Efficacia della clown terapia sul dolore procedurale nei bambini con paralisi cerebrale. Revisione sistematica e meta-analisi

Autori

  • Luca Giuseppe Re ASST Grande Ospedale Metropolitano Niguarda https://orcid.org/0000-0003-1755-6892
  • Viviana Fusetti Fondazione IRCCS Istituto Nazionale dei Tumori, Milano

DOI:

https://doi.org/10.54103/dn/18716

Parole chiave:

clown terapia, dolore procedurale, bambini, paralisi cerebrale

Abstract

INTRODUZIONE:
Quasi il 10% del dolore che colpisce i bambini con paralisi cerebrale (PC) deriva da una procedura medica. La clownterapia è una diffusa tecnica di distrazione per ridurre il dolore; alcune revisioni sistematiche valutano l'efficacia di questo intervento in ambito pediatrico, ma nessuna su bambini con PC.

OBIETTIVO:
Valutare l'effetto della clown terapia sul dolore procedurale nei bambini con PC.

METODI:
Revisione sistematica con meta-analisi di trial clinici con gruppo di controllo. Reperimento degli studi tramite interrogazione di database biomedici, risorse online e registri di trial. La clown terapia è stata confrontata con le cure standard. L'esito primario era il livello di dolore dopo l'intervento. Il rischio di bias è stato valutato con RoB 2. La dimensione d'effetto è stata calcolata con un modello a effetti casuali.

RISULTATI
Tre studi con 164 pazienti sono stati inclusi. Il rischio di bias è alto per due studi e solleva qualche dubbio per uno. Tutti gli studi hanno analizzato l'effetto della clown terapia sul dolore procedurale dopo l'iniezione di tossina botulinica. È stata rilevata una riduzione statisticamente non significativa del dolore nel gruppo di intervento rispetto a quello di controllo (DSM: -0,20, IC 95%: -0,56, 0,17). L'eterogeneità tra gli studi è elevata.

CONCLUSIONE:
La clown terapia per il dolore procedurale da iniezioni di tossina botulinica nei bambini con PC sembra efficace ma i limiti metodologici degli studi non consentono un giudizio definitivo. Mancano studi che valutino l'effetto dell’intervento su altre procedure a cui si sottopongono periodicamente i bambini con PC

Riferimenti bibliografici

Centers for Disease Control and Prevention [Internet]: CDC, c2022. Cerebral palsy; 2022 May 2 [cited 2022 Jun 25]. Available from: https:// www.cdc.gov/ncbddd/cp/facts.html; 2022

Morgan C, Fahey M, Roy B, Novak I. Diagnosing cerebral palsy in full-term infants. J Paediatr Child Health 2018;54(10):1159-64. doi: 10.1111/jpc.14177.

Colver A, Fairhurst C, Pharoah PO. Cerebral palsy. Lancet 2014;383(9924):1240-9. doi: 10.1016/S0140-6736(13)61835-8

Maenner MJ, Blumberg SJ, Kogan MD, Christensen D, Yeargin-Allsopp M, Schieve LA. Prevalence of cerebral palsy and intellectual disability among children identified in two U.S. National Surveys, 2011–2013. Ann Epidemiol 2016; 26(3):222–6. doi: 10.1016/j.annepidem.2016.01.001

Oskoui M, Coutinho F, Dykeman J, Jett´e N, Pringsheim T. 2013. An update on the prevalence of cerebral palsy: a systematic review and meta-analysis. Dev Med Child Neurol 2013;55(6): 509–519. doi: 10.1111/dmcn.12080

Reddihough D. Cerebral palsy in childhood. Aust Fam Physician 2011; 40(4): 192–6. PMID: 21597527

Van Naarden Braun K, Doernberg N, Schieve L, Christensen D, Goodman A, Yeargin-Allsopp M. (2016). Birth Prevalence of Cerebral Palsy: A Population-Based Study. Pediatrics 2016; 137(1): 1–9. https://doi.org/10.1542/peds.2015-2872

Wimalasundera N, Stevenson VL. Cerebral palsy. Pract Neurol 2016; 16(3): 184-94.

Agarwal A, Verma I. Cerebral palsy in children: an overview. J Clin Orthop Trauma 2012;3(2):77–81. https://doi.org/10.1016/j.jcot.2012.09.001

Graham D, Paget SP, Wimalasundera N. Current thinking in the health care management of children with cerebral palsy. Med J Aust 2019;210(3):129-35.

Novak I, Hines M, Goldsmith S, Barclay R. Clinical prognostic messages from a systematic review on cerebral palsy. Pediatrics 2012; 130(5):e1285–e1312. https://doi.org/10.1542/peds.2012-0924

Penner M, Xie, WY, Binepal N, Switzer L, Fehlings D. Characteristics of pain in children and youth with cerebral palsy. Pediatrics 2013; 132(2):e407–13. https://doi.org/10.1542/peds.2013-0224

Rabach I, Peri F, Minute M, Aru E, Lucafò M, Di Mascio A, Cozzi G, Barbi E. (2019). Sedation and analgesia in children with cerebral palsy: a narrative review. World J Pediatr 2019;15(5):432–40. https://doi.org/10.1007/s12519-019-00264-0

Cortellazzi P, Lamperti M, Minati L, Falcone C, Pantaleoni C, Caldiroli D. Sedation of neurologically impaired children undergoing MRI: a sequential approach. Paediatr 2007; 17(7):630–6. https://doi.org/10.1111/j.1460-9592.2006.02178.x

Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, Dan B, Jacobsson. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007;109:8–14. PMID: 17370477

Engel JM, Jensen MP, Hoffman AJ, Kartin D. Pain in persons with cerebral palsy: extension and cross validation. Arch Phys Med Rehabil 2003; 84(8): 1125–8. doi: 10.1016/s0003-9993(03)00263-6

Parkinson KN, Gibson L, Dickinson HO, Colver AF. Pain in children with cerebral palsy: a cross-sectional multicentre European study. Acta Paediatr 2010; 99(3): 446-51. doi: 10.1111/j.1651-2227.2009.01626.x

Parkinson KN, Dickinson HO, Arnaud C, Lyons A, Colver A, SPARCLE group. Pain in young people aged 13 to 17 years with cerebral palsy: cross-sectional, multicentre European study. Arch Dis Child 2013; 98(6): 434–40. doi: 10.1136/archdischild-2012-303482.

McKearnan KA, Kieckhefer GM, Engel JM, Jensen MP, Labyak S. Pain in children with cerebral palsy: a review. J Neurosci Nurs 2004; 36(5): 252–9. doi: 10.1097/01376517-200410000-00004

Penner M, Davis WH, Wing K, Bemenderfer T, Waly F, Anderson RB. The Infinity Total Ankle System: Early Clinical Results With 2- to 4-Year Follow-up. Foot Ankle Spec 2019:12(2), 159–66. https://doi.org/10.1177/1938640018777601

Ostojic K, Paget SP, Morrow AM. Management of pain in children and adolescents with cerebral palsy: a systematic review. Dev Med Child Neurol 2019: 61, 315–21. doi: 10.1111/dmcn.14088

Roscigno CI. Addressing spasticity-related pain in children with spastic cerebral palsy. The J Neurosci Nurs 2002; 34(3), 123–33. doi: 10.1097/01376517-200206000-00005

Castle K, Imms C, Howie L. Being in pain: a phenomenological study of young people with cerebral palsy. Dev Med Child Neurol 2007; 49(6):445-9. doi: 10.1111/j.1469-8749.2007.00445

Engel JM, Petrina TJ, Dudgeon BJ, McKearnan KA. Cerebral palsy and chronic pain: a descriptive study of children and adolescents. Phys Occup Ther Pediatr 2005; 25(4):73-84. doi: 10.1300/j006v25n04_06.

Hadden KL, von Baeyer CL. Pain in children with cerebral palsy: common triggers and expressive behaviours. Pain 2002; 99(1-2): 281–8. doi: 10.1016/s0304-3959(02)00123-9

Nolan JI, Chalkiadis GA, Low J, Olesch CA, Brown TC. Anaesthesia and pain management in cerebral palsy. Anaesthesia 2000; 55(1): 32–41. doi: 10.1046/j.1365-2044.2000.01065.x

Breau LM, Camfield CS, McGrath PJ, Finley GA. The incidence of pain in children with severe cognitive impairments. Arch Pediatr Adolesc Med 2003; 157(12):1219–26. https://doi.org/10.1001/archpedi.157.12.1219

Fein JA, Zempsky WT, Cravero JP, Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine, American Academy of Pediatrics. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2012; 130(5):e1391-405. doi: 10.1542/peds.2012-2536

Pascolo P, Peri F, Montico M, Funaro M, Parrino R, Vanadia F, Rusalen F, Vecchiato L, Benini F, Congedi S, Barbi E, Cozzi G. Needle-related pain and distress management during needle-related procedures in children with and without intellectual disability. Eur J Pediatr 2018;177(12), 1753-60. doi: 10.1007/s00431-018-3237-4

Trottier ED, Doré-Bergeron MJ, Chauvin-Kimoff L, Baerg K, Ali S (2019) Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures. Paediatr Child Health 2019;24(8):509-35. doi: 10.1093/pch/pxz026

Pancekauskaitė G, Jankauskaitė L (2018) Paediatric pain medicine: pain differences, recognition and coping acute procedural pain in paediatric emergency room. Medicina (Kaunas) 2018;54(6):94. doi: 10.3390/medicina54060094

Ali S, McGrath T, Drendel AL, Amy LDO. An evidence based approach to minimizing acute procedural pain in the emergency department and beyond. Pediatr Emerg Care 2016;32(1):36-42; quiz 43-4. doi: 10.1097/PEC.0000000000000669

Ostojic K, Paget S, Kyriagis M & Morrow A. (2020). Acute and chronic pain in children and adolescents with cerebral palsy: prevalence, interference, and management. Arch Phys Med Rehabil 202;101(2):213-9. doi: 10.1016/j.apmr.2019.08.475

Cooke MW. UK Ambulance Service Clinical Practice Guidelines 2006; 2006 Oct [cited 2022 Sept 16]. Available from: http:// www. ambo. com. au/ download/ uk_guide lines_ 2006. pdf.

Chen E, Joseph MH, Zeltzer LK. Behavioral and cognitive interventions in the treatment of pain in children. Pediatr Clin North Am 2000;47(3):513-25. doi: 10.1016/s0031-3955(05)70223-6

Berk LS, Tan SA, Fry WF, Napier BJ, Lee JW, Hubbard RW, Lewis JE, Eby WC. Neuroendocrine and stress hormone changes during mirthful laughter. Am J Med Sci 1989;298(6):390-6. doi: 10.1097/00000441-198912000-00006

Ding Y, Yin H, Wang S, Meng Q, Yan M, Zhang Y, Chen L. Effectiveness of clown intervention for pain relief in children: A systematic review and meta-analysis. J Clin Nurs 2022. doi: 10.1111/jocn.16195. Online ahead of print

Fusetti V, Re L, Pigni A, Tallarita A, Cilluffo S, Caraceni AT, Lusignani M. Clown therapy for procedural pain in children: a systematic review and meta-analysis. Eur J Pediatr 2022;181(6):2215-25. doi: 10.1007/s00431-022-04440-9

Könsgen N, Polus S, Rombey T, Pieper D. Clowning in children undergoing potentially anxiety-provoking procedures: a systematic review and meta-analysis. Syst Rev 2019;8(1):178. doi: 10.1186/s13643-019-1095-4

Lopes-Junior LC, Silveira DS, Olson K, Bomfim EO, Veronez LC, Santos JC, Lima RA. Clown intervention on psychological stress and fatigue in pediatric patients with cancer undergoing chemotherapy. Cancer Nurs 2020;43(4):290-9. doi: 10.1097/NCC.0000000000000690

Sridharan K, Sivaramakrishnan G. Therapeutic clowns in pediatrics: a systematic review and meta-analysis of randomized controlled trials. Eur J Pediatr 2017;176(5):681-2. doi: 10.1007/s00431-017-2889-9.

Ucun Y, Küçük L. Terapötik Palyaço Müdahalesinin Çocukların Ruh Sağlığına Etkisi: Sistematik Derleme. Jaren 2020;6(3):598-609. doi:10.5222/jaren.2020.93584

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898. doi: 10.1136/bmj.l4898.

McGuinness, LA, Higgins, JPT. Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments. Res Syn Meth 2021;12(1):55-61. doi:10.1002/jrsm.1411

Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: Lawrence Erlbaum Associates;1998.

Cochran WG. The comparison of percentages in matched samples. Biometrika 1950; 37(3/4), 256-66. PMID: 14801052

Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327(7414):557-60. doi: 10.1136/bmj.327.7414.557

Calderón MA, Boyle RJ, Penagos M, Sheikh A. Immunotherapy: the meta-analyses. What have we learned? Immunol Allergy Clin North Am 2011;31(2):159-73, vii. doi: 10.1016/j.iac.2011.02.002.

Sterne JA, Egger M. Funnel plots for detecting bias in metaanalysis: guidelines on choice of axis. J Clin Epidemiol 2001;54(10):1046-55. doi: 10.1016/s0895-4356(01)00377-8

Duval S, Tweedie R. Trim and fill: a simple funnel-plotbased method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000;56(2):455-63. doi: 10.1111/j.0006-341x.2000.00455.x.

Egger M, Smith GD, Schneider M, Minder C (1997) Bias in metaanalysis detected by a simple, graphical test. BMJ 1997;315(7109):629-34. doi: 10.1136/bmj.315.7109.629.

Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994;50(4):1088-101. PMID: 7786990

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi:10.1136/bmj.n71

Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011;64(4):401-6. doi: 10.1016/j.jclinepi.2010.07.015

Ben-Pazi H, Cohen A, Kroyzer N, Lotem-Ophir R, Shvili Y, Winter G, et al. Clown-care reduces pain in children with cerebral palsy undergoing recurrent botulinum toxin injections-A quasi-randomized controlled crossover study. PLoS One 2017;12(4):e0175028. doi: 10.1371/journal.pone.0175028

Hansen LK, Kibaek M, Martinussen T, Kragh L, Hejl M. Effect of a clown’s presence at botulinum toxin injections in children: a randomized, prospective study. J Pain Res 2011;4:297-300. doi: 10.2147/JPR.S23199

Houx L, Dubois A, Brochard S, Pons C. Do clowns attenuate pain and anxiety undergoing botulinum toxin injections in children?. Ann Phys Rehabil Med 2020;63(5):393-9. doi: 10.1016/j.rehab.2018.12.004

Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs 1997;23(3):293-7. PMID: 9220806

Luo D, Wan X, Liu J, Tong T. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res 2018;27(6):1785-1805. doi: 10.1177/0962280216669183

Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014;14:135. doi: 10.1186/1471-2288-14-135

Copeland L, Edwards P, Thorley M, Donaghey S, Gascoigne-Pees L, Kentish M, et al. Botulinum toxin A for nonambulatory children with cerebral palsy: a double blind randomized controlled trial. J Pediatr 2014;165(1):140-6.e4. doi: 10.1016/j.jpeds.2014.01.050.

Whelan MA, Delgado MR. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology and the practice committee of the child neurology society. Neurology 2010;75(7):669. doi: 10.1212/WNL.0b013e3181ec670b

Multani I, Manji J, Hastings-Ison T, Khot A, Graham K. Botulinum toxin in the management of children with cerebral palsy. Paediatr Drugs 2019;21(4):261-81. doi: 10.1007/s40272-019-00344-8.

Druschel C, Althuizes HC, Funk JF, Placzek R. Off label use of botulinum toxin in children under two years of age: a systematic review. Toxins (Basel) 2013;5(1):60-72. doi: 10.3390/toxins5010060.

Novak I, McIntyre S, Morgan C, Campbell L, Dark L, Morton N, et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol 2013;55(10):885-910. doi: 10.1111/dmcn.12246.

Brochard S, Blajan V, Lempereur M, Le Moine P, Peudenier S, Lefranc J, et al. Effectiveness of nitrous oxide and analgesic cream (lidocaine and prilocaine) for prevention of pain during intramuscular botulinum toxin injections in children. Ann Phys Rehabil Med 2009;52(10):704-16. doi: 10.1016/j.rehab.2009.09.001

Cantador-Hornero M, Jiménez-Espuch P, de Torres-Garcia I, Contreras-Jiménez M, Martínez-Mezo G, Morales de los Santos J, et al. Sedation analgesia protocol for the injection of botulinum toxin a in cerebral palsy. An Pediatr (Engl Ed) 2019;91(5):317-27. doi: 10.1016/j.anpedi.2018.12.018

Heinen F, Desloovere K, Schroeder A, Berweck S, Borggraefe I, Van Campenhout A, et al. The updated European Consensus 2009 on the use of botulinum toxin for children with cerebral palsy. Eur J Paediatr Neurol 2010;14(1):45-66. doi: 10.1016/j.ejpn.2009.09.005

Bakheit A. Botulinum toxin in the management of childhood muscle spasticity: comparison of clinical practice of 17 treatment centres. Eur J Neurol 2003;10(4):415-9. doi: 10.1046/j.1468-1331.2003.00619.x.

Brochard S, Blajan V, Lempereur M, Garlantezec R, Houx L, Le Moine P, et al. Determining the technical and clinical factors associated with pain for children undergoing botulinum toxin injections under nitrous oxide and anesthetic cream. Eur J Paediatr Neurol 2011;15(4):310-5. doi: 10.1016/j.ejpn.2010.12.006

Zier JL, Rivard PF, Krach LE, Wendorf HR. Effectiveness of sedation using nitrous oxide compared with enteral midazolam for botulinum toxin A injections in children. Dev Med Child Neurol 2008;50(11):854-8. doi: 10.1111/j.1469-8749.2008.03069.x.

Pérez‐Aranda A, Hofmann J, Feliu‐Soler A, Ramírez‐Maestre C, Andrés‐Rodríguez L, Ruch W, et al. Laughing away the pain: A narrative review of humour, sense of humour and pain. Eur J Pain 2019;23(2):220-33. doi: 10.1002/ejp.1309

Kurudirek F, Arikan D, Sarialioğlu A. Effects of therapeutic clowning on pain and anxiety during venous blood sampling in Turkey: Randomised controlled trial. J Spec Pediatr Nurs 2021;26(4):e12352. doi: 10.1111/jspn.12352

Kingsnorth S, Blain S, McKeever P. (2011). Physiological and emotional responses of disabled children to therapeutic clowns: a pilot study. Evid Based Complement Alternat Med 2011;2011:732394. doi: 10.1093/ecam/neq008

Battrick C, Glasper EA, Prudhoe G, Weaver K. Clown humour: the perceptions of doctors, nurses, parents and children. J Child Young People Nurs 2007;1(4), 174-9. doi:10.12968/jcyn.2007.1.4.24403

Koller D, Gryski C. The life threatened child and the life enhancing clown: towards a model of therapeutic clowning. Evid Based Complement Alternat Med 2008;5(1):17-25. doi: 10.1093/ecam/nem033

Javed T, Khan AS, Jarral NA, Taqi Z, Raza M, Shahid Z. Medical Clowning: A Cost-Effective Way to Reduce Stress Among Children Undergoing Invasive Procedures. Cureus 2021;13(10):e18886. doi: 10.7759/cureus.18886

Felluga M, Rabach I, Minute M, Montico M, Giorgi R, Lonciari I, et al. A quasi randomized-controlled trial to evaluate the effectiveness of clown therapy on children’s anxiety and pain levels in emergency department. Eur J Pediatr 2016;175(5):645-50. doi: 10.1007/s00431-015-2688-0.

Cummins D, Kerr C, McConnell K, Perra O. Risk factors for intellectual disability in children with spastic cerebral palsy. Arch Dis Child 2021;106(10):975-80. doi: 10.1136/archdischild-2020-320441.

Pubblicato

2023-01-30

Come citare

Re, L. G., & Fusetti, V. (2023). Efficacia della clown terapia sul dolore procedurale nei bambini con paralisi cerebrale. Revisione sistematica e meta-analisi. Dissertation Nursing, 2(1), 43–62. https://doi.org/10.54103/dn/18716

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