CONTENTS
Behavioral pain assessment
Characteristics of a
clinically useful pain tool
The FLACC pain tool
Limitations of behavioral
observation of pain
Difficulties assessing pain in individuals who cannot use self-report scales has led to their
exclusion from clinical trials and rendered them vulnerable to undertreatment of pain.
Although several observational pain scales are available for use in these populations,
many lack the characteristics necessary for routine implementation into practice or
research. The Face, Legs, Activity, Cry And Consolability pain scale was developed as a
simple measure of pain intensity in young children. It has been validated in the
postoperative setting in children 27 years of age and children aged 418 years with
varying degrees of cognitive impairment. With minor revisions, the Face, Legs, Activity, Cry
and Consolability pain scale may be useful to assess acute pain across populations of
children and adults who are unable to self-report their pain.
Expert Rev. Pharmacoeconomics Outcomes Res. 3(3), 317325 (2003)
KEYWORDS:
children, cognitively impaired,
FLACC pain tool, measurement
of analgesic efficacy,
pain assessment
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Department of Anesthesiology,
CS Mott Childrens Hospital,
University of Michigan Health
Systems, F3900 Box 0211,
1500 E. Medical Ctr. Dr.,
Ann Arbor, MI
48109 0211, USA
Tel.: +1 734 936 0747
Fax: +1 734 763 6651
terriv@umich.edu
Table 1. Comparison of behavioral categories and scoring characteristics of commonly cited observational pain scales.
Categories
FLACC [22]
CHIPPS [37]
CHEOPS [30]
TPPPS [25]
RIPS [20]
Facial
X3
Legs
Activity
Cry/vocal
X2
X3
Consolability
X
Posture of trunk
Other
Touching of wound
Sleep
Response to touch
(5 behaviors)
(5 behaviors)
(6 behaviors)
(7 behaviors)
(4 behaviors)
Categories
0-2
0-2
Variable scoring
0-1
0-2 or 3
Total score
0-10
0-10
413
0-7
0-11
Scoring
CHEOPS: Children's Hospital of Eastern Ontario Pain Scale (only the behavioral components have been included here); CHIPPS: Children and Infants Postoperative Pain
Scale; FLACC: Face, Legs, Activity, Cry and Consolability; RIPS: Riley Infant Pain Scale; TPPPS: Toddler-Preschooler Postoperative Pain Scale; X: Indicates the tool contains an
item; X2: Indicates that the tool contains two items; X3: Indicates that the tool contains three items.
Scoring
010
Utility
Children/CI
Acute pain
UAB [51]
DS-DAT [28]
NCCPC-PV [19]
NAPI [20]
Vocal complaintsverbal
Vocal complaintsnonverbal
Down-time
Facial grimaces
Standing posture
Mobility
Body language
Use of supportive equipment
Stationary movement
Medication use
Noisy breathing
Negative vocalization
Content facial expression
Sad facial expression
Frightened expression
Frown
Relaxed body language
Tense body language
Fidgeting
Vocal
Social
Facial
Activity
Body/limbs
Physilolgical signs
Verbal/vocal
Body movement
Facial
Respose to touch
010
027
081
011
Elderly,
chronic pain
acute pain
Young childern
incomplete testing
in CI
CI: Cognitively impaired; DS-DAT: Discomfort ScaleDementia Alzheimer's Type; FLACC Face, Legs, Activity, Cry And Consolability; NAPI: Nursing Assessment of Pain
Intensity; NCCPC-PV: Noncommunicating Children's Pain Checklistpostoperative Version; UAB: University of Alabama Pain Scale.
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Table 3. Face, Legs, Activity, Cry and Consolability (FLACC) observational pain scale [22].
Score
Face
0
1
2
Legs
0
1
2
Activity
0
1
2
Cry
0 = No cry
1 = Moans or whimpers, occasional complaint
2 = Crying steadily, screams or sobs, frequent complaints
0
1
2
Consolability
Reprinted from Pediatric Nursing 23(3), 294 (1997) with permission from the publisher, Jannetti Publications, Inc., East Holly Ave Box 56, Pitman, NJ, 08071 0056 USA,
Tel.: +1 856 256 2300, Fax: +1 856 589 7463. For a sample copy of the journal, please contact the publisher.
The FLACC pain assessment tool contains those core behavioral categories that have been reliably associated with pain in
infants, young children and in the cognitively impaired, attesting
to its general content validity. The tool has been evaluated against
several criteria in previous studies of children during their early
and later (i.e., in patient) postoperative recovery periods [22,31,57].
In a study of 89 cognitively intact children aged 27 years of age,
the FLACC was found to have excellent correlations with the
Observational Pain Scale (OPS) (r = 0.8; p < 0.001) and significant but lower correlations with the bedside nurses global ratings
of pain using the VAS (r = 0.41; p < 0.005) [22]. In another study
of 30 cognitively intact children aged 37 years, FLACC scores
were compared to the childrens self-reported FACES scores [57].
The correlations between FLACC and FACES scores for all children were moderate but significant (r = 0.58; p = 0.001) and
were better in children aged 57 years (r = 0.83) compared with
those of less than 5 years of age (r = 0.25). None of the children
in this study, however, were tested for their ability to use selfreport scales. The FACES scores from the younger children may,
therefore, have been unreliable. Lastly, FLACC scores were compared with parent-reported VAS scores for 113 observations in
79 cognitively impaired children aged 418 years of age [31]. Correlations were significant, ranging from 0.50.7, suggesting moderate criterion validity. In this study, parent scores tended to be
higher than FLACC scores assigned by video observers blinded
to treatment and procedure and, to a lesser degree, bedside nurses
(overall bias + 0.59, precision 2.3).
Construct validity of the FLACC has been tested in both cognitively intact young children and in the cognitively impaired,
by comparing scores before and after analgesics [22,31]. In earlier
studies, observers scores decreased significantly following analgesics (7 2.9 vs. 1.7 2.2; p < 0.001), however, these nurses were
not blinded to analgesic administration. In the recent study of
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initial responses to pain. This may explain some of the discordance between self-reported and behavioral pain scores described
in previous studies. Additionally, the behavioral reaction to
long-term pain has been described as more similar in manifestation to depression. Assessment of chronic pain requires the consideration of several other behavioral patterns, such as sleep
quality, appetite and psychological manifestations. Other available pain tools may provide a more reliable assessment of
chronic pain compared with simple behavioral scales, such as
the FLACC [71].
It is important to note that behavioral pain tools are meant
to score the intensity of pain. There are several dimensions of
pain sensation that must be incorporated into pain assessment.
The qualities of the pain, its location, duration and frequency
have important implications for appropriate diagnoses and
selection of effective pain treatments. Comprehensive pain
assessment must include these dimensions in addition to
assessment of intensity.
Lastly, behavioral observation should be reserved for scoring
pain in those who cannot self-report. Young children and the
cognitively impaired often can identify the presence of pain
(i.e., yes/no) and can discriminate pain intensity using a small
number of options (i.e., three to four choices) [3]. For these
individuals, selecting the appropriate self-report tool, such as
one with a limited number of options, may provide the best
method for pain assessment. When the reliability of self-report
remains questionable, however, information obtained from
behavioral observation and from other sources, such as physiologic parameters or parental input may provide convergent data
on which to base treatment decisions.
Summary & conclusions
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Information resources
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of the Noncommunicating Childrens Pain ChecklistPostoperative Version. Anesthesiology 96(3), 528535 (2002).
McGrath PJ. Behavioral Measures of Pain. In: Measurement
of Pain in Infants and Children, Progress in Pain Research and
Management. Finley GA, McGrath PJ. (Eds). IASP Press,
Seattle, WA, USA, 83102 (1999).
The American Pain Society at www.ampainsoc.org
(Accessed April 2003).
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Affiliations
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Websites
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CentricityTM Clinical
General Electric
Information System (CIS):
www.gemedicalsystems.com/it_solutions/
clinical/it_cis_index.html
(Assessed May, 2003)
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