Ò

PAIN 155 (2014) 851–858

www.elsevier.com/locate/pain

Topical review

Where it hurts: A systematic review of pain-location tools for children

James K. Hamill a,b,⇑, Mataroria Lyndon b, Andrew Liley c, Andrew G. Hill b
a
Paediatric Surgery, Starship Children’s Hospital, Private Bag 92024, Auckland 1172, New Zealand
b
Department of Surgery, University of Auckland, South Auckland Clinical School, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand
c
Department of Anaesthesia, Starship Children’s Hospital, Private Bag 92024, Auckland 1172, New Zealand

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

1. Introduction Von Baeyer et al. recently reviewed pain charts for pediatric
pain-location assessment, noting 2 widely published multidimen-
sional assessments, the Adolescent and Pediatric Pain Tool (APPT)
and the Pediatric Pain Questionnaire (PPQ), along with other pen-
. . .human figure drawing represents a concept of body image as
cil-and-paper, electronic and online charts [61]. The authors
experienced at that time; it will tend to express, unconsciously
touched on pertinent issues, including how intensity by location
and symbolically, the hurt. . .
should be measured and the validity of pain charts, but they
[Di Leo 1973 [14]]
focused primarily on chronic and recurrent pain [61]. To date,
no systematic reviews of pain charts in children have been
1.1. Rationale performed.

Location is a pain dimension routinely noted in histories but

seldom recorded on observation charts. Pediatric nurses use a vari- 2. Objectives
ety of validated self-report pain-intensity tools, such as faces pain
scales [6,21,65], visual analogue scales [43], color analogue scales The primary goal of this systematic review is to analyze evi-
[43], and verbal-numeric rating scales [3,12,35,60,62]. These are dence for the validity and reliability of all graphic-based pain-loca-
unidimensional scores of pain severity; none record intensity by tion tools reported in the pediatric setting. Specifically, we
location when more than one part of the body hurts. Pain scores examine, in children and adolescents, the reliability and validity
can guide systemic analgesic administration [59], but because of body charts, drawings and other graphical methods for docu-
the site of pain may not directly influence the care delivered by menting pain location reported in published papers or theses.
nursing staff there may be little motivation to record location.
Location is relevant in multifocal conditions, such as sickle cell
3. Methods
disease, arthritis and cancer. In acute pain, location may surprise
and have therapeutic implications; for example, when a child iden-
3.1. Inclusion criteria
tifies pain caused by an intravenous line rather than the throat
after tonsillectomy [34]. Laparoscopic surgery involves multiple
1. Children or adolescents up to 20 years of age.
incisions, and pain may arise from the peritoneal inflammation at
2. Pain location score or assessment able to be analyzed quan-
other sites or may be poorly localized, vagally mediated visceral
titatively or qualitatively.
pain [9]. Use of regional nerve blocks or peritoneal local anesthetic
3. Graphical, i.e., diagram- or drawing-based.
techniques further underline the need for pain-location assess-
4. Evidence of validity or reliability presented in the paper,
ment [44,68].
whether or not a specified aim of the study.
Palmer espoused the diagnostic benefits of the pain chart (body
outline drawings) 75 years ago [39]. Di Leo recognized children’s
3.2. Exclusion criteria
expression of inner pain in their use of pencil and paper [14].
1. Case reports.
⇑
Corresponding author. Address: Department of Paediatric Surgery, Starship 2. Studies reported only as abstracts.
Children’s Hospital, Private Bag 92024, Auckland 1142, New Zealand. Tel.: +64 9 3. Studies involving adult participants, without a separately
3797440; fax: +64 9 3078952.
E-mail address: jamesh@adhb.govt.nz (J.K. Hamill).
analyzed pediatric or adolescent group.

0304-3959/$36.00 Ó 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.pain.2013.11.019
 Ò
852 J.K. Hamill et al. / PAIN 155 (2014) 851–858

3.3. Comparisons and measures Table 1

Search strategy for MEDLINE OvidSP interface.

For validity, we included measures of face and content validity, Search terms Articles
concurrent validity, and all comparisons adding to the construct 01. pain ADJ drawing*

validity of pain charts as well as, for reliability, any measure of 02. pain ADJ diagram*
inter-rater or test-retest reliability. 03. pain ADJ location*
04. pain ADJ map*
05. body outline*
3.4. Information sources
06. line drawing*
07. body map*
Drawing from the Cochrane Handbook for Systematic Reviews 08. homuncul*
of Interventions [22], we selected a priori 17 electronic databases 09. mannequin* or manikin* or mannikin*
of medical, nursing and psychology literature, encompassing 10. Combine 1–9 5932
11. scale*
bibliographic databases, including MEDLINE (Ovid and Pubmed 12. score*
interfaces, 1946–present); EMBASE (1980–present); and 13. assessment*
CENTRAL/CCTR; subject-specific databases, including PsycINFO 14. measurement*
(1806–present); CINAHL Plus (1937–present); and AMED 15. pain measurement (MeSH)
16. Combine 11–15 2109940
(1985–present); citation indexes, including Scopus and Web of
17. 10 and 16 2234
Science; dissertations and theses, including ProQuest Disserta- 18. pain (MeSH) or pain (keyword) 426040
tions & Theses and Index to Theses; the International Clinical Tri- 19. 17 and 18 630
als Register; the Cochrane Database of Systematic Reviews; the 20. Limit to human, child and adolescent 126
journal-specific database ScienceDirect; and gray literature, MeSH, MEDLINE subject heading.
including PsycEXTRA and OpenGrey. We tracked citations from *
OvidSP truncation wild card.
key papers and review articles, searched for papers published
by leading authors in the field, surfed pain-association websites, 3.8. Data items
including the International Association for the Study of Pain,
the American Academy of Pain Medicine and the Wong Baker Information extracted from each study included: (1) the charac-
Faces Foundation; and we interrogated the Australia and New teristics of participants, including age, gender, diagnosis (e.g.,
Zealand Clinical Trials Register to search for trials planned or un- arthritis, cancer) and setting (e.g., hospital, outpatient); (2) the
der way. No language limits were applied, and foreign papers measurement method (e.g., body outline, free drawing, electronic)
were translated. Searching began on 14 March 2013 and ended and whether it recorded intensity by location; (3) qualitative or
on 4 May 2013. quantitative evidence for face or content validity; (4) quantitative
evidence for concurrent, convergent or construct validity; (5)
3.5. Search reliability correlations (test-retest or inter-rater).

The search strategy combined 3 concepts: pain, measurement
and location. For each we developed a list of synonyms and related
words, allowed for alternative spellings, and added corresponding
standardized subject terms for each database. For example, terms
related to location included drawing, diagram, body map, body
outline, homunculus, and manikin. Each aspect was built up
separately, then merged using the appropriate Boolean operators
(joining words) or For example, in the MEDLINE database (Ovid
interface) the Boolean term or joined synonyms, and the term
and joined together the 3 concepts (Table 1).
3.6. Study selection
We collated the literature in an Endnote reference manage-
ment library and took an iterative approach to study selection.
In the first 2 phases, 1 author (JKH) screened titles and abstracts
followed by full-text articles for eligibility based on child or
adolescent participants and diagram/drawing pain location
assessments. In the third phase, 2 authors (JKH, ML) indepen-
dently assessed articles for validity or reliability content in a
standardized manner using a check list. Concordance was 0.875
(agreed include, 23/64; agreed exclude, 33/64; variance, 8/64
articles). We resolved disagreements by consensus (4 further
articles included).
3.7. Data collection process
We developed a data-extraction form during a preliminary
search phase. The data form doubled as the eligibility check list
(see study selection). One reviewer (JKH) extracted demographic
data. Two reviewers (JKH, ML) independently extracted evidence
of validity and reliability, resolving differences by consensus.
3.9. Quality of individual studies
To assess quality, we modified Jerosch-Herold’s Checklist for the
Critical Appraisal of Validity, Reliability and Responsiveness Stud-
ies [29] and added a 10-point rating scale in an attempt to quantify
individual study quality. Jerosch-Herold designed a method of
appraising studies based on outcome measures and facilitatating
systematic reviews, recognizing their paucity in the literature
[29]. The original checklist contained 14 yes/no tick boxes under
the headings methods, results-validity, results-reliability, and re-
sults-responsiveness [29]. Our modified version awarded points
for methods (4), results-validity (6) or results-reliability (5)
(Appendix A).
3.10. Summary measures
To assess validity we extracted correlations and ratios (pre-
sented as percentages). To describe correlations, we interpreted
<0.3 as weak, 0.3–0.7 as moderate and >0.7 as strong. The hetero-
geneic nonoutcome nature of the data precluded meta-analysis.
3.11. Methods of analysis
Adapting Hawe et al.’s Theorising Interventions as Events in
Systems, we regarded pain location and its assessment as a com-
plex system and constructed a network model to represent rela-
tionships among measurements and the variety of comparisons
contributing to construct validity [20]. Measurements included:
(1) the specific site of pain; (2) the summation of the number of
painful sites on a body outline divided into segments, or the sur-
face area drawn on a body outline; (3) mean pain intensity, defined
as the sum of pain-intensity ratings at each site divided by the
 Ò
J.K. Hamill et al. / PAIN 155 (2014) 851–858 853

number of painful sites (used for the Pediatric Pain Questionnaire

[58]); (4) recognizable patterns of pain drawn either freely or on
a body outline (Fig. 1).

4. Results

4.1. Study selection

We uncovered 25 references to 24 studies [1,7,10,11,13,17,19,

24,26,27,30,34,36,37,46–53,56,57,63]. Searches found 655
citations (after excluding duplicates) of which 515 were excluded,
based on titles and abstracts, for the following reasons: 126 did not
address pain measurement; 247 did not address pain location; 120
addressed location but included only adult participants; 5 were
case reports; and 17 were review articles. Full-text review of the
remaining 140 studies excluded 78 in the second phase (single re-
viewer) and 37 in the third phase (2 reviewers). Included studies
comprised 3 dissertations [10,24,63] and 1 chapter in a textbook
[16]; the rest were journal papers. Jacob reported her work in both
a dissertation [24] and a paper [27]; we found no inconsistencies
and regarded the 2 reports as a single study. A research assistant Fig. 2. Flow diagram of study selection process.
translated 1 article that was written in Chinese [11]; all other
articles were in English (Fig. 2 and Table 2). Table 2
Studies excluded after full-text review, with reasons.
4.2. Study characteristics
Single-reviewer assessment N
Not child or adolescent 20
4.2.1. Participants
Pain location not assessed 22
A total of 2342 children and adolescents were represented: 52% No diagram/drawing pain location tool 23
female, average age 10 years (1 paper did not report the number of Case report 2
participants [7]; 6 reported no gender [1,7,11,17,36,50]; and 10 re- Abstract 3
ported no average age [7,10,11,17,30,36,46,48,56,57]). More than Review 8
2-reviewer assessment
one third (37%) of the studies involved children in the hospital with Did not assess validity or reliability of pain location 37
acute illnesses, and the remainder involved children suffering
chronic or recurrent conditions: arthritis, sickle cell disease, cancer,
spina bifida, or headache or were patients of chronic-pain clinics. The PPQ incorporates a line drawing of front and back views of a
No paper addressed pain location in laparoscopic surgery. Of the child. Children choose a crayon color to represent mild, moderate
studies, 16 arose from North America [13,17,26,27,30,34,37,46– or severe pain. A transparent overlay divides the diagram into 78
49,51–53,56,57]; 5 from Europe or the United Kingdom sectors for scoring. Average pain equals the sum of severity scores
[1,7,19,36,50]; and 3 from Asia [10,11,63] (Table 3). divided by 78. Two studies evaluated PPQ [49,63].

4.2.2. Tools
 Body outlines: All but 4 studies used some form of body outline.
The APPT incorporates an outline drawing of the front and back
of a child. Children are asked to ‘‘color in the areas on these draw-
ings to show where you have pain.’’ Ten studies evaluated APPT, 4
in the acute hospital or postoperative setting. The number of APPT
studies equaled the number of studies using all other forms of body
outlines combined (Fig. 3).
 Electronic: Two studies assessed electronic tools, each incorpo-
rating a body outline [7,53].
 Free drawings: In 2 studies, children drew pictures of themselves
in pain [51,52].
 Picture communication aids: Mesko et al. used picture flash cards
to depict possible pain sites for children after tonsillectomy [34]
(Table 3).
4.3. Study quality

The mean quality score was 4.4/10 (SD 1.7), range 2–8. The
highest quality scores were achieved for studies utilizing the APPT
for acute conditions (Table 4 and Fig. 3).

4.4. Results of individual studies

Individual study results are presented in Tables 5–7.

Fig. 1. Network model showing 4 pain-location measures (solid squares) connected 4.5. Synthesis of results
to 3 groups of validity comparators (open circles). Pain-location measures, solid
squares: (A) pain site; (B) number of painful sites or surface area drawn on diagram;
(C) average pain (sum of pain intensity at each site divided by the number of painful Because the participants, methods and measurements varied
sites); (D) spatial pattern drawn. Validity comparators, open circles: (1) children markedly, we analyzed the results in a qualitative synthesis.
point to where they are sore; (2) clinical: (2a) clinical diagnosis/clinically apparent
sites of pain on examination; (2b) disease time course; (2c) expected spatial
4.5.1. Validity
distribution of pain; (3), questionnaires/scores: (3a) concurrent validity with
another pain location score; (3b) Health Related Quality of Life scores; (3c) Disease To gather disparate methods into a sensible synthesis we
Severity Index; (4) potential pain-causing factors. looked to systems theory and developed a network model. To build
 Ò
854 J.K. Hamill et al. / PAIN 155 (2014) 851–858

Table 3
Characteristics of the children in each study.

Author, year Participants Tool N F% Age

Mean SD Range
Adamson 2007 School BO (Nordic) 679 – 12.83 0.90 11–14
Calam 2000 Hospitalized Computer – – – – 4–18
Cheng 2002 Hospitalized BO (Eland) 90 50 – – 5–14
Chiang 1994 Hospitalized BO (Eland) 80 – – – 5–14
Dampier 2002 Sickle BO (APPT) 39 51 10.90 3.60 5–19
Eland 1977 Hospitalized BO (Eland) 172 – – – 4–10
Guariso 1999 Gastroent. BO (Eland) 86 52 9.50 3.00 4–15
Jacob 2001, 2003 Sickle APPT 27 41 13.56 4.34 5–19
Jacob 2008 Cancer APPT 44 41 8.90 1.90 8–12
Jerrett 1985 ENT OP Drawings 40 55 – – 5–13
Mesko 2011 ENT postop Pictures 27 30 6.58 1.58 3–9
O’Donnell 1985 Recurrent BO (APPT) 32 – – – 4–14
Palermo 2006 CF BO (APPT) 46 52 12.90 3.00 8–17
Savedra 1989 Hospitalized APPT 171 49 13.00 – 8–17
Savedra 1990 Postop APPT 55 51 – – 8–17
Savedra 1993 Postop APPT 65 52 – – 8–17
Schanberg 1997 Arthritis PPQ 56 64 12.40 3.50 6–20
Staes 1999 Back pain BO 67 – 16.62 0.57 16–18
Stafstrom 2002 Headache Drawings 226 53 11.40 3.40 4–19
Stafstrom 2005 Headache Drawings 111 59 11.60 3.10 5–18
Stinson 2006 Arthritis e-Ouch 20 80 13.55 2.68 10–18
Van Cleve 1993 Hospitalized APPT 46 48 – – 4–7
Van Cleve 2004 Leukemia APPT 95 42 – – 4–17
Von Weiss 2003a Arthritis PPQ 68 62 10.44 2.94 6–18

APPT, Adolescent and Pediatric Pain Tool; BO, body outline; F, females; N, number of participants; OP, outpatient; PPQ, Pediatric Pain Questionnaire.
a
Age mean plus SD imputed from the subgroup data in study.

 Construct (3): Some scoring systems should correlate with certain

pain locations. A variety of clinical scores correlated with the
number of painful sites drawn on body outlines. Specific qual-
ity-of-life scores and body outline drawings correlated as one
might expect; for example, respiratory-specific quality of life
decreased as chest pain markings increased: moderate negative
(in the expected direction) correlations of r = –0.37 to –0.62).
Correlation of the Disease Severity Index with body outline
markings varied from weak to moderate in difference studies
(r = 0.09–0.41) (Tables 5 and 6).

Fig. 3. Bubble graph of mean study quality (y-axis) for studies involving children
with acute or chronic conditions (x-axis) for the Adolescent and Pediatric Pain Tool
(APPT) and other tools utilizing a body outline (BO). Bubble volume = number of
studies (data labels within bubbles).
the model we extracted from the studies the various pain location
may be expressed (represented as open circles in Fig. 1). For exam-
ple, children can point to where they are sore; a nurse may note a
clinically painful site such as an incision; a clinician will make a
diagnosis associated with a known pain distribution pattern, e.g.,
migraine. These validity comparators link to various measure-
ments taken from the pain location tools.
 Construct (1): Children can point to where they are sore. Pointing
to ‘‘where it’s sore’’ correlated positively and significantly with
drawings on body outlines, and was concordant with the spe-
cific site drawn, the number of sites drawn and the surface area
drawn on the body outlines: moderate correlation of r = 0.57
and concordance of 83%–94% with pointing (Tables 5 and 6).
 Construct (2): Clinicians can evaluate sites and expected patterns of
pain. Clinically apparent painful sites, the spatial distribution or
an expected disease course correlated with body outline mark-
ings: moderate correlations of r = 0.54–0.57 and concordance
74%–100% (Tables 5 and 6).
4.5.2. Reliability
Taken together, the studies demonstrated moderate reliability.
All assessments of reliability in surgical patients were by Savedra
et al., who calculated inter-rater reliability for coding the location
of pain, the number of sites marked, the surface area, and the
reversal errors [47]. Right-left reversals occurred in 10.3% and
front-back reversals in 4.6% [47]. The reliability of the body outline
surface area, number of segments and specific segments marked
was in the fair to moderate range.
5. Discussion
5.1. Summary of evidence
Overall, the literature presents moderately strong evidence that
pain location can be measured in children, and graphic tools are
valid and reliable. The evidence is insufficient to recommend any
current tool for use in pediatric surgery, and no tool has been eval-
uated for pediatric laparoscopic surgery.
A significant body of evidence exists for body outline tools in
acute and chronic pediatric conditions. The APPT has been most
extensively evaluated. The 3  3 gridded abdomen of Guariso
et al. has not been evaluated in surgical patients, but the concept
has proven to be useful in developing an assessment in pediatric
surgery [19]. Free drawings have been validated in recurrent head-
ache/migraine and ear-nose-throat pain, but their limited ability to
classify and score location may limit more general applicability.
 Ò
J.K. Hamill et al. / PAIN 155 (2014) 851–858 855

Table 4
Critical appraisal checklist of study quality (adapted from Jerosch-Herold).

Author Aims clear Sample size Valid face Valid construct Reliability Score
Adamson 202007 3
Calam 2000 2
Cheng 2002 6
Chiang 1994 2
Dampier 2002 6
Eland 1977 5
Guariso 1999 4
Jacob 2001, 2003 6
Jacob 2008 4
Jerrett 1985 3
Mesko 2011 3
O’Donnell 1985 5
Palermo 2006 3
Savedra 1989 8
Savedra 1990 5
Savedra 1993 7
Schanberg 1997 3
Staes 1999 5
Stafstrom 2002 5
Stafstrom 2005 5
Stinson 2006 2
Van Cleve 1993 7
Van Cleve 2004 2
Von Weiss 2003 5

Scoring: Aims clear: aim to assess validity or reliability stated indirectly, 1 point; overtly stated, 2 points. Sample size: >25, 1 point; if power analysis, 2 points. Face/content
validity, 1 point. Construct/convergent validity: 2 points for the first comparison, 4 points for a second comparison. Inter-rater or test-retest reliability: 2 points one; 4 points
if both. Highest possible score, 10.

Table 5
Validity evidence from correlations between the number of painful sites marked on body outline and a concurrent pain score, HRQOL scores and a disease severity score.

Study Measure Comparator m c n r

Van Cleve 1993 Pain site Pointing A 1 46 0.57
Von Weiss 2003 Number of sites Number of clinically active joints B 2a 34 0.54
Von Weiss 2003 Average pain Number of clinically active joints C 2a 34 0.57
Palermo 2006 Chest pain Physical functioning CFQ-R B 3b 46 -0.53
Palermo 2006 Number of sites Physical functioning CFQ-R B 3b 46 -0.37
Palermo 2006 Chest pain Respiratory symptoms CFQ-R B 3b 46 -0.50
Palermo 2006 Number of sites Respiratory symptoms CFQ-R B 3b 46 -0.49
Palermo 2006 Abdominal pain Digestive symptoms CFQ-R B 3b 46 -0.46
Palermo 2006 Number of sites Digestive symptoms CFQ-R B 3b 46 -0.62
Palermo 2006 Number of sites Disease Severity Index B 3c 56 0.41
von Weiss 2003 Number of sites Disease Severity Index B 3c 34 0.09
von Weiss 2003 Average pain Disease Severity Index C 3c 34 0.27

CFQ-R, Cystic Fibrosis Questionnaire-Revised (a disease-specific health-related quality-of-life score); c, construct (see Fig. 1); HRQOL, health-related quality of life; m,
measure; n, number of participants in study; r, correlation.
Note: Correlations: Spearman rank sum from Palermo 2006, Scanberg 1997; zero order correlations von Weiss 2003; correlation type not stated in van Cleve 1993 or Mack
2009.

Picture communication cards, as reported by Mesko et al., may be
useful in certain conditions, but they limit children to choosing
from predetermined pictures [34].
Nongraphical assessments were excluded from the present
study, but they include the most common method in clinical prac-
tice, the patient interview. Another approach is the checklist of
anatomical sites; this has been used in several epidemiology stud-
ies of pain in children and adolescents [15,23,42].
Von Baeyer et al. reviewed published pain charts for children,
noting how they differ from simple checklists and discussing scor-
ing methods (including transparent overlays to divide the body
outline diagram into a number of segments); technical details of
the drawings (including gender, clothing, etc.); and the age at
which children may be able to report pain location accurately
[61]. While pain location can be assessed in young children, von
Baeyer et al. noted that children under 8 years of age may need
adult guidance in completing pain charts [61].
Electronic approaches are tantalizing, but we discovered just 2
reports presenting face validity [7,53]. Several electronic pain-
location tools have been described for personal computers
[4,7,33,64], personal digital assistants (PDAs) [53,54] and the
web [25,28,31]). An electronic version of a faces pain scale was
completed with greater accuracy and compliance by 8- to
16-year-olds compared to the paper version in a randomized
controlled trial by Palermo et al.; however, technical failure,
breakages and losses were problems with PDA devices [38]. Wood
et al. found that 87% of 4- to 12-year-old children preferred the
PDA to the paper version of the revised faces pain scale [66].
Stinson et al. demonstrated construct validity for the intensity
component of a multidimensional electronic pain diary but did
not evaluate the location component [54].
Local anesthetic techniques have progressed since Wright
demonstrated the efficacy of bupivacaine wound infiltration for
analgesia in pediatric appendectomy [67]. The transverse abdomi-
nal plane block provides effective analgesia after open appendec-
tomy [8] but confers little benefit over port-site local anesthetic
infiltration in a study of laparoscopic appendectomy [44]. Laparo-
scopic appendectomy generates less pain than the open approach
 Ò
856 J.K. Hamill et al. / PAIN 155 (2014) 851–858

Table 6
Clinically apparent sites of pain correlate with body outline mark.

Study Measure Comparator m c n %

Savedra 1989 Pain site Pointing A 1 175 94
Savedra 1989 Number of sites Pointing B 1 175 91
Savedra 1989 Surface area Pointing B 1 175 83
Cheng 2002 Pain site Surgical site and medical diagnoses A 2a 90 100
Eland 1977 Pain site Child’s pathology, surgical procedure or painful events A 2a 172 98
O’Donnell 1985 Pain site Final confirmed diagnosis A 2a 32 84
Savedra 1989 Pain site At least 1 clinically apparent pain site A 2a 175 98
Savedra 1989 Pain site All clinically apparent pain sites A 2a 175 80
Savedra 1990 Pain site Clinically apparent pain sites A 2a 55 94
Savedra 1993 Pain site Surgical incision marked at least once A 2a 65 98
Savedra 1993 Pain site Incision site marked every day A 2a 65 74
Van Cleve 1993 Pain site At least 1 painful site (IV line, dressing, etc.) A 2a 46 100
Van Cleve 1993 Number of sites Clinically apparent pain sites B 2a 46 96*
Jacob 2001, 2003 Number of sites Resolution of acute sickle cell crisis B 2b 27 –
Savedra 1993 Number of sites Daily reduction in pain post-operatively B 2b 65 –
Stafstrom 2005 Spatial pattern Migraine headache diagnosis D 2b 111 –
Dampier 2002 Spatial pattern Expected distribution of sickle cell cf. other pain D 2c 39 –
Guariso 1999 Spatial pattern Gastrointestinal pain diagnosis D 2c 86 –
Jacob 2008 Spatial pattern Compared lymphoma, leukaemia & sarcoma D 2c 44 –
Stafstrom 2002 Spatial pattern Migraine vs not migraine headache D 2c 226 –
Adamson 2007 Spatial pattern School bag weight carrying method D 4 679

c, construct (see Fig. 1); m, measure; n, number of participants in study.

*
Imputed ratio of mean number of sites drawn by children (2.89) to sites clinically apparent to the investigators (3.00).

Table 7
Inter-rater and test-retest reliability of pediatric pain-location assessments.

Study Methods Concordance% K

Jerrett 1985 That drawings signified location of pain IR 77

Savedra 1989 Left/right reversal IR 93

Savedra 1989 Front/back reversals IR 92
Savedra 1989 Number of sites marked (range of K for pairs of observers) IR 78 0.55
0.71
Savedra 1989 Location of sites (range of K for pairs of observers) IR 75 0.30
0.35
Savedra 1989 Surface area (range of K for pairs of observers) IR 66 0.36
0.47
Stafstrom 2002 Usefulness of drawings to differentiate migraine headache IR 0.92
Stafstrom 2005 Serial pictures of migraine were either improved or not improved IR 89 0.77
Staes 1999 Agreement for neck location TT 95
Staes 1999 Agreement for thoracic location TT 94
Staes 1999 Agreement for lumbar location TT 100
Staes 1999 Agreement for pain radiation TT 100
Savedra 1993 Number of body segments marked each postoperative day correlates: 0.55–0.91 TT

IR, inter-rater reliability; K, kappa statistic; TT, test-retest reliability.

[18,45] but remains a painful operation [55]. Multiple incisions
(umbilical, left iliac fossa, suprapubic) distant from the primary
pathology site (right iliac fossa) complicate pain assessment. Taken
together, the challenges in postoperative pain management argue
for the need for pain-location assessments validated for pediatric
surgery.
5.2. Limitations
5.2.1. Review-level limitations
The present article reviews studies of validity and reliability.
We followed the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) guidelines, although they are for re-
views of studies of interventions [32]. Methodology for certain as-
pects of the PRISMA statement has not been developed for validity
and reliability studies; for example, the assessment of bias. We
modified Jerosch-Herold’s Checklist for the Critical Appraisal of
Validity, Reliability and Responsiveness Studies [29] and added a
scoring system; however, we have no evidence for the validity of
such a score. The modified checklist awarded points for clearly sta-
ted aims; however, excellent validity data can be obtained from
randomized controlled trials or other studies not necessarily de-
signed to assess validity, reliability or responsiveness, and this
could be considered a limitation of our quality score. The risk of
bias assessments for randomized trials, as recommended in the
PRISMA statement [32] (e.g., the Cochrane Collaboration tool
checklist [22]), cannot be applied to validity studies, and further
development in this area is needed. Heterogeneity in methods of
evaluating validity precluded grouping results together in a
meta-analysis. Conversely, this same heterogeneity contributes to
construct validity. Systems theory was described more than
60 years ago [5] and has been applied to social sciences and biology
[2,20,41]. We found conceptualizing pain as a complex system to
be a useful paradigm, and this novel approach helped us to make
sense of the multiple influences on the pain experience and its
expression (developmental age, central sensitization, social factors,
etc.)
5.2.2. Study level limitations
The overall study quality was not high. In many studies, the ter-
minologies concerning reliability, accuracy, etc., were inconsistent.
Several studies reported face validity only.
 Ò
J.K. Hamill et al. / PAIN 155 (2014) 851–858
5.3. Conclusions
Graphic pain-location tools have been validated in children, but
their applicability to pediatric surgery requires further elucidation.
Future studies could examine the spatial accuracy of the APPT and
PPQ body outlines in pediatric laparoscopic surgery. A gridded
abdominal outline could be developed and tested in pediatric
surgery.
Researchers should strive to minimize the risk for reversals and
other errors when designing pain-location tools. Finally, electronic
versions hold promise but require validation.
Conflict of interest statement
The International Prospective Register of Systematic Reviews
registration number for this review is CRD2012003470 [40]. The
authors report no conflict of interest.
Acknowledgements
We thank the librarians of the Philson Library, University of
Auckland, for their help in retrieving texts. We thank Clara Chong
for translating the text into Chinese.
Appendix A.
Study quality scoring system, modified from Jerosch-Herold
2005 [29]. For scoring, add subtotal methods plus subtotal validity
or subtotal reliability (maximum total score for validity studies,
10; and for reliabitity studies, 9).
References
[1] Adamson G, Murphy S, Shevlin M, Buckle P, Stubbs D. Profiling schoolchildren
in pain and associated demographic and behavioural factors: a latent class
approach. PAINÒ 2007;129:295–303.
[2] Anderson LM, Petticrew M, Rehfuess E, Armstrong R, Ueffing E, Baker P, Francis
D, Tugwell P. Using logic models to capture complexity in systematic reviews.
Res Synth Meth 2011;2:33–42.
[3] Bailey B, Daoust R, Doyon-Trottier E, Dauphin-Pierre S, Gravel J. Validation and
properties of the verbal numeric scale in children with acute pain. PAINÒ
2010;149:216–21.
[4] Balogun O, Hernandez J, Labotka RJ, Wilkie DJ, Kim YO, Pelligra SA, Mack AK.
Determining the accuracy and reliability of computer generated pain location
data from the painreportit pain assessment tool for sickle cell disease (SCD)
patients. Blood 2009;114.
[5] Bertalanffy LV. An outline of general system theory. Br J Philos Sci
1950;1:134–65.
[6] Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The Faces Pain Scale for
the self-assessment of the severity of pain experienced by children:
development, initial validation, and preliminary investigation for ratio scale
properties. PAINÒ 1990;41:139–50.
[7] Calam RM, Jimmieson P, Cox AD, Glasgow DV, Larsen SG. Can computer-
based assessment help us understand children’s pain? Eur J Anaesth
2000;17:284–8.
[8] Carney J, Finnerty O, Rauf J, Curley G, McDonnell JG, Laffey JG. Ipsilateral
transversus abdominis plane block provides effective analgesia after
appendectomy in children: a randomized controlled trial. Anesth Analg
2010;111:998–1003.
[9] Cervero F, Laird JM. Visceral pain. Lancet 1999;353:2145–8.
[10] Cheng S. A multi-method study of Taiwanese children’s pain experiences.
University of Colorado Health Sciences Center. [dissertation]. 2002; p.
256.
[11] Chiang LC, Mao HC. Assessing pain perception and pain responses of post-
operative children [Chinese]. J Nurs Res 1994;2:239–52.
[12] Connelly M. The verbal numeric rating scale in the pediatric emergency
department: what do the numbers really mean? PAINÒ 2010;149:167–8.
[13] Dampier C, Ely B, Brodecki D, O’Neal P. Characteristics of pain managed at
home in children and adolescents with sickle cell disease by using diary self-
reports. J Pain 2002;3:461–70.
[14] Di Leo JH. Children’s drawings as diagnostic aids. New York, NY: Brunner/
Mazel; 1973.
[15] Du Y, Knopf H, Zhuang W, Ellert U. Pain perceived in a national community
sample of German children and adolescents. Eur J Pain 2011;15:649–57.
857
[16] Eland JM. Children’s communication of pain. College of Nursing, Master of Arts.
Iowa City, IA: Graduate College of the University of Iowa [master’s thesis].
1974; p. 60.
[17] Eland JM, Anderson JE. The experience of pain in children. In: Jacox AK, editor.
Pain: a sourcebook for nurses and other health professionals. Boston,
MA: Little Brown; 1977. p. 453–73.
[18] Esposito C, Calvo AI, Castagnetti M, Alicchio F, Suarez C, Giurin I, Settimi A.
Open versus laparoscopic appendectomy in the pediatric population: a
literature review and analysis of complications. J Laparoendosc Adv Surg
Tech A 2012;22:834–9.
[19] Guariso G, Mozrzymas R, Gobber D, Benini F, Zancan L, Zacchello F. Self-report
assessment of recurrent abdominal pain. Pediatr Med Chir 1999;21:255–60.
[20] Hawe P, Shiell A, Riley T. Theorising interventions as events in systems. Am J
Commun Psychol 2009;43:267–76.
[21] Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The faces
pain scale-revised: toward a common metric in pediatric pain measurement.
PAINÒ 2001;93:173–83.
[22] Higgins JPT, Green S. Cochrane handbook for systematic reviews of
interventions. West Sussex, UK: John Wiley & Sons; 2008.
[23] Holm S, Ljungman G, Soderlund A. Pain in children and adolescents in primary
care: chronic and recurrent pain is common. Acta Paediatr 2012;101:1246–52.
[24] Jacob E. Pain in children with sickle cell anemia. San Francisco, CA: University
of California, San Francisco [dissertation]. 2001.
[25] Jacob E, Duran J, Stinson J, Lewis MA, Zeltzer L. Remote monitoring of pain and
symptoms using wireless technology in children and adolescents with sickle
cell disease. J Am Acad Nurse Pract 2013;25:42–54.
[26] Jacob E, McCarthy KS, Sambuco G, Hockenberry M. Intensity, location, and
quality of pain in Spanish-speaking children with cancer. Pediatr Nurs
2008;34:45–52.
[27] Jacob E, Miaskowski C, Savedra M, Beyer JE, Treadwell M, Styles L. Changes in
intensity, location, and quality of vaso-occlusive pain in children with sickle
cell disease. PAINÒ 2003;102:187–93.
[28] Jacob E, Stinson J, Duran J, Gupta A, Gerla M, Ann Lewis M, Zeltzer L. Usability
testing of a smartphone for accessing a web-based e-diary for self-monitoring
of pain and symptoms in sickle cell disease. J Pediatr Hematol Oncol
2012;34:326–35.
[29] Jerosch-Herold C. An evidence-based approach to choosing outcome
measures: a checklist for the critical appraisal of validity, reliability and
responsiveness studies. Br J Occup Ther 2005;68:347–53.
[30] Jerrett MD. Children and their pain experience. Child Health Care
1985;14:83–9.
[31] Lalloo C, Stinson JN, Hochman JR, Adachi JD, Henry JL. Adapting the Iconic Pain
Assessment Tool Version 2 (IPAT2) for adults and adolescents with arthritis
pain through usability testing and refinement of pain quality icons. Clin J Pain
2013;29:253–4.
[32] Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke
M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting
systematic reviews and meta-analyses of studies that evaluate health care
interventions: explanation and elaboration. Ann Intern Med
2009;151:W65–94.
[33] Mack AK, Pelligra SA, Labotka RJ, Molokie RE, Thompson AA, Wilkie DJ. The
utilization of a computerized pain assessment tool-painreportit in adolescents
with sickle cell disease. Blood 2009;114.
[34] Mesko PJ, Christ-Libertin C, Shelestak D, Eliades AB. Use of picture
communication aids to assess pain location in pediatric post-operative
patients. J Perianesth Nurs 2011;26:200.
[35] Miro J, Castarlenas E, Huguet A. Evidence for the use of a numerical rating scale
to assess the intensity of pediatric pain. Eur J Pain 2009;13:1089–95.
[36] O’Donnell PJ, Curley H. Validation of a nonverbal instrument for pain location
descriptions in children. Percept Mot Skills 1985;60:1010.
[37] Palermo TM, Harrison D, Koh JL. Effect of disease-related pain on the health-
related quality of life of children and adolescents with cystic fibrosis. Clin J
Pain 2006;22:532–7.
[38] Palermo TM, Valenzuela D, Stork PP. A randomized trial of electronic versus
paper pain diaries in children: impact on compliance, accuracy, and
acceptability. PAINÒ 2004;107:213–9.
[39] Palmer H. Pain charts: a description of a technique whereby functional pain
may be diagnosed from organic pain. NZ Med J 1949;48:187–213.
[40] PROSPERO, International Prospective Register of Systematic Reviews. 2012.
Available at http://www.crd.york.ac.uk/PROSPERO/display_record.asp?
ID=CRD42012003470.
[41] Rickles D, Hawe P, Shiell A. A simple guide to chaos and complexity. J
Epidemiol Commun Health 2007;61:933–7.
[42] Roth-Isigkeit A, Thyen U, Stoven H, Schwarzenberger J, Schmucker P. Pain
among children and adolescents: restrictions in daily living and triggering
factors. [Erratum in Pediatrics 2005 115:1118]. Pediatrics
2005;2005:e152–62.
[43] Sanchez-Rodriguez E, Miro J, Castarlenas E. A comparison of four self-report
scales of pain intensity in 6- to 8-year-old children. PAINÒ 2012;153:1715–9.
[44] Sandeman DJ, Bennett M, Dilley AV, Perczuk A, Lim S, Kelly KJ. Ultrasound-
guided transversus abdominis plane blocks for laparoscopic appendicectomy
in children: a prospective randomized trial. Br J Anaesth 2011;106:882–6.
[45] Sauerland S, Jaschinski T, Neugebauer AME. Laparoscopic versus open surgery
for suspected appendicitis. Cochrane Database Syst Rev 2010:CD001546.
http://dx.doi.org/10.1002/14651858.CD001546.pub3.
 Ò
858 J.K. Hamill et al. / PAIN 155 (2014) 851–858
[46] Savedra MC, Holzemer WL, Tesler MD, Wilkie DJ. Assessment of postoperation
pain in children and adolescents using the adolescent pediatric pain tool. Nurs
Res 1993;42:5–9.
[47] Savedra MC, Tesler MD, Holzemer WL, Wilkie DJ, Ward JA. Pain location:
validity and reliability of body outline markings by hospitalized children and
adolescents. Res Nurs Health 1989;12:307–14.
[48] Savedra MC, Tesler MD, Holzemer WL, Wilkie DJ, Ward JA. Testing a tool to
assess postoperative pediatric and adolescent pain. Adv Pain Res Ther
1990;15:85–93.
[49] Schanberg LE, Lefebvre JC, Keefe FJ, Kredich DW, Gil KM. Pain coping and the
pain experience in children with juvenile chronic arthritis. PAINÒ
1997;73:181–9.
[50] Staes F, Stappaerts K, Vertommen H, Everaert D, Coppieters M. Reproducibility
of a survey questionnaire for the investigation of low back problems in
adolescents. Acta Paediatr 1999;88:1269–73.
[51] Stafstrom CE, Goldenholz SR, Dulli DA. Serial headache drawings by children
with migraine: correlation with clinical headache status. J Child Neurol
2005;20:809–13.
[52] Stafstrom CE, Rostasy K, Minster A. The usefulness of children’s drawings in
the diagnosis of headache. Pediatrics 2002;109:460–72.
[53] Stinson JN, Petroz GC, Tait G, Feldman BM, Streiner D, McGrath PJ, Stevens BJ.
E-Ouch: usability testing of an electronic chronic pain diary for adolescents
with arthritis. Clin J Pain 2006;22:295–305.
[54] Stinson JN, Stevens BJ, Feldman BM, Streiner D, McGrath PJ, Dupuis A, Gill N,
Petroz GC. Construct validity of a multidimensional electronic pain diary for
adolescents with arthritis. PAINÒ 2008;136:281–92.
[55] Tomecka MJ, Bortsov AV, Miller NR, Solano N, Narron J, McNaull PP, Ricketts KJ,
Lupa CM, McLean SA. Substantial postoperative pain is common among
children undergoing laparoscopic appendectomy. Paediatr Anaesth
2012;22:130–5.
[56] Van Cleve L, Bossert E, Beecroft P, Adlard K, Alvarez O, Savedra MC. The pain
experience of children with leukemia during the first year after diagnosis. Nurs
Res 2004;53:1–10.
[57] Van Cleve LJ, Savedra MC. Pain location: validity and reliability of body outline
markings by 4- to 7-year-old children who are hospitalized. Pediatr Nurs
1993;19:217–20.
[58] Varni JW, Thompson KL, Hanson V. The Varni/Thompson Pediatric Pain
Questionnaire. I. Chronic musculoskeletal pain in juvenile rheumatoid
arthritis. PAINÒ 1987;28:27–38.
[59] Voepel-Lewis T. Pain assessment and decision making: have we missed the
mark? Pediatr Pain Lett 2011;13:1–6.
[60] Von Baeyer CL. Numerical rating scale for self-report of pain intensity in
children and adolescents: recent progress and further questions. Eur J Pain
2009;13:1005–7.
[61] Von Baeyer CL, Lin V, Seidman LC, Zeltzer LK. Pain charts (body maps or
manikins) in assessment of the location of pediatric pain. Pain Manag
2011;1:61–8.
[62] Von Baeyer CL, Spagrud LJ, McCormick JC, Choo E, Neville K,
Connelly MA. Three new datasets supporting use of the Numerical Rating
Scale (NRS-11) for children’s self-reports of pain intensity. PAINÒ
2009;143:223–7.
[63] Von Weiss RT. A cross-cultural comparison of pain description in children with
polyarticular juvenile rheumatoid arthritis in the United States and in Egypt.
Lawrence, KS: University of Kansas [dissertation]. 2003.
[64] Watson S, Calam R, Jimmieson P. Can computers help in assessing children’s
postoperative pain? initial validation of a computer-assisted interview. Eur J
Anaesth 2002;19:510–6.
[65] Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr
Nurs 1988;14:9–17.
[66] Wood C, von Baeyer CL, Falinower S, Moyse D, Annequin D, Legout V.
Electronic and paper versions of a faces pain intensity scale: concordance and
preference in hospitalized children. BMC Pediatr 2011;11:87.
[67] Wright JE. Controlled trial of wound infiltration with bupivacaine for
postoperative pain relief after appendicectomy in children. Br J Surg
1993;80:110–1.
[68] Zanetta VC, Meier-Haran P, Houck CS, Pereira LM, Nguyen HT, Cilento BG. The
use of intraperitoneal nebulization of bupivacaine reduces the need for
postoperative opioids in young children undergoing robotic-assisted
laparoscopic reconstructive surgery. J Urol 2012;187:e298.