This study set out to determine the prevalence of chronic pain and associated factors among children with CP. We found that 64.3 % of these patients who had chronic pain with severe gross motor function level involvement or disability were more at risk. The prevalence of chronic pain in this study is consistent with previous studies done in Malaysia in 2015  and turkey in 2017 , where the prevalence of chronic pain in children with CP in both 2 studies was found to be 65%. Also, the prevalence of pain in children with CP in this study is similar to a previous report that indicated that around 60 % of children with CP experience recurrent pain on a daily or weekly basis that significantly interferes with their daily activities . In this study, the most common type of CP with the highest prevalence of chronic pain was spastic bilateral CP. Knowing that children with spastic bilateral CP have more severe functional motor limitation and experiencing stiffness and contractures which usually prone them to ongoing pain. A similar pattern was found in a study done by Badia et al. in 2014 where most participants with pain had bilateral spastic . Participants with GMFCS, MACS, CFCS, EADACS level IV, V had the highest prevalence of pain in this study; these findings are concurring with a previous cross-sectional multi-centre European study done by Gibson et al. in 2009 that reported a higher frequency and severity of pain commonly found if the child is more severely impaired in terms of walking ability, hand function, feeding and communication difficulties, intellect and CP type . Another study done in Sweden in 2017 by Lena et al indicated that children with Level V in both Gross Motor Function Classification System (GMFCS) and Manual Ability Classification System (MACS) were associated with the highest prevalence of pain . Furthermore, 2 other studies done by Parkinson et al.in 2013  and Barney et al in 2013  discovered that pain frequency, intensity, and duration were significantly predicted by GMFCS level, being greater among children with a higher GMFCS level 4,5. Similarly, a study done in Turkey in 2017 , showed that children with GMFCS 4,5 had a high percentage of getting pain compared to patients at GMFCS levels 1, 2, and 3. In this study majority of participants had moderate pain. A similar pattern was reported in a study done in Malaysia by Subhashini et al. in 2015 where patients with moderate pain were more than those with severe pain . These findings are also similar to a previous study done in Spain that showed that persons with CP experience recurrent pain of moderate-intensity on a daily or weekly basis that significantly interferes with daily activities .
Epilepsy, sleep disorders, vision impairment, hearing impairment, dental caries, malnutrition, gastro-esophageal reflux disease, behavioral problem, and learning problem were comorbid conditions in children with pain and CP in this study. These findings are similar to a previous study done by Badia et al. in 2014, where epilepsy, hearing disabilities, visual disability, behavior problem, communication problem, feeding problem were the most common comorbid conditions in children with pain and CP . Another study done by Raymond et al. presented similar findings to ours where the commonest comorbid conditions that parents reported in their children with pain and CP were a developmental delay, vision problem, learning problem, behavior problem, speech problem, seizure disorder, hearing impairment, and sleep disturbance . In this study, we found that gross motor function classification level 4 & 5, Communication function classification level 4 & 5, eating and drinking ability classification system level 4 & 5, female participants, and caretaker age of more than 30 years were independently significant factors associated with chronic pain. Indeed in the multi-centre European cross-sectional study done by Parkinson et al.in 2009, it was reported that a higher frequency and severity of pain was common if the child was more severely impaired in terms of walking ability, hand function, feeding and communication difficulties, intellect and CP type . Knowing that patients with GMFCS, EADACS, CFCS level 4 & 5 usually have a severe disability in term of motor impairment and persons with severe impairment tend to have more spasticity, which causes ongoing pain. Also in this study, we found that female participants had at least two times the odds of having chronic pain compared to the male child. A similar pattern was reported by Christine et al, in 2004 where the female was reported to have a greater frequency of pain compare to the male . Children with older caretakers (30+ years) were less likely to have chronic pain. This may be explained by the fact that older caretakers have much more experience of recognition of pain, and may be giving more support to relieve this chronic pain.
The limitation of this study was a relatively small sample size. The nature of the study design could only describe chronic pain among children with CP. The type and location of pain could not be clearly ascertained when dealing with children with speech and cognitive impairments. Although we used validated tools from previous studies, children with CP in sub-Saharan African countries could have benefited from an adjusted tool regarding local realities.