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INTRODUCTION

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Chronic pain is a primary feature of juvenile arthritis (JA) (1). Patients with JA often report mild to moderate pain (2–6). Approximately 25–30% report moderate to severe pain (7, 8), and most children with JA report at least some pain lasting from 30 minutes to 24 hours a day, with a mean of 4.3 hours per day (9). A 2-month daily diary study showed that children with JA report pain on an average of 73% of the days, with the majority (76%) reporting pain on >60% of the days (10). Approximately 60% of children with JA report joint pain at disease onset, 50% report pain at 1-year followup, and 40% continue to report pain 5 years later (11). Moreover, adults who as children were diagnosed with JA report significantly more pain, fatigue, and disability than sex-matched healthy controls (12). Therefore, pain is a significant problem for some children with JA that persists into adulthood and is associated with greater disability. However, the above pain references are from 1997 or earlier, which precedes the use of biologic agents. More recent studies have shown lower levels of pain (13).

In order to effectively document and treat JA-associated pain, we need reliable, valid, and clinically useful measures of pain. Both self-report and observational measures of pain have been used to measure pain in children and adolescents (14, 15). However, observational measures are limited for recurrent or chronic pain, as with JA, because overt pain behaviors tend to habituate or dissipate over time (15). Therefore, self-report measures are preferable when measuring JA-associated pain, except with very young children or children with cognitive deficits. Autonomic measures (e.g., pulse) have been used in JA (16), but are not always considered proxy measures of pain (17). The following is a review of self-report and observational pain measures that have been tested with children and adolescents with JA. For measures that have been used for other pediatric acute and chronic recurring pain conditions, please see the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations (18). All but one of the measures included in the current review are self-report measures.

21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Description

Purpose.

The 21–numbered circle VAS measures overall well-being, pain intensity, and overall disease activity in children with juvenile arthritis (JA). The 21–numbered circle VAS was originally examined in adults with rheumatoid arthritis (RA). It was recently evaluated with physician and parent ratings of children with JA.

Content.

Physician and parent report using the 21–numbered circle VAS may be completed as part of a battery of assessments used to monitor symptoms of children with JA being seen in a rheumatology clinic. The domains assessed by the 21–numbered circle VAS include overall well-being, pain intensity, and overall disease activity. Each domain is assessed using a VAS with anchors at each end and 21 circles in 0.5-unit increments. When selecting a rating, the parent or physician fills in 1 of the 21 circles on the VAS.

Number of items.

The 21–numbered circle VAS consists of 3 items: 1) parent global rating of child's well-being, 2) parent rating of child's pain intensity, and 3) physician global assessment of overall disease activity.

Response options/scale.

Parent overall rating of child's well-being is assessed with a 21–numbered circle VAS anchored at “very well” to “very poorly,” with a drawing of a face at each end. Parent rating of child's pain intensity is assessed with a 21–numbered circle VAS anchored at “no pain” to “very severe pain,” with a drawing of a face at each end. Physician global assessment of overall disease activity is assessed with a 21–numbered circle VAS anchored at “no activity” and “maximum activity.” There are no drawings present on this item.

Recall period for items.

Recall period for the 3 domains are as follows: 1) “at this time” for parent overall rating of child's well-being, 2) “in the past week” for parent rating of child's pain intensity, and 3) “at the time of the present visit” for physician global assessment of overall disease activity.

Endorsements.

None.

Examples of use.

Pincus T, Bergman M, Sokka T, Roth J, Swearingen C, Yazici Y. Visual analog scales in formats other than a 10 centimeter horizontal line to assess pain and other clinical data. J Rheumatol 2008;35:1550–8 (13).

Filocamo G, Davi S, Pistorio A, Bertamino M, Ruperto N, Lattanzi B, et al. Evaluation of 21–numbered circle and 10-centimeter horizontal line visual analog scales for physician and parent subjective ratings in juvenile idiopathic arthritis. J Rheumatol 2010;37:1534–41 (19).

Practical Application

How to obtain.

The 21–numbered circle VAS for pediatric rheumatology was developed by researchers in Genoa, Italy (Dr. A. Ravelli, Pediatria II, Istituto G. Gaslini, Largo G. Gaslini 5, 16147 Genoa, Italy. E-mail: angeloravelli@ospedale-gaslini.ge.it).

Method of administration.

Parent and physician report.

Scoring.

The values for each item on the 21–numbered circle VAS may be seen underneath each of the 21 circles. Computer scoring is not necessary.

Score interpretation.

The score range for each item is 0–10. Higher values indicate poorer overall well-being, more severe pain, and more disease activity.

Respondent burden.

Each of the 3 items on the 21–numbered circle VAS requires ∼5–10 seconds to complete.

Administrative burden.

The 21–numbered circle VAS requires 7.4 seconds to hand score.

Translations/adaptations.

The 21–numbered circle VAS was originally evaluated with a sample of adults with RA. It was subsequently evaluated with a sample of children with JA receiving treatment in a rheumatology clinic in Italy.

Psychometric Information

Method of development.

The American College of Rheumatology (ACR) pediatric response criteria for JA (20) were considered during the development of the 21–numbered circle VAS. Two items on the 21–numbered circle VAS (i.e., parent global rating of child's well-being and physician global assessment of overall disease activity) are included by the ACR as criteria demonstrating responsiveness in JA.

Acceptability.

The authors of the only study assessing the 21–numbered circle VAS in a pediatric rheumatology population suggest respondents better understand the measure than a traditional 10-cm horizontal-line VAS. Ceiling effects were found for 32.9% and 43.7% for parent global rating of overall well-being and physician global assessment of overall disease activity, respectively (19).

Reliability.

Not reported.

Validity.

Construct validity for the 21–numbered circle VAS has been established. Spearman's correlations between scores on the 21–numbered circle VAS and other JA outcomes (i.e., the Juvenile Arthritis Functionality Scale, tender joint count, restricted joint count, and active joint count) ranged from 0.42–0.88. Correlations between scores on the 21–numbered circle VAS and laboratory variables (i.e., erythrocyte sedimentation rate and C-reactive protein level) were lower, with a range of 0.33–0.54. Correlations between scores on the 21–numbered circle VAS and the Pediatric Rheumatology Quality of Life scale ranged from 0.30–0.75 (19).

Ability to detect change.

One study established the responsiveness of the 21–numbered circle VAS. Children in this study attended a second clinic visit at a mean ± SD of 6 ± 3 months after an initial visit. At this second visit, physicians and parents rated the child's disease course from the previous visit as: 1) “much improved,” 2) “slightly improved,” 3) “stable,” 4) “slightly worsened,” or 5) “much worsened.” The standardized response mean (SRM) was calculated as the mean score change divided by the SD of the individual's score change. SRM values in children with improved disease were ∼0.8, and in children with worsened disease values ranged from 0.6–0.8. SRM values in children with stable disease were ∼0. Separate physician and parent minimum clinically significant difference (MCID) values were computed by calculating the mean change in score between visits in patients rated as “slightly improved” or “slightly worsened.” MCID values for improvement ranged from −2.2 to −0.6, and ranged from 1.4–2.3 for worsening. MCID values for children classified as “stable” were ∼0 (19).

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

The 21–numbered circle VAS is easy to administer and score. It has been found to perform similarly to a traditional 10-cm horizontal-line VAS. Initial evaluations suggest it may be appropriate for evaluating interventions.

Caveats and cautions.

Ceiling effects of physician rating of disease activity may be a problem in children with well-controlled disease. This problem may not be unique to this measure, but common to JA due to use of increasingly effective treatments (e.g., use of biologic medications). Additional psychometric evaluations, particularly reliability assessments, are needed. Current studies do not include evaluation of child self-report of pain or overall well-being.

Clinical usability.

The 21–numbered circle VAS is appropriate for clinical use. Specifically, it may be more feasible than a traditional 10-cm horizontal-line VAS as scoring does not require the use of a ruler.

Research usability.

The 21–numbered circle VAS is appropriate for research use. It allows for more precise assessment than traditional 10-cm horizontal-line VAS, given that it does not require reproduction of an exact line in printing or photocopying.

E-OUCH ELECTRONIC PAIN DIARY

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Description

Purpose.

The e-Ouch is a multidimensional electronic diary that uses a real-time data capture approach to measure pain intensity, pain unpleasantness, and pain's interference with features of health-related quality of life (HRQOL) in adolescents with juvenile arthritis (JA). The e-Ouch was originally published in 2006.

Content.

A personal digital assistant is programmed to sound an audible alarm to obtain 3 daily pain ratings (upon waking, after school, and before bed). The ratings are designed to evaluate multiple dimensions of pain: 1) sensory discriminant, 2) affective motivational, and 3) cognitive evaluative.

Number of items.

The number of items presented is dependent on whether the adolescent endorses having current pain. If the adolescent does not report current pain, the diary does not present detailed pain questions, and advances to questions regarding stiffness and fatigue. Assuming the adolescent reports pain, they will be presented 12 items in the morning, 15 in the afternoon, and 16 in the evening.

Response options/scale.

Adolescents move a visual analog scale (VAS) slider anchored at “no pain” and “very much pain” to indicate pain intensity. Pain unpleasantness is evaluated using a VAS slider anchored at “not at all unpleasant” and “very unpleasant.” Pain interference is evaluated using several VAS sliders anchored at “doesn't get in the way at all” and “totally gets in the way.” Adolescents report on the level of interference in the following activities: “things you do,” “how you feel,” “walking,” “sleeping,” “enjoying life,” “schoolwork,” and “relationships.”

Recall period for items.

With a few exceptions, items ask adolescents to report how their pain is “right now.” The recall period for the remaining items is “today,” or “last night” when questioning pain's interference with sleep.

Endorsements.

None.

Examples of use.

Stinson JN, Petroz GC, Stevens BJ, Feldman BM, Streiner D, McGrath PJ, et al. Working out the kinks: testing the feasibility of an electronic pain diary for adolescents with arthritis. Pain Res Manage 2008;13:375–82 (21).

Stinson JN, Petroz GC, Tait G, Feldman BM, Streiner D, McGrath PJ, et al. E-Ouch: usability testing of an electronic chronic pain diary for adolescents with arthritis. Clin J Pain 2006;22:295–305 (22).

Practical Application

How to obtain.

The e-Ouch was developed by Jennifer N. Stinson at the University of Toronto (Jennifer N. Stinson, PhD, MSc, BScN, Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Room 276, Toronto, Ontario, M5T 1P8 Canada. E-mail: jennifer.stinson@utoronto.ca).

The e-Ouch is currently being evaluated as part of a study funded by the Childhood Arthritis and Rheumatology Research Alliance. It may be viewed, with permission and a password, online at www.superkidzpain.ca.

Method of administration.

Patient completed.

Scoring.

The e-Ouch is computer scored. Pain indices are reported across the 3 diary entries. Each VAS is measured in millimeters. Scores for the following VAS are reported: pain intensity, pain unpleasantness, pain interference (i.e., activities, mood, walking, sleep, schoolwork, relationships, and enjoyment of life), stiffness, tiredness, and control over pain. The number of painful joints and number of pain words selected by the adolescent to describe current pain are reported. Missing data are handled by summarizing data over time of day, day of week, and week. E-Ouch diary entries are averaged across each of the 3 time periods separately within weekdays and weekends.

Score interpretation.

The range of scores for each VAS is 0–100. Higher scores indicate more pain, unpleasantness, interference, stiffness, tiredness, and control over the pain. Adolescents are able to select each major joint on the body picture. Higher scores indicate a higher number of painful joints. Pain word descriptors are chosen from a list of 30 words, with a range of 0–30.

Respondent burden.

Adolescents complete all 3 daily pain ratings in <9 minutes. It is possible that user fatigue may occur, resulting in decreased compliance over time and subsequent missing data. During usability testing, all adolescent participants (n = 20) stated the e-Ouch was “easy to understand” and “self-explanatory.”

Administrative burden.

The administrative burden associated with the e-Ouch is very low, given automatic electronic data entry and scoring.

Translations/adaptations.

None.

Psychometric Information

Method of development.

Development of the e-Ouch has occurred over 3 phases: 1) usability (i.e., intuitiveness of the user interface), 2) feasibility (i.e., acceptability and adherence), and 3) psychometric evaluation. Usability testing involved semistructured interviews and observation of e-Ouch use by 10 adolescents with JA (22). Changes were made to the e-Ouch based on this initial feedback, and a second iterative cycle of 10 adolescents was completed. Next, 13 adolescents participated in feasibility testing in 2 cycles (21). Technical difficulties evident in the first cycle were addressed in the second cycle. Psychometric evaluation of the e-Ouch began following refinement of the prototype.

Acceptability.

During initial testing, 2 semistructured interviews with 20 adolescents with JA were conducted to evaluate learnability, efficiency, errors, and satisfaction. All of the adolescents stated the e-Ouch was “very easy to learn” and “very easy to use.” The majority of adolescents stated the e-Ouch was “quick” to complete. Errors made during the first cycle of testing were corrected and no errors occurred during the second cycle. All of the adolescents were “very satisfied” with the e-Ouch. Authors of a study evaluating the construct validity and feasibility of the e-Ouch reported 22% of data for electronic pain ratings was missing.

Reliability.

Not reported.

Validity.

Construct validity for the e-Ouch has been established (22). Adolescents with JA completed e-Ouch diary entries 3 times per day for a 2-week period. At the end of the first week, participants used paper VAS ratings to recall their least, average, and worst pain intensity, unpleasantness, and interference rating for the preceding week. At the end of the 2-week period, participants completed the Pediatric Quality of Life (PedsQL) Inventory 4.0, the PedsQL 3.0 Arthritis Module, and the Pain Coping Questionnaire. Statistically significant correlations were found between e-Ouch pain indices and scores from recalled paper VAS ratings. Correlations were positive and ranged from 0.49–0.84. Correlations between e-Ouch pain indices and scores from overall HRQOL, disease-specific HRQOL, and emotion-focused coping ranged from −0.64 to −0.18. Correlations between e-Ouch pain indices and physician-rated disease activity indices were not significant.

Ability to detect change.

Evidence suggests that the e-Ouch is responsive to changes in pain intensity, unpleasantness, and interference in adolescents following intraarticular joint injections. Specifically, medium effect sizes have been reported, with a range from 0.52–0.71 (22).

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

A significant strength of the e-Ouch is its use in real time, which should minimize recall bias. The e-Ouch is appropriate for research use and may be used to evaluate interventions. E-Ouch diary entries contained no errors. This is a significant strength, especially relative to the high number of errors typical for paper diaries.

Caveats and cautions.

Analysis of e-Ouch data requires challenging statistical analyses that may be unfamiliar to many statisticians. Prompting participants to complete diary entries at prespecified reporting times (i.e., a signal-contingent approach) might result in reporting bias due to prespecified reporting times. Further research is needed to examine the effect that self-monitoring may have on pain reports over time in adolescents using the e-Ouch.

Clinical usability.

Consistent use of the e-Ouch in a clinical setting will be more feasible if it can be adapted for electronic medical record format. Likewise, the e-Ouch may be more usable if developed as an application for smart phones (e.g., iPhone) or other personal electronic devices (e.g., iPod).

Research usability.

Initial reports of the psychometric properties of the e-Ouch are promising and provide support for further evaluation. The e-Ouch is feasible for some research use, but will be limited by the resources available to the researcher.

OUCHER

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Description

Purpose.

The Oucher is a single-item measure of pain intensity in children ages 3–12 years. The Oucher has been used extensively in numerous pediatric pain populations. It has been used in 1 published study of children with juvenile arthritis. The Oucher was developed by Judith E. Beyer in 1980. The first published study using the Oucher was in 1992. The metric used for the Oucher was changed from 0–100 to 0–10 in 2000 to be consistent with other visual analog scale (VAS) pain measures (24). A recent review of evidence-based pediatric pain measures rated the Oucher as “well-established” (25).

Content.

The Oucher contains 2 separate scales: a numerical scale and a photographic scale. Only 1 scale is used with any given child. The Oucher provides a measure of current pain intensity.

Number of items.

The Oucher contains 1 item measuring child self-reported pain intensity.

Response options/scale.

The child selects a number (i.e., 1–10) or photograph (i.e., 1 of 6) corresponding to the amount of “hurt” they have.

Recall period for items.

Children are asked, “How much hurt do you have right now?”

Endorsements.

None.

Examples of use.

Schanberg LE, Lefebvre JC, Keefe FJ, Kredich DW, Gil KM. Pain coping and the pain experience in children with juvenile chronic arthritis. Pain 1997;73:181–9 (26).

Practical Application

How to obtain.

The Oucher posters are not currently being produced, but remaining inventory is available for purchase. Posters of the Caucasian, African American, and Hispanic versions of the Oucher may be purchased for $2 each at the following address: Pain Associates in Nursing, PO Box 411714, Kansas City, MO 64141. E-mail address: info@oucher.org. All versions of the Oucher may be downloaded for free from http://www.oucher.org/.

Method of administration.

Patient self-report.

Scoring.

The Oucher does not require computer scoring. If the photographic scale is used, the photograph selection must be converted to an ordinate scale ranging from 0–5: the bottom photograph is scored as 0 and the top photograph is scored as 5. If the numerical scale is used, the child's selection can be recorded directly; no conversions are necessary.

Score interpretation.

The score range for the numerical scale of the Oucher is 0 (“no hurt”) to 10 (“biggest hurt of all”). The photographic scale is anchored by 6 photographs displaying varying degrees of discomfort.

Respondent burden.

Following initial training on how to use the Oucher, ∼15 seconds is required to complete the measure.

Administrative burden.

Approximately 3–4 minutes are required to train a child to use the Oucher. Prior to administering the Oucher, children are asked to complete a series of cognitive tasks to determine which scale is appropriate to administer. Children use the numerical scale if they can count to 100 by ones or tens and they can identify which of any 2 numbers is larger.

Translations/adaptations.

There are 5 versions of the Oucher currently available: 1) white or Caucasian, 2) black or African American, 3) Hispanic, 4) First Nations (boy and girl), and 5) Asian (boy and girl). Psychometric evaluations of the various versions of the Oucher have generally been conducted with children in the ethnic group depicted in the Oucher photographs.

Psychometric Information

Method of development.

The Oucher was developed in line with several recommendations for measures of pediatric pain: 1) required only simple instructions, 2) appropriate for children ages 3–12 years, 3) direct pain or discomfort cues provided, and 4) verbal communication not required (26). Photographs of a child's face while in pain or discomfort were chosen as the direct cue. The photographs were arranged from a neutral expression to one in which the child's face was distorted in pain or discomfort.

Acceptability.

Not available.

Reliability.

Test–retest reliability for the Oucher has been evaluated indirectly. One study used the Charleston Pediatric Pain Pictures to present hypothetical pain stimuli to 50 nonpatient preschoolers ages 3–6 years. The pictures were accompanied by a brief vignette and depicted scenes commonly experienced by preschool children. Each picture was previously rated by 6 experienced child clinicians as representing no pain (e.g., looking at a picture book at home), low pain (e.g., having an adhesive bandage removed), moderate pain (e.g., stubbing toe on sidewalk), and high pain (e.g., burning hand on stove at home). For each of 17 pictures, participants were instructed to use 3 different measures of pain intensity (i.e., Oucher, Pain Thermometer, and Faces Scale) to indicate “how much hurt you would have” in each picture. Thirty-six of the children rated the pictures again 1 week later. The average test–retest correlation of individual items rated using the Oucher was 0.43, with a range of 0.11–0.83 (28).

Validity.

Numerous studies have examined the validity of the Oucher. Content validity was established in a sample of 78 children ages 3–7 years. The children arranged the 6 photographs of the original Oucher according to their perception of least to most hurt. Agreement, reported as Kendall's coefficient of concordance, was 0.73 (29). Construct validity was evaluated in the study described above in Reliability. Intercorrelations between the Oucher and the Pain Thermometer ranged from 0.62–0.86. Intercorrelations between the Oucher and the Faces Scale ranged from 0.70–0.88 (28).

Ability to detect change.

Evidence of the responsiveness of the Oucher was provided by a study of 25 children between the ages of 3.0 and 12.4 years hospitalized for traumatic injuries or surgery. Participants used 3 measures of pain intensity (i.e., the Oucher, the Poker Chip Tool, and a VAS) to provide postoperative pain ratings. Pain ratings occurred within 30 minutes before receiving analgesic medication and at four 1-hour intervals after receiving medication. The mean preanalgesic pain score on the numerical scale of the Oucher was 70, with a range of 30–100. Mean postanalgesic pain scores over the 4-hour period ranged from 29.9–41.3. Paired-samples t-tests demonstrated that postanalgesic pain scores were significantly lower (P < 0.01) at each time interval. The median preanalgesic pain score on the photographic scale of the Oucher (n = 7) was 2, with a range of 2–5. Postanalgesic pain scores ranged from 0–3, with a median of 1. Mean and median postanalgesic scores for each time period were lower than preanalgesic scores for all participants (30).

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

The Oucher is the only pediatric pain tool that includes color photographs of real children who are in pain or discomfort. Other scales use simple line drawings to depict faces. It is appropriate for clinical use. The Oucher attempts to directly address ethnic differences in assessment of pediatric pain.

Caveats and cautions.

Additional evidence is required to demonstrate the validity and appropriateness of the use of the various versions of the Oucher as culturally-specific measures of pediatric pain.

Clinical usability.

The Oucher is appropriate for clinical use. It is likely to be most useful as a basic measure of pain intensity that may be routinely administered in an effort to monitor pediatric pain.

Research usability.

Current psychometric research supports the use of the Oucher for research purposes. More studies are needed to validate the different ethnic versions of the Oucher.

PAIN BEHAVIOR OBSERVATION METHOD

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Description

Purpose.

The Pain Behavior Observation Method measures pain behaviors in children with juvenile arthritis (JA). It is the only observational pain behavior measure validated for use with this population. It was originally published in 1995.

Content.

The Pain Behavior Observation Method uses an interval sampling method to measure the frequency of 6 pain behaviors: 1) guarding, 2) bracing, 3) active rubbing, 4) rigidity, 5) single flexing, and 6) multiple flexing.

Number of items.

Six pain behaviors are coded.

Response options/scale.

Observers code whether each of the 6 pain behaviors occurs during a total of twenty 30-second intervals.

Recall period for items.

Not applicable.

Endorsements.

None.

Examples of use.

Jaworski TM, Bradley LA, Heck LW, Roca A, Alarcon GS. Development of an observation method for assessing pain behaviors in children with juvenile rheumatoid arthritis. Arthritis Rheum 1995;38:1142–51 (31).

Practical Application

How to obtain.

The Pain Behavior Observation Method was developed by Theresa M. Jaworski while at the University of Alabama at Birmingham (Theresa M. Jaworski, PhD, Licensed Psychologist, 6507 Transit Road, Suite B, East Amherst, NY 14051. E-mail: tmj3@buffalo.edu).

Method of administration.

Clinician completed.

Scoring.

Children perform a standardized sequence of behaviors (two 1-minute sitting periods, two 1-minute standing periods, two 1-minute reclining periods, and four 1-minute walking periods). A trained observer views the videotape and codes pain behaviors using an interval-sampling method for a total of twenty 30-second intervals (with a 20-second observation phase followed by a 10-second recording phase for each 30-second interval). Following this method, observed behaviors are only coded as occurring once during any 20-second observation phase.

Score interpretation.

The range of scores is 0–20 for each of the 6 pain behaviors. The range of total pain behavior scores is 0–120. Higher scores indicate greater number of pain behaviors.

Respondent burden.

The Pain Behavior Observation Method requires ∼10 minutes to complete.

Administrative burden.

The Pain Behavior Observation Method requires ∼10 minutes to administer the standardized sequence of behaviors and 10–20 minutes to hand score. Extensive training is required to administer and score the Pain Behavior Observation Method.

Translations/adaptations.

None.

Psychometric Information

Method of development.

The Pain Behavior Observation Method was adapted from an observational method developed by McDaniel and colleagues for use with adults with rheumatoid arthritis (32). Six children were videotaped while completing a sequence of activities (e.g., sitting and walking). These videotapes were reviewed by 4 chronic pain experts to identify and operationally define frequent pain behaviors specific for children and adolescents with JA.

Acceptability.

The physical maneuvers required to conduct the Pain Behavior Observation method are doable for children with JA.

Reliability.

The percentage of overall interrater agreement is 90–95%. The percentage of effective agreement (i.e., occurrences only) is 63–87%. Kappa coefficients range from 0.53–0.79 (31).

Validity.

Correlations between pairs of individual pain behaviors are generally not significant. The amount of variance shared by all possible pairs of behaviors ranged from 13–25%. The total pain behavior score is significantly correlated with functional disability (r = 0.64, P = 0.0001), but not significantly correlated with self-reports of depression. The total pain behavior score is significantly correlated with children and parent visual analog scale ratings of pain (r = 0.50, P = 0.005 and r = 0.48, P = 0.007, respectively) (31).

Ability to detect change.

Not reported.

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

This method is likely to be particularly useful to assess pain in those children who are not able to provide reliable and valid reports of pain (i.e., younger children or those with cognitive deficits). The Pain Behavior Observation Method may provide useful supplemental data to supplement other measures of pain.

Caveats and cautions.

This measure would not be appropriate for use with children who have difficulty ambulating. To date, there is only 1 published study evaluating the Pain Behavior Observation Method with 30 participants. More research is needed to further evaluate the usefulness of the Pain Behavior Observation Method.

Clinical usability.

This method has a number of weaknesses making it not feasible for clinical use. Both administrative and respondent burden are likely to limit clinical use. Extensive training is required to use the Pain Behavior Observation Method. Patients must be able to perform a standardized sequence of behaviors on videotape. Behaviors associated with chronic pain (e.g., joint pain) are difficult to observe reliably due to associated pain habituation.

Research usability.

Current psychometric evaluation supports continued research use. Administrative and respondent burden may limit research use to those projects with the resources required to use the Pain Behavior Observation Method.

PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Description

Purpose.

The PPAT is a multidimensional measure of pediatric pain intensity. The PPAT has been used with school-aged children to measure pain associated with juvenile arthritis (JA), cancer, and surgical operations. It was originally developed in The Netherlands and published in 1990. A recent review of evidence-based pediatric pain measures rated the PPAT as “approaching well-established” (24).

Content.

The PPAT assesses the sensory, affective, and evaluative domains of pediatric pain.

Number of items.

32 word descriptors and a 10-cm visual analog scale (VAS) for current and worst pain intensity.

Response options/scale.

A 10-cm VAS with 1-cm gradations (where 1 = “I have no pain” and 10 = “I have very severe pain”) measures the child's present and worst pain. The child chooses from a list of 32 word descriptors of various aspects of pain.

Recall period for items.

Word descriptors, VAS for current pain intensity, and VAS for worst pain intensity “this week.”

Endorsements.

A Society of Pediatric Psychology task force on evidence-based measures of pain in children identified the PPAT as “approaching well-established.”

Examples of use.

Abu-Saad HH, Uiterwijk M. Pain in children with juvenile rheumatoid arthritis: a descriptive study. Pediatr Res 1995;38:194–7 (33).

Practical Application

How to obtain.

The PPAT was developed by Huda Huijer Abu-Saad while at the University of Limburg, The Netherlands (Huda Huijer Abu-Saad, RN, PhD, FEANS, Professor of Nursing Science, Director, School of Nursing, Faculty of Medicine, American University of Beirut. E-mail: Huda.Huijer@aub.edu.lb).

Method of administration.

Patient self-report, parent report, physician report, nurse report, and interviewer administered.

Scoring.

Pain intensity is scored by measuring the 10-cm scale with a ruler. The word descriptors may be scored 2 ways. The first is to count the number of word descriptors the child chooses to describe their pain. The second is to compute an average pain intensity score from the intensity scores for each of the selected word descriptors.

Respondent burden.

The PPAT requires ∼5–10 minutes to complete. School-aged children report no difficulty understanding the terms used.

Administrative burden.

The PPAT requires ∼5–10 minutes to administer and score.

Translations/adaptations.

The PPAT was originally developed for use in The Netherlands. It has been administered to Arab-American (34) and Jordanian (35) children.

Psychometric Information

Method of development.

The McGill Pain Questionnaire (36) and Pediatric Pain Questionnaire (37) served as models for the development of the PPAT. Ten children ages 9–15 years hospitalized for surgical procedures were asked to describe their pain (38). Their responses were recorded verbatim. A similar procedure was later conducted with 355 healthy children ages 7–17 years (39).

Acceptability.

In the 1 study using the PPAT with a JA population, the authors reported that children ages 7–16 years had no difficulty describing their pain using the PPAT (33).

Reliability.

Interrater agreement correlations between child, parent, and physician VAS pain intensity ratings ranged from 0.32–0.77. Agreement between parent and physician VAS current pain ratings were not significant (r = 0.10) (33). A Cronbach's alpha of 0.83 was reported for the PPAT (39).

Validity.

Content validity has been established (39). Evidence of construct validity has been provided in a factor analysis (39) and in a study investigating postoperative pain reports of 105 children ages 5–15 years before and after analgesic administration (17). This study also provided evidence of convergent validity (17). Participants rated postoperative pain using the 10-cm scale and word descriptors from the PPAT, the Oucher, and a 100-mm VAS. Correlations between the 10-cm scale of the PPAT, PPAT word descriptors, the Oucher, and the 100-mm VAS ranged from 0.88–0.98. Correlations between the number of word descriptors and the 10-cm scale of the PPAT, the Oucher, and the 100-mm VAS ranged from 0.47–0.81. Correlations between the word descriptors and the 10-cm scale of the PPAT, the Oucher, and the 100-mm VAS ranged from 0.02–0.67. Evidence of divergent validity was provided by correlating postoperative pain reports using multiple measures and a scale measuring fear in children (i.e., The Child Medical Fear Scale). Correlations ranged from 0.14–0.26 (17).

Ability to detect change.

Not reported.

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

The PPAT is based on comprehensive theories of pain. It is easy to score and administer and has adequate reliability and validity.

Caveats and cautions.

The PPAT has been used in 1 study with 33 children with JA. The ability of the PPAT to detect change has not been established.

Clinical usability.

The PPAT is feasible for clinical use, but more studies are needed with children and adolescents with JA.

Research usability.

The PPAT is appropriate for research use.

PEDIATRIC PAIN QUESTIONNAIRE (PPQ)

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Description

Purpose.

The PPQ is a measure of pain intensity and location. It has primarily been applied to children with sickle cell disease and juvenile arthritis. It was originally published in 1987. A recent review of evidence-based pediatric pain measures rated the PPQ as “well-established” (25).

Content.

The PPQ assesses the sensory, affective, and evaluative domains of pediatric pain.

Number of items.

6 items.

Response options/scale.

The sensory domain is assessed with child visual analog scale (VAS) ratings of pain intensity and a body outline to describe the location of pain. Having the child choose words that describe their current pain or how they feel when in pain assesses affective and evaluative domains.

Recall period for items.

VAS for current and worst pain “this week” and body outline for current pain.

Endorsements.

A Society of Pediatric Psychology task force on evidence-based measures of pain in children identified the PPQ as “well-established.”

Examples of use.

Varni JW, Thompson KL, Hanson V. The Varni/Thompson Pediatric Pain Questionnaire. I. Chronic musculoskeletal pain in juvenile rheumatoid arthritis. Pain 1987;28:27–38 (37).

Practical Application

How to obtain.

The PPQ was developed by James W. Varni. It may be obtained from www.pedsql.org.

Method of administration.

Patient self-report, parent report, or interviewer administered.

Scoring.

Pain intensity is scored by measuring the VAS with a ruler. The body outline is used to score the number of body sites with current pain and intensity.

Score interpretation.

Range of pain intensity scores using the VAS is 0 (no pain) to 100 (severe pain). Range of pain intensity scores using the body outline is 0 (none) to 3 (severe).

Respondent burden.

The PPQ requires ∼10–15 minutes to complete.

Administrative burden.

The PPQ requires <5 minutes to hand score.

Translations/adaptations.

The PPQ has been translated into Danish, Norwegian, Portuguese, Spanish, Swedish, and French.

Psychometric Information

Method of development.

The PPQ was adapted from the McGill Pain Questionnaire developed by Melzack for use with adults (36). Pediatric psychologists and rheumatologists reviewed items for content appropriateness and feasibility of use with children and adolescents.

Acceptability.

Content was deemed developmentally appropriate for children ages 4–16 years.

Reliability.

Test–retest reliability correlations for 1-week, 3-week, and 6-month intervals ranged from 0.29–0.41 (2). Interrater agreement correlations between child, parent, nurse, and physician VAS pain intensity ratings ranged from 0.40–0.85 (40).

Validity.

Construct validity has been established. Evidence of convergent validity of the PPQ with disease status ranged from 0.27–0.68, and ranged from 0.06–0.45 with psychological functioning (2).

Ability to detect change.

The PPQ is commonly used in pain treatment studies to document changes in pain intensity following intervention.

Critical Appraisal of Overall Value to the Rheumatology Community

Strengths.

The PPQ is a widely disseminated measure of pediatric pain. It assesses pediatric pain using a developmentally appropriate format. The PPQ is appropriate for both clinical and research use.

Caveats and cautions.

There is currently no comprehensive manual with detailed instructions for use of the PPQ.

Clinical usability.

The body outline used in the PPQ is particularly useful to assess pediatric pain in a clinical setting.

Research usability.

The words generated by children and those selected from a list of sensory, affective, and evaluative words is particularly useful for research purposes.

DISCUSSION

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Compared to our original review article of pediatric pain measures for juvenile arthritis (JA) (41), 2 of 3 made it into this current review: the Pain Behavior Observation Method and the Pediatric Pain Questionnaire (PPQ). We dropped the Pain Coping Questionnaire from the previous review because it was not a measure of pain per se. In this review, we added 3 additional measures: the 21–numbered circle visual analog scale (VAS), the e-Ouch Electronic Pain Diary, and the Oucher, which have all been used with children and adolescents with JA. Future research needs to validate these measures in other pediatric rheumatic conditions.

The PPQ has been most widely used and is considered a “well-established” instrument by empirical standards for measuring pain (24). The 21–numbered circle VAS looks very promising and includes parental ratings of their child's global well-being and physician ratings of overall disease activity, which are criteria endorsed by the American College of Rheumatology for demonstrating responsiveness to treatments for JA. The downside to the 21–numbered circle VAS is that there is no child self-report version. The Oucher has been used to assess pediatric acute and chronic pain since being developed by Judith Beyer in 1980, and is a well-established instrument with different ethnic versions and a picture versus a numerical VAS that can be used by younger children. The e-Ouch has very promising VAS and a body outline. Electronic measures are going to be the wave of the future as we move into paperless electronic medical records (EMRs). We need to develop e-versions of pain measures for EMRs as well as web-based programs for children and adolescents with JA and other rheumatic diseases.

Table  . Summary Table of Pediatric Pain Measures*
ScalePurpose/ contentMethod of administrationRespondent burdenAdministrative burdenScore interpretationReliability evidenceValidity evidenceAbility to detect changeStrengthsCautions
  • *

    When information was not available in the published literature, we contacted authors via e-mail to attempt to retrieve information, most notably for ease of administration and scoring. VAS = visual analog scale; NR = not reported; JA = juvenile arthritis; PPAT = Pediatric Pain Assessment Tool; PPQ = Pediatric Pain Questionnaire.

21–numbered circle VASA VAS with 21 circles in 0.5-unit increments measuring overall well-being, pain intensity, and overall disease activityParent and physician report∼5–10 seconds to complete7.4 seconds to hand scoreVAS, 0 (very well) to 10 (very poorly), 0 (no pain) to 10 (very severe pain), 0 (no activity) to 10 (maximum activity)NRConstruct validity establishedResponsiveness to change over time and minimum clinically significant important difference establishedEasy to administer and score, easy to reproduce, appropriate for clinical useNo child self-report, ceiling effects of disease activity
E-Ouch electronic pain diaryElectronic pain diary measure validated with adolescents who have JA Pain intensity, pain unpleasantness, and pain interferencePatient self-report3 daily pain ratings requiring <9 minutes to completeComputer scored100-mm VAS for pain intensity, pain unpleasantness, pain interference, stiffness, and fatigue; body picture (major joints); pain word list (30 pain word descriptors)NRConstruct validity establishedDetects changes in pain ratings in adolescents undergoing joint injectionsUsed in real time, few entry errors, appropriate for research use, feasible in a home settingPotential reactive effects and reporting bias, challenging data analyses
OucherSelf-report measure of pain intensityPatient self-report∼15 seconds to complete once trained to use the Oucher3–4 minutes to train child to use the OucherNumerical scale: 0 (no hurt) to 10 (biggest hurt of all); photographic scale: 0 (no hurt) to 10 (biggest hurt of all)Test–retest range 0.11–0.83Content and construct validity establishedDetects changes in postoperative pain ratings in childrenAppropriate for clinical use, uses color photographsFurther validation of different ethnic versions is needed
Pain Behavior Observation Method
  • Observational pain behavior measure validated with children who have JA

  • 6 pain behaviors (guarding, bracing, active rubbing, rigidity, single flexing, and multiple flexing)

Clinician completed∼10 minutes to complete∼10 minutes to administer, 10–20 minutes to hand scoreScore range 0–20 for each of the 6 pain behaviors; total pain behavior score range 0–120, where higher scores represent greater number of pain behaviorsInterrater agreement: acceptableConcurrent validity establishedNRAppropriate for research use, useful with children unable to provide reliable and valid pain reportsRequires extensive training, not feasible for clinical use, limited research
PPAT10-cm scale of pain intensity and 32 word descriptors of the sensory and affective/evaluative domains of painPatient self-report, parent, nurse, and physician proxy report5–10 minutes to complete5–10 minutes to administer and score10-cm scale: 0 (no hurt) to 10 (severe hurt); pain word list: number of word descriptors and word descriptor intensityInterrater agreement: acceptable Cronbach's α = 0.83Content, construct, convergent, and divergent validity establishedNRBased on comprehensive pain theories, easy to score and administer, appropriate for clinical and research useFurther use in JA population is needed
PPQA measure of pain intensity (VAS) and location (body outline) and the sensory, affective, and evaluative qualities of pain (words describing pain), appropriate for children and adolescentsPatient self-report or interviewer administered10–15 minutes to complete5 minutes to hand scorePain intensity range using VAS 0 (no pain) to 100 (severe pain); body outline intensity range 0 (none) to 3 (severe)Moderate stability Interrater agreement: acceptableConcurrent validity establishedUsed in pain treatment studies to record pre- to posttreatment changes in pain intensityWidely distributed, appropriate for both clinical and research useNo inclusive manual with detailed instructions

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES

Both authors were involved in drafting the article or revising it critically for important intellectual content, and both authors approved the final version to be published.

REFERENCES

  1. Top of page
  2. INTRODUCTION
  3. 21–NUMBERED CIRCLE VISUAL ANALOG SCALE (VAS)
  4. E-OUCH ELECTRONIC PAIN DIARY
  5. OUCHER
  6. PAIN BEHAVIOR OBSERVATION METHOD
  7. PEDIATRIC PAIN ASSESSMENT TOOL (PPAT)
  8. PEDIATRIC PAIN QUESTIONNAIRE (PPQ)
  9. DISCUSSION
  10. AUTHOR CONTRIBUTIONS
  11. REFERENCES
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