Scoring the APPT provides the individual with 5 subscale scores. The first subscale is pain location and is calculated by counting the number of pain sites marked on the body outline diagram.15 The second subscale is pain intensity and is calculated by using a 10-cm ruler to measure where the child placed his or her line on the word graphic rating scale.15 The third subscale is pain quality that is calculated by counting the number of sensory, affective and evaluative pain descriptor words circled by the child.15 The fourth subscale is temporal pain quality and is calculated by counting the number of temporal pain descriptors identified.15 Finally, adding both pain quality subscales provides a total pain quality subscale score.15
The APPT has been used and validated as a multidimensional measure of child and adolescent pain in a wide variety of conditions.15,26,27 Because this tool does not produce a total score, the APPT in its entirety has not been validated, but each dimension of the tool (location, intensity, quality) has demonstrated adequate reliability and validity independently.15,26,27 Several researchers have used the APPT to assess pain in children with hematologic and oncologic diseases as it is one of the only measures to address the quality of a child's pain.15,26 Responsiveness data have not been reported.
Six measures of pain were deemed reasonable to use by the task force. Although these tools may demonstrate good clinical utility (Table 4), the authors did not recommend or highly recommend these tools for the reasons highlighted below. The Brief Pain Inventory was developed to measure pain in adults with cancer and has been used in those as young as 18 years.45 However, this tool has not been validated in the pediatric population and can therefore not be given a higher ranking despite its relevance to oncology. The COMFORT Behavior Scale is used to measure pain in infants and young children aged birth to 3 years and appears to have sound psychometric properties and good clinical utility.46 There are no studies regarding the use of or validity of this tool in infants with cancer, but it remains a viable option for those under age 3 as none of the recommended or highly recommended measures are appropriate for this age group.
The Visual Analog Scale and the Numeric Rating Scales demonstrate good psychometric properties and clinical utility in the adult and young adult populations but have less impressive psychometric properties or limited study in pediatrics and a lack of research in pediatric oncology.47,48 The Faces Pain Scale-Revised and the Pediatric Pain Questionnaire are the final 2 measures deemed reasonable to use. They both demonstrate good psychometric properties and clinical utility in children but have had inadequate study thus far in the pediatric oncology population.8,40,49,50
The task force did not recommend the use of 7 measures. The Preschool and Adolescent Body Outlines do not measure pain intensity and would therefore need to be combined with another measure to accurately reflect a child's pain.11 The Color Analogue Scale has been shown to be valid and reliable in the acute care setting, but the authors were unable to locate the tool.51 Because of this difficulty in acquiring the sliding scale tool, the measure is not recommended. Similarly, the Rainbow Pain Scale could not be located and does not demonstrate adequate validity and reliability testing.52 The Faces, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale has been used extensively with infants and children, but it is based on caregiver report, not child self-report.53 Also, a recent systematic review uncovered limited and conflicting data regarding psychometric properties of the tool that do not support its use at this time.54 The Pain Squad APP for the iPhone or iPad appeared promising as it was developed for measuring pain in children with cancer.55 However, it only allows pain to be recorded at specific times and therefore does not seem appropriate for use during individual therapy sessions. Finally, the McGill Pain Questionnaire and the Iowa Pain Thermometer demonstrate sound psychometric properties and clinical utility with adults, but have limited study in children.56,57 They are therefore not recommended for use at this time.
The authors recognize that new studies may have been published since the date of this literature search (July 31, 2017). There may be outcome measures that have been excluded from this review because of limited data available at the time. Similarly, a measure may have been given a lower rating score because of lack of study in the target population that has since been rectified. This search was limited to English-language journals, which could also limit the number of measures reviewed. This review did not assess the quality of study methodology, so it is possible that some psychometric data are flawed.
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