities with the highest pain intensity on the FLACC-r
were standing (9/10, 1 case), invasive anal care (7/10, 2 activities)
and transfers, dressing, washing, massages, mouth care and eye
care (all rated 6/10) (Table 2).
3.3. Types of care activities that induced pain and discomfort
The most painful care activities were activities of daily living
(dressing, transfers, washing, etc.) (29/47 activities), which were
performed by auxiliary staff. Only one physiotherapy activity was
painful (chest physiotherapy). The most uncomfortable activities
were physiotherapy activities (passive mobilisation/stretching and
light mobilisation in bed; 55/143 activities) and activities of daily
living (dressing and transfers; 38/143 activities).
We also analyzed the specific pain-prevention measures taken
for each care activity. Preventative measures were rarely used:
they were reported for only 21 of 1302 care activities.
3.4. Profile of children at risk of induced pain
To determine the characteristics of children at risk of
experiencing care-related pain, we examined the children who
experienced the 47 painful activities. Eight children (5 boys; mean
age: 7.1  2.8 years) with similar medical characteristics had
experienced 90% of the painful events. These children all had
neurological pathologies and permanent disability, and their level of
dependence was ‘‘totally dependent’’ for both ambulation (median
PMSI scale = 4, first quartile = 4) and cognition (median PMSI
scale = 4, first quartile = 4).
3.5. Concurrent validity of the assessment procedure
Concurrent validity was assessed to determine the concordance
between the scores of the different pain scales used. A total of
1302 FLACC-r and 998 VAS caregiver scores were collected as
proxy measures; 362 VAS patient (self-report) scores were
obtained. We found excellent correlation between the FLACC-r
and VAS caregiver proxy measures (r = 0.888; P < .05) and
moderate correlation between the FLACC-r and VAS patient scores
(r = 0.564; P < .05).
For the 52 mouth-care events with available concurrent
evaluations, the mean FLACC-r score was 1.12  1.93 and the
mean VAS care score 1.26  2.22. For 5 eye-care events with available
concurrent evaluations, the mean FLACC-r score was 3.6  3.29 and
mean VAS caregiver score 4.5  3.
4. Discussion
Care-related pain has been reported in several studies involving
children with motor disability [7–11], but it has not been
exhaustively studied in children undergoing a rehabilitation
program. We developed and evaluated a methodological paradigm
for the continuous assessment of care-related pain and discomfort
over 1 week in children with motor disability. We assessed
32 children over 19 weeks and rated 1302 care activities. The
continuous assessment of pain was feasible and could be
integrated into the child’s daily care routine. The results confirmed
the relevance of evaluating care-related pain and discomfort in
children with motor disability undergoing a rehabilitation
program.
Although staff in the participating rehabilitation centres were
already trained in pain assessment and management before
beginning the study, 3% of care activities were found to be painful
Table 1
Characteristics of children in the study.

Patient Age Gender Hospitalization Pathology Continence Behaviour Relationship Ambulation Dressing Feeding PMSI scale Disabilitya Analgesic No. of care
no. (years) (in/outpatient) treatmentb activities
per patientc

1 4 M Out Spina bifida 4 3 2 1 3 2 15 P NT 27

2 12 F In Cerebral palsy 4 4 4 4 4 4 24 P P 90
3 2 M Out Hand burn 1 1 1 1 2 2 8 T NT 9
4 6 M In Cerebral palsy 4 4 4 4 4 4 24 P P 102
5 6 M Out Cerebral palsy 4 4 4 4 4 4 24 P CP 56
6 13 M Out Cerebral palsy 4 4 4 4 4 4 24 P P 33
7 15 F In Paraplegia 4 1 1 4 3 1 14 P P 108
8 13 M Out Polytrauma 3 1 2 1 4 2 13 T P 15
9 13 F Out Femur fracture 1 1 1 4 1 1 9 T P 7

J.-S. Bourseul et al. / Annals of Physical and Rehabilitation Medicine 59 (2016) 314–319
10 5 M Out Pelvic osteotomy 3 1 1 3 2 1 11 T P 20
11 4 M Out Spina bifida 4 3 2 1 3 2 15 P NT 25
12 5 M In Cerebral palsy 4 4 4 4 4 4 24 P P 75
13 15 M Out Idiopathic stiff knee 1 1 1 2 1 1 7 T P 12
14 14 F In Polytrauma 1 2 1 3 2 1 10 T P 40
15 13 F Out Patella refocusing 1 2 1 3 1 1 9 T CP 23
16 11 M In Epiphysiodesis 1 2 1 3 1 1 9 T CP 42
17 14 M In Knee ligamentoplasty 1 2 1 2 1 1 8 T CP 31
18 9 F Out Brain tumor 1 2 2 1 1 1 8 T NT 14
19 5 M In Cerebral palsy 4 4 4 4 4 4 24 P P 58
20 6 M In Encephalopathy 4 4 4 4 4 4 24 P CP 60
21 7 M Out Neurofibromatosis 3 3 2 2 3 2 15 P P 14
22 11 F Out Partial monosomy 5Q 4 3 3 2 3 2 17 P NT 31
23 14 M In Cerebral palsy 4 2 3 4 4 4 21 P P 70
24 5 F In Encephalopathy 4 4 4 4 4 4 24 P NT 23
25 5 F In Campomelic dwarfism 4 2 3 2 2 3 16 P P 37
26 5 M In Lissencephaly 4 4 4 4 4 4 24 P P 42
27 7 F In West syndrome 4 4 4 4 4 4 24 P P 37
28 15 F In Niemann pick type C 4 4 4 4 4 4 24 P P 27
29 1 M In Encephalopathy 4 4 4 4 4 4 24 P P 54
30 8 F In Cerebral palsy 4 4 4 4 4 4 24 P P 52
31 3 F In Sturge-Weber-Krabbe 4 2 3 2 4 3 18 P P 7
32 6 M In Encephalopathy 4 4 4 4 4 4 24 P P 61
Total 8.5  5 M = 19/ In = 19/ Neurologic, n = 23 4 (1–4) 3 (2–4) 3 (1–4) 4 (2–4) 4 (2–4) 3 (1–4) 17 (10–24) P = 22/T = 10 P, n = 21/ 40.7  26.9
(range: 1–15) F = 13 out = 13 Orthopaedic, n = 9 CP, n = 5/
NT, n = 6
Data are no., mean  SD or median (interquartile range).
a
P: permanent; T: temporary.
b
No. of care activities per patient during the week of evaluation.
c
P: paracetamol as required; CP: continuous paracetamol; NT: no treatment.

317
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Table 2
The 10 activities most frequently causing pain (among all evaluations), with the highest FLACC-r score and highest rating of pain (visual analog scale [VAS]).

Activities most frequently causing pain Activities with the highest rating of pain (VAS) Activities with the highest FLACC-r score

Care activity No. FLACC-r, median (IQR) Care activity No. activities/activities Care activity FLACC-r score
performed (%)

Mouth care 15 4 (4–4) Eye care 3/5 (60) Standing 9

Transfers 4 6 (4–6) Gastrostomy 3/12 (25) Invasive anal care 7
Standing 4 6 (6–6) Mouth care 15/63 (23.8) Aerosols 6
Dressing 4 6 (4–6) Invasive anal care 2/10 (20) Invasive chest care 6
Eye care 3 6 (6–6) Invasive chest care 3/15 (20) Dressing 6
Gastrostomy care 3 4 (4–4) Standing 4/30 (13) Washing 6
Washing 3 6 (6–6) Chest physiotherapy 1/11 (9) Massage 6
Invasive chest care 3 6 (6–6) Massage 2/53 (3.8) Mouth care 6
Massage 2 6 (6–6) Washing 3/93 (3.2) Eye care 6
Invasive anal care 2 7 (7–7) Dressing 4/204 (2) Transfers 6

FLACC-r: Face, Legs, Activity, Cry, Consolability-revised scale; IQR: interquartile range.

and 11% uncomfortable. This prevalence is probably low because of
staff awareness as well as the pain being assessed by the person
performing the care activity. By comparison, in neonatal units,
69.6% of care activities were found to be painful and 30.4%
produced stress [19]. However, our findings are consistent with
studies highlighting that pain seems to be under-treated and
under-recognised by professionals who work with children with
motor disorders who are unable to orally communicate pain
[29,30]. We expected to find higher levels of pain for physiothera-
py-related activities from reports in the literature [10,12,14];
however, physiotherapy activities were evaluated as uncomfort-
able (55/143 activities) rather than painful (1/47 painful activities).
The activities assessed as painful and uncomfortable were mostly
activities of daily living (e.g., dressing, transfers and washing),
which were carried out by auxiliary staff several times a day for the
most dependent children. Standing was one of the most painful
activities, both in intensity (the most painful activity with a
maximal FLACC-r score of 9/10) and frequency (13%). Children
were regularly positioned upright by using custom-made equip-
ment to prevent complications related to the lying position.
However, the evidence for the effectiveness of standing for these
children is only moderate [31], so whether the benefits outweigh
the risks of provoking pain is uncertain. In all cases, standing, as
well as all the more painful activities we highlighted, should be
carried out with particular care, and analgesic prophylaxis should
be given.
The children with permanent neurological pathology who were
totally dependent experienced the highest levels of pain. A larger
scale study in a greater number of centres is needed to confirm
these preliminary results. This finding is consistent with a recent
population-based registry study showing significantly more
children reporting pain at Gross Motor Function Classification
System levels III and V than I [6]. In our study, children who were
highly dependent may require the most medical and paramedical
involvement as well as rehabilitation. They are frequently
manipulated throughout the day and have a high risk of
experiencing pain. Moreover, these children frequently have
sociocommunicative and cognitive impairments [32,33], for
difficulties in detecting, recognizing and preventing painful care
and medical procedures [34,35]. Specific attention must be given
to preventing care-related pain in this population. The greater the
level of dependence, the greater may be the risk of care-related
pain.
This study showed that continuously monitoring care-related
pain in children with motor disability is feasible. Other studies
with similar methodological processes have demonstrated the
feasibility of collecting quantitative and qualitative data related to
painful activities in neonatal intensive care units [19], rehabilita-
tion centres after orthopaedic trauma [36] and centres and
institutions for people older than 65 [20]. Therefore, continuous
assessment of care-related pain can be integrated into the daily
care of patients in different types of healthcare centres. Because the
evaluation is performed during care activities, it can be integrated
into daily clinical practice and performed by all care professionals
who wish to evaluate care-related pain. However, particular care
must be taken to reduce the impact of the pain on function in
children with chronic pain who are admitted to paediatric
rehabilitation units. The several-times daily assessment of pain
could exacerbate the pain. Conclusions cannot be drawn from the
one case we observed; however, such children likely have a specific
reaction to care-related pain, and particular attention and methods
should be used in these cases.
The method of continuous pain measurement we describe can
be applied to all centres and institutions for children and adults
with all levels of disability. It can be used for assessing care-related
pain within a centre both quantitatively (analysis of the prevalence
of induced pain) and qualitatively (e.g., identifying the types of
activities, characteristics of the children, professionals involved). In
the long term, such assessments could help improve pain
prevention, particularly through the awareness and training of
caregivers. Preventative measures can range from not performing
care activities that are unnecessary, to changing practices (e.g.,
improving methods of handling during activities of daily living) or
administering medication before the care activity (e.g., painkillers
or anti-inflammatories).
The 2 main limitations of this study relate to the data collection.
The evaluation of pain by the professional who performed the care
activity as well as the ‘‘burn-out’’ effect in the middle of the week
likely led to an underestimation of care-related pain. To limit such
bias, the assessments could be more objectively carried out by an
independent assessor who could also help maintain the motivation
of the teams. Furthermore, the ‘‘Face’’ item of the FLACC-r scale
may not be pertinent for certain activities such as eye and mouth
care because a facial expression may not be related to pain but
could be reflex-induced. However, we had no overestimations in
our results because we found similar FLACC-r scale and VAS
caregiver scores.
In conclusion, this study shows that children with motor
disability, especially disabilities of a neurological origin, experi-
ence care-related pain in rehabilitation centres. The results
highlight the importance of considering pain in children who
require assistance with activities of daily living several times a day.
The continuous assessment of care-related pain in children with
motor disabilities was feasible and clinically relevant and showed
moderate to excellent concurrent validity. A large-scale study is
needed to confirm these preliminary results and to specify the
characteristics of children at risk and the risk factors for care-
related pain.
 J.-S. Bourseul et al. / Annals of Physical and Rehabilitation Medicine 59 (2016) 314–319
Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgements
The authors particularly thank the DIS-HANDI group (Olivier
Rémy-Néris, Sophie Blonz, Claire Morvan, Anna Faujour, Mathieu
Paumier, Alain Bellec, Patrick Rohou, Steeve Desanglois, Arnaud
Brasseur), the care and rehabilitation staff of the paediatric units of
the Fondation Ildys, Marie Hélène Lallier from the DIRC (Innovation
and clinical research department) of Brest University Hospital,
Emmanuel Nowak and Julien Couadic from the Brest Clinical
Investigation Centre, Mathieu Lempereur for the database and
statistical analysis, the national centre for research on pain (CNRD)
for methodological assistance and Johanna Robertson for translat-
ing this paper. This study was supported by grants from the
Fondation APICIL, the Fondation Motrice and la Fondation de France.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.rehab.2016.04.
009.
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