Florida-California Cancer Health Equity Center (CaRE2) Community Scientist Research Advocacy Program

The Community Scientist Program (CSP), a model connecting researchers with community members, is effective to inform and involve the general population in health-related clinical research. Given the existing cancer disparities among Black/African American and Hispanic/Latino/a populations, more models describing how cancer-related CSPs are designed, implemented, and evaluated are needed. The Florida-California Cancer Research, Education and Engagement (CaRE2) Health Equity Center is a tri-institutional, bicoastal center created to eliminate cancer health disparities among Black/African American and Hispanic/Latino/a populations living in California and in Florida. The CaRE2 Center created a Community Scientist Research Advocacy (CSRA) training program for community members to become cancer research advocates. The CSRA program is currently a 13-week program conducted 100% virtually with all materials provided in English and Spanish for participants to learn more about prostate, lung, and pancreas cancers, ongoing research at CaRE2, and ways to share cancer research throughout their communities. Participants attend didactic lectures on cancer research during weeks 1-5. In week 4, participants join CSRA self-selected groups based on cancer-related topics of interest. Each group presents their cancer-related advocacy project developed during weeks 5-12 at the final session. In this paper, we describe the CaRE2 Health Equity Center's CSRA program, share results, and discuss opportunities for improvement in future program evaluation as well as replication of this model in other communities.

Oral health conditions affect functional and social activities of terminally ill cancer patients

PURPOSE

Oral conditions are established complications in terminally ill cancer patients. Yet despite significant morbidity,the characteristics and impact of oral conditions in these patients are poorly documented. The study objective was to characterize oral conditions in terminally ill cancer patients to determine the presence, severity, and the functional and social impact of these oral conditions.

METHODS

This was an observational clinical study including terminally ill cancer patients (2.5–3-week life expectancy). Data were obtained via the Oral Problems Scale (OPS) that measures the presence of subjective xerostomia, orofacial pain, taste change, and the functional/social impact of oral conditions and a demographic questionnaire. A standardized oral examination was used to assess objective salivary hypofunction, fungal infection, mucosal erythema, and ulceration. Regression analysis and t test investigated the associations between measures.

RESULTS

Of 104 participants, most were ≥50 years of age,female, and high-school educated; 45 % were African American, 43 % Caucasian, and 37 % married. Oral conditions frequencies were: salivary hypofunction (98 %), mucosal erythema (50 %), ulceration (20 %), fungal infection(36 %), and other oral problems (46 %). Xerostomia, taste change, and orofacial pain all had significant functional impact; p <.001, p =.042 and p <.001, respectively. Orofacial pain also had a significant social impact (p <.001). Patients with oral ulcerations had significantly more orofacial pain with a social impact than patients without ulcers (p =.003). Erythema was significantly associated with fungal infection and with mucosal ulceration (p <.001).

CONCLUSIONS

Oral conditions significantly affect functional and social activities in terminally ill cancer patients. Identification and management of oral conditions in these patients should therefore be an important clinical consideration.

Presence of neuropathic pain as an underlying mechanism for pain associated with cold weather in patients with sickle cell disease

Less than 20 years after Herrick described the first case, the cold was proposed as having a role in precipitating pain in sickle cell disease. Numerous publications focus on weather changes, in particular exposure to the cold, and their association with vaso-occlusive (painful) episodes. Whereas several theories have been proposed to explain the association, a plausible hypothesis based on our current understanding of the pathophysiology of pain has not been offered. We hypothesize that the pain evoked by these weather changes are allodyinic (pain with stimulus not typically painful) and hyperalgesic (heightened pain with painful stimulus) responses due to the presence of neuropathic pain. This hypothesis represents a paradigm shift in understanding, as well as explaining at least some of the pain experience in sickle cell disease, and should be the impetus to further determine the characteristics of those patients who develop allodynia and hyperalgesia to cold weather. Whereas some researchers have suggested that those with sickle cell disease may have neuropathic pain, including a report from our own ongoing study [1], it has not been well accepted nor has it been applied in understanding pain associated with sickle cell disease. The conceptual shift and new understanding is important to develop preventive strategies, apply pain therapies new to the sickle cell population, and view pain in sickle cell disease in the context of a chronic disease.

Symptom profile of nasopharyngeal cancer patients during radiation therapy

PURPOSE

This prospective, longitudinal study was aimed to describe the prevalence, severity, and pattern of symptoms over the course of radiation therapy in persons with nasopharyngeal carcinoma and to explore symptom severity by treatment modality.

DESCRIPTION OF STUDY

Thirty-seven patients completed this study, and 46% received chemotherapy before radiation therapy. A self-reported radiation symptom checklist and an objective mucositis assessment tool were used weekly to document oropharyngeal, skin, nose or ear, or more general side effects, and mucositis.

RESULTS

Oropharyngeal problems were the most severe complaints during radiation therapy. All patients experienced dry mouth, taste change, difficulty in swallowing, difficulty in opening their mouths, hoarseness, sore throat, and observable mucositis. Most reported moderate-to-severe dry mouth, difficulty in swallowing, and sore throat from weeks 3 through 7. Skin problems were not prominent until week 4. Patients also lost an average of 3.9 kg during the therapy. Sequential chemotherapy and radiation therapy was associated with more severe oropharyngeal problems than radiation therapy alone, but no significant differences in other problems were found.

CLINICAL IMPLICATIONS

Despite recognition of the oropharyngeal side effects associated with irradiation, effective management protocols for such symptoms have not been implemented in the studied institution. The frequency and intensity of the symptoms reported indicate an urgent need for increased vigilance about radiation-related side effects and pain management. As well, patient education about expected side effects may help mitigate the anxiety that patients experience when these symptoms occur.

Nociceptive and neuropathic pain in patients with lung cancer: a comparison of pain quality descriptors

Predictive validity of each word from the McGill Pain Questionnaire (MPQ) has not been investigated in relation to pain etiology. The purpose of this study was to explore differences in the words used to describe nociceptive and neuropathic pain. Patients with lung cancer (N = 123) selected words from the 78 MPQ pain quality descriptors and indicated the corresponding pain site for each word. Using only the MPQ pain location, and the cancer and treatment data abstracted from medical records, each pain site was classified as nociceptive or neuropathic (etiology). Pain etiology and quality descriptors were tested for proportional differences with sensitivity, specificity, and predictive value calculated for statistically significant descriptors. Of the 457 pain sites, 343 were classified as nociceptive (75%), 114 as neuropathic (25%). Lacerating, stinging, heavy, and suffocating were selected for a significantly larger proportion of nociceptive sites whereas throbbing, aching, numb, tender, punishing, pulling, tugging, pricking, penetrating, punishing, miserable, and nagging were selected for a larger proportion of neuropathic sites. Ten words correctly predicted 78% of the sites with 81% sensitivity to nociceptive pain and 59% sensitivity to neuropathic pain. Interestingly, several pain quality descriptors (burning, shooting, flashing, tingling, itching, and cold) previously associated with neuropathic pain did not distinguish between neuropathic and nociceptive pain. Infrequent selection of many MPQ words and lack of neurological exam data in the medical records are possible explanations for inconsistency with previous literature. Prospective studies are needed to validate pain quality descriptors for nociceptive and neuropathic types of lung cancer pain.

Cancer symptom control: feasibility of a tailored, interactive computerized program for patients

This study evaluated the feasibility of an innovative computerized symptom assessment tool, SymptomReport, and a computerized, tailored education tool, SymptomConsult, in a sample of 41 outpatients with cancer. After patients completed the computerized programs, an audiotaped telephone interview was conducted to assess patients' impressions. The study found that patients required less than 40 minutes on average to complete SymptomReport. The mean acceptability score was high 11 +/- 2. The 12 patients who completed SymptomConsult did so in an average of 20 minutes. The majority of participants indicated that the computer programs were easy, enjoyable, and informative tools. Initial formative research supports further study of these feasible computerized programs.

Excellence in teaching end-of-life care: a new multimedia toolkit for nurse educators

Nursing strongly values comfort and patient-centered care at the end of life, but little end-of-life content is included in most basic nursing education programs. An innovative way to improve nursing education about the end-of-life transition is to provide nurse educators with an electronic toolkit. This article describes a newly created multimedia toolkit (TNEEL), which includes engaging strategies for teaching and learning about end-of-life care.

Symptom profile of nasopharyngeal cancer patients during radiation therapy

PURPOSE

This prospective, longitudinal study was aimed to describe the prevalence, severity, and pattern of symptoms over the course of radiation therapy in persons with nasopharyngeal carcinoma and to explore symptom severity by treatment modality.

DESCRIPTION OF STUDY

Thirty-seven patients completed this study, and 46% received chemotherapy before radiation therapy. A self-reported radiation symptom checklist and an objective mucositis assessment tool were used weekly to document oropharyngeal, skin, nose or ear, or more general side effects, and mucositis.

RESULTS

Oropharyngeal problems were the most severe complaints during radiation therapy. All patients experienced dry mouth, taste change, difficulty in swallowing, difficulty in opening their mouths, hoarseness, sore throat, and observable mucositis. Most reported moderate-to-severe dry mouth, difficulty in swallowing, and sore throat from weeks 3 through 7. Skin problems were not prominent until week 4. Patients also lost an average of 3.9 kg during the therapy. Sequential chemotherapy and radiation therapy was associated with more severe oropharyngeal problems than radiation therapy alone, but no significant differences in other problems were found.

CLINICAL IMPLICATIONS

Despite recognition of the oropharyngeal side effects associated with irradiation, effective management protocols for such symptoms have not been implemented in the studied institution. The frequency and intensity of the symptoms reported indicate an urgent need for increased vigilance about radiation-related side effects and pain management. As well, patient education about expected side effects may help mitigate the anxiety that patients experience when these symptoms occur.

Metastatic bone pain. Meanings associated with self-report and self-management decision making

Patients with cancer and bone metastases are vulnerable to severe pain, especially when changing their body position, and many such persons die with unrelieved pain. One step in obtaining acceptable pain control is communicating one's pain to health care providers. This descriptive study aimed to depict possible gender differences in the meaning of pain in the context of pain self-report and self-management decision making for 10 men and 10 women with cancer and bone metastasis. No clear gender differences were found in the narrative data obtained during semistructured interviews. Both men and women equated pain with cancer recurrence. Pain interfered with work, social activities, and relationships. Most participants preferred not to tell others, even health care providers, about their pain. More than one half of the 20 participants did not take pain medications on schedules recommended by physicians. The study findings provide oncology nurses with direction for education related to pain management for persons with metastatic bone pain and their family members. Further research with a larger sample is needed to clarify how to overcome barriers to better pain management in this population.

Cancer pain and common pain: a comparison of patient-reported intensities

PURPOSE/OBJECTIVES

To compare patient reports of present and worst cancer-related pain intensity to the recalled intensity of several commonly experienced types of pain.

DESIGN

A secondary analysis on baseline data from patients with cancer pain.

SETTING

Tertiary-care facilities and patients' homes. Patients were enrolled between 1988 and 1995.

SAMPLE

Patients who were diagnosed with either primary lung cancer or cancer metastatic to bone, able to read and write English, over 18 years of age, and able to provide written informed consent. The sample of 125 patients was 62% male with a mean age of 60 years (SD = 11).

METHODS

Patients completed the McGill Pain Questionnaire as a baseline measure in a pain research study. Investigators conducted comparisons among pain intensity scores reported for present pain intensity and worst cancer pain with the worst toothache, headache, and stomachache ever experienced using the Stuart test of marginal homogeneity.

MAIN RESEARCH VARIABLES

Present cancer pain intensity and worst toothache, headache, and stomachache pain intensity.

FINDINGS

Only 14% of the subjects reported that their present pain intensity was distressing, horrible, or excruciating, but 83% of them reported that their worst cancer pain was at these levels. The subjects reported that they experienced (a) significantly more intense pain with their worst toothache than either their present pain intensity (p < 0.001) or their worst cancer pain (p < 0.001), (b) significantly more intense pain with their worst headache than their present pain intensity (p < 0.001), and (c) significantly more intense pain with their worst stomachache than their present pain intensity (p < 0.001). In contrast, subjects reported that their worst cancer pain was significantly more intense than their worst headache (p = 0.047) or stomachache (p = 0.001).

CONCLUSIONS

The findings suggest that present cancer pain is not only experienced at lower intensity levels than common pains, but at lower levels than expected by patients, their families, and the public. Consistent with common beliefs though, the worst cancer pain is severe and not adequately controlled for 9 out of 10 patients.

IMPLICATIONS FOR NURSING PRACTICE

Healthcare professionals could use study findings to inspire hope in patients with lung cancer or bone metastasis and their families that present pain in cancer can be controlled successfully. Clinicians should devote greater efforts to relieve the worst cancer pain to levels achieved for the present pain experienced by people with cancer.

Advancing nursing practice: acute care nurse practitioners meet challenges at and beyond the health care horizon

Preparation of advanced practice nurses (APNs) with acute care skills relevant to today's health care environment is a challenge faced by nurse educators, care providers, professional organizations, and regulatory agencies. The acute care nurse practitioner (ACNP) is prepared to provide multidimensional, risk-appropriate management of medically vulnerable patients with serious illness in a variety of settings. ACNPs conduct comprehensive health assessments, order and interpret diagnostic tests, diagnose and manage health problems and disease-related symptoms, prescribe and evaluate drugs and treatments, and coordinate care during setting transitions. Working independently and collaboratively the ACNP enhances access to care and quality of care for patients and families through cost-effective, outcome-oriented practice. This article describes health care market factors fostering ACNP practice, ACNP practice domain, the University of Washington ACNP program, and collaborative contributions from educators, care providers, professional organizations, and regulatory groups needed to implement the role.

Family members' perceptions of cancer pain. Comparisons with patient sensory report and by patient psychologic status

This study was the first to compare patient and family member perceptions of sensory pain and to describe the relationships between these perceptions and psychological factors in patients with lung cancer and pain. Our findings indicate that family members understand the patient's pain location about 75% of the time; however, family members rarely understand the patient's pain intensity, pain quality, or pain pattern. Our findings also indicate that family members tend to overestimate strategies used by patients to cope with pain, especially in patients with low levels of anxiety and in patients with an internal locus of control. Although findings from this study differ from some previous studies, our study provides additional data to suggest that discrepancies may exist between family member and patient perceptions of the cancer pain experience. Nurses need to be aware of potential discrepancies and to combine assessment information from both patients and family members when developing pain management interventions.

Sublingual and oral morphine administration. Review and new findings

Clinical reports rave about the efficacy of sublingual morphine, but most research data suggest that sublingual morphine lacks the necessary physical characteristics to be absorbed through sublingual tissues. This article clarifies these assertions by reviewing the clinical literature that supports sublingual administration, the theories relevant to sublingual morphine administration, and the pharmacokinetic research that supports or negates the benefit of this route. Recommendations for clinical nursing practice are provided to guide decision-making in care of patients with cancer pain.

Coaching persons with lung cancer to report sensory pain. Literature review and pilot study findings

Because clinicians often do not recognize that patients have pain and patients do not spontaneously communicate their pain, clinicians may fail to prescribe or administer adequate pain medications. One method of improving clinicians' assessments of pain is to coach patients to communicate their pain in ways that clinicians recognize. The aims of our pilot study were to (a) examine the feasibility of implementing a randomized clinical trial of a COACHING protocol in 18 outpatients with lung cancer pain and (b) estimate the effects of COACHING on nurses' knowledge of patients' pain location, intensity, quality, and pattern. The expectation was that COACHING would show a trend toward reducing the discrepancy between patients self-report of sensory pain and sensory pain data known to nurse clinicians. Patients were randomly assigned to be COACHED or NOT-COACHED (usual care) and pretest-posttest measures with the McGill Pain Questionnaire (MPQ) and Visual Analogue Scale (VAS) were taken from nurses and patients. Patients- and nurse-completed MPQs and VASs were compared for agreement. Improvement in percent agreement occurred consistently more often (pretest to posttest) between patient self-report of sensory pain and nurses' pain assessments in the COACHED group than in the NOT-COACHED group. Pilot study findings demonstrated feasibility of implementing the COACHING protocol and suggest that COACHING may be effective in reducing discrepancies between patients' self-reports and nurses' assessments of sensory pain. Design modifications are recommended for implementation of future studies.

Postoperative analgesics for children and adolescents: prescription and administration

Pain was measured and analgesic treatment examined in 131 children and adolescents, 8-17 years of age, for 5 days after surgery. Analgesic data were converted to 10 mg intramuscular morphine-equivalent doses (IMMSEQ) and were designated appropriate or inappropriate for body weight. Analgesic onset, peak, and duration were calculated in relation to administration routes and the time pain assessments were made. Children reported moderately severe pain in many body locations. Initially, all but two children were prescribed and ultimately all but one received analgesics. Prescribed and administered doses were frequently less than doses recommended for weight. Two-thirds of the children were beyond analgesic action when pain was assessed. Weak to moderately strong associations were noted between IMMSEQ doses and pain intensity scores on each of the 5 postoperative days. Unfortunately, findings indicate that children continue to be undertreated when they experience postoperative pain.

Analgesics for cardiac surgery patients in critical care: describing current practice

BACKGROUND: In the last 10 years, the American Association of Critical-Care Nurses has twice ranked pain management as a priority issue for research and practice. Recent research findings suggest that undermedication of patients continues both in and out of critical care. Postoperative cardiac surgery patients have reported detailed recollections of pain experiences while in critical care, yet little is known about management of postoperative cardiac surgery pain. OBJECTIVE: The purpose of this study was to describe current practice related to analgesic prescription and administration for postoperative cardiac surgery patients in critical care. METHODS: Medical records of 80 adults undergoing cardiac surgery in two hospitals were randomly selected for review. Data pertaining to pain medications prescribed and doses administered for the day of surgery, first and second postoperative days were recorded for 66 eligible subjects. RESULTS: All but one patient had a prescription for intravenous morphine, hourly as needed. In addition, all patients had prescriptions for one or more oral analgesics as needed. Gender and age effects were noted for analgesic prescriptions. The average total amount of intravenous morphine given over the 3 days was 13.9 +/- 13.5 mg in an average of 4 +/- 3.7 doses. The average total number of acetaminophen with oxycodone tablets given over the 3 days was 5.8 +/- 5.4 tablets in an average of 3.6 +/- 3.0 doses. Age and hospital effects were noted in the administration of analgesics. CONCLUSIONS: The finding of small and infrequent analgesic doses is consistent with other studies conducted in and out of critical care. Important inconsistencies, or variations in practice, exist in both the prescription and administration of analgesics for postoperative cardiac surgery patients in the critical care setting.

Analgesics for cardiac surgery patients in critical care: describing current practice

BACKGROUND

In the last 10 years, the American Association of Critical-Care Nurses has twice ranked pain management as a priority issue for research and practice. Recent research findings suggest that undermedication of patients continues both in and out of critical care. Postoperative cardiac surgery patients have reported detailed recollections of pain experiences while in critical care, yet little is known about management of postoperative cardiac surgery pain.

OBJECTIVE

The purpose of this study was to describe current practice related to analgesic prescription and administration for postoperative cardiac surgery patients in critical care.

METHODS

Medical records of 80 adults undergoing cardiac surgery in two hospitals were randomly selected for review. Data pertaining to pain medications prescribed and doses administered for the day of surgery, first and second postoperative days were recorded for 66 eligible subjects.

RESULTS

All but one patient had a prescription for intravenous morphine, hourly as needed. In addition, all patients had prescriptions for one or more oral analgesics as needed. Gender and age effects were noted for analgesic prescriptions. The average total amount of intravenous morphine given over the 3 days was 13.9 +/- 13.5 mg in an average of 4 +/- 3.7 doses. The average total number of acetaminophen with oxycodone tablets given over the 3 days was 5.8 +/- 5.4 tablets in an average of 3.6 +/- 3.0 doses. Age and hospital effects were noted in the administration of analgesics.

CONCLUSIONS

The finding of small and infrequent analgesic doses is consistent with other studies conducted in and out of critical care. Important inconsistencies, or variations in practice, exist in both the prescription and administration of analgesics for postoperative cardiac surgery patients in the critical care setting.

Assessment of postoperation pain in children and adolescents using the adolescent pediatric pain tool

The location, intensity, and quality of pediatric postoperative pain were assessed in a convenience sample of 65 multiethnic children and adolescents, 8 to 17 years old. Pain was measured daily for 5 days during hospitalization using the Adolescent Pediatric Pain Tool (APPT). Mean pain intensity scores and mean number of pain descriptors (quality) decreased over time, but there was no significant change over time for the number of body segments marked (location). The findings provided valid and reliable estimates of adolescents' and children's self-reports of the location, intensity, and quality of postoperative pain.

Coping strategies of patients with lung cancer-related pain

Previous findings in patients with nonmalignant pain indicate a relationship between pain coping strategies and psychological factors. Although coping strategies have been explored in patients with cancer pain, relationships with such factors have not been reported. We wished to examine relationships between selected pain and psychological variables and the use of pain coping strategies. Forty-five patients with pain related to lung cancer indicated how they expressed their pain to others and completed the McGill-Melzack Pain Questionnaire (MPQ), State-Trait Anxiety Inventory, Visual Analogue Scale of pain intensity, and the Coping Strategies Questionnaire (CSQ). Forty-two percent of the patients reported that they tried not to let others know they had pain, and 40% indicated they told others when they had pain. Preferences for not telling others was associated with more frequent pain coping attempts for all CSQ subscales but those of catastrophizing and reinterpreting pain sensation. State anxiety demonstrated positive correlation with catastrophizing coping strategies (r = 0.48) and negative correlation with ability to control (r = -0.50) and decrease (r = -0.50) pain. The number of pain sites was correlated with coping self-statements (r = 0.34). Pain intensity and state anxiety demonstrated similar relationships. Pain quality as measured with the MPQ demonstrated moderately strong correlation with diverting attention, praying and hoping, catastrophizing, and increased activity. Interventions aimed at reinforcing or expanding a patient's pain coping repertoire should be developed with consideration given to the patient's anxiety level, pain intensity, pain quality, and pain expression preference.

The word-graphic rating scale as a measure of children's and adolescents' pain intensity

A program of studies was designed to select and test a pain intensity scale for inclusion in a multidimensional pain assessment tool for children and adolescents. The focus was on determining each scale's validity, reliability, ease of use, preference, and the lack of age, gender, and ethnic biases. Five pain scales were evaluated in four separate studies: a word-graphic rating scale, a visual analogue scale, a graded-graphic rating scale, a magnitude estimation scale (0 to 10), and a color scale. Subjects (N = 1,223) were 8 to 17 years of age and, in three of the studies, were hospitalized and judged to be in pain. In Study 1, well children used the scales to assess pain in an analogue situation selecting the color scale easiest to use and best liked. Convergent validity for the five scales was supported. In Study 2, hospitalized children, who were experiencing pain, overwhelmingly selected the word-graphic rating scale as their choice. A pilot version of a multidimensional pain assessment tool incorporating the word-graphic rating scale was tested in Study 3 using a repeated measures design. The scale demonstrated sensitivity to changes in postoperative pain intensity over time. In Study 4, convergent validity of the five scales and test-retest reliability of the word-graphic rating scale were supported. The series of four studies provides strong evidence to support use of the word-graphic rating scale to measure pain intensity in pediatric populations.

Cancer pain management. State-of-the-art nursing care

Cancer pain management is a dynamic field. Advances in basic science research have tremendous implications for the clinical management of cancer pain. New drugs and innovative methods of delivering old drugs have been developed. The challenge facing clinicians is to use the newer techniques systematically and appropriately once they have been adequately tested. Nurses play a particularly important role in helping patients with cancer pain to manage their pain experience in ways that are effective for the patients to meet their personal goals.

Use of the McGill Pain Questionnaire to measure pain: a meta-analysis

A meta-analysis of 51 studies was done to estimate normative mean McGill Pain Questionnaire (MPQ) scores and to assess pain quality and pain intensity as measured by the MPQ in 3,624 subjects with seven painful conditions. Across the painful conditions, all of the estimated normative mean scores were no more than 50% of the maximum score, suggesting that scores may be skewed to the left. Although the estimated normative mean scores were similar among the seven painful conditions, higher affective scores appeared to differentiate chronic painful conditions from acute painful conditions. Of the 78 MPQ words that describe pain quality, only 19 were selected by more than 20% of the subjects. Data reported in the majority of these studies were inadequate to test for differences in scores or word selection pattern by the seven painful conditions.

Pain location: validity and reliability of body outline markings by hospitalized children and adolescents

Although pain location is an important assessment parameter, little research has addressed validity and reliability of a body outline in pediatric populations. In a descriptive study, validity and reliability of markings on a body outline were examined in a convenience sample of 8- to 17-year-old hospitalized children (n = 175). Children marked their pain location on a body outline. Each child then pointed to the pain location on his/her body as a nurse data collector, blind to the child's markings, recorded the location on a second body outline. Data were obtained to substantiate the pain location. Findings provide strong support for the validity and reliability of a body outline and for its inclusion in a multidimensional pediatric pain tool.