James Sherpa

HONORS 222C

FLACC Scores
Overview and Methodology
The face, legs, activity, cry and consolability pain scale, abbreviated as FLACC, was
designed to infer acute pain levels from behavior in patients that cannot self-report pain. The
target group of patients for this pain scale includes: critically ill adults with loss of verbal
communication abilities, young children, and neonates[x]. The scale uses three outcomes of five
different observed behaviors to assign a numerical value representing the patients perceived pain
level. Caretakersnurses, physicians, midwivesare instructed to assess the patients behavior
for one to five minutes with the patients legs and body uncovered, touching the patient to gain a
sense of tenseness and tone. The recommended time of observation is longer than five minutes if
the patient is asleep [x]. Clinicians score each respective behavior against a standardized FLACC
rubric (Figure 1). Each substituent score is summed to a total numerical score in the range of 010; the assessment of pain based on these scores is as follows: 0 = no pain, 1-3 = mild pain, 4-7 =
moderate pain and 8-10 = severe pain.
Responses to pain are based on these scores ranging
from no action to non-pharmacological intervention and finally pharmacological intervention;
these three responses reflect the three pain severities described.

Figure 1 shows the methodology of deriving FLACC scores. The above criteria are the basis of the
FLACC scores. Caretakers assess each area given in the patient and add up this score; the final score is a
numerical value ranging from 0 (no pain) to 10 (most pain). Generally the interpretation of scores is as
follows: 0 = no pain, 1-3 = mild pain, 4-7 = moderate pain and 8-10 = severe pain [x].

Strengths
The strengths of the FLACC are found in its validity, reliability and internal consistency.
The criterion validity, the consistency between FLACC pain assessment and other pain
assessments, was highly consistent in neonates (= 0.849; P < .01) [x]. Further, the construct
validity, a measure of how a measurement responds in light of pain treatment (analgesics in this
case), showed that FLACC scores decreased alongside treatment across patient populations. This

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does however raise a controversial point regarding if FLACC scores are conflated with
misleading behaviors caused by analgesic treatment.
Reliability is measured by consistent repeated results of the any medical tool regardless
of who may be using itin the study referenced, FLACC scores from three different providers
observing video tapes were compared. The reliability of a pain assessment scale provides an
excellent insight into not only the consistency of its results, but further its ease of useboth
important factors in determining clinical relevance. The FLACC scores proved to be incredibly
consistent among observers regardless of the patient profile; data was consistent among children,
adults and patients receiving mechanical ventilation [x]. Perhaps the FLACCs greatest strength is
this usefulness regardless of patient and setting.
The FLACC behavioral pain assessment is a tool with great validity and reliability in
assessing pain in patients unable to self-report. It is very similar in content to most other
observational pain scales, yet the inclusion of the consolobility dimension and its ease of use
offer an advantage of use across populations and settings.

Limitations
Most of the criteria of FLACC scores are standards amongst the range of behavioral pain
assessment scales; however, consolability is not included in these standards of infant pain
assessment. This feature serves to provide an insight into the pain a neonate is experiencing by
measuring how difficult it is to ameliorate the pain of the infant. This measure offers a contextual
dimension to the pain experience: how does the patient respond to a given treatment? The
contextual dimension is an extremely valuable indicator of the progression of the patients pain;
unfortunately it also limits the standardization of FLACC score: not all patients are feasibly
consolable, nor are the methods of consoling said patients consistent among medical
practitioners, further neonate response to treatment is varies depending on the presence of a
parent [x]. Although this feature detracts from the standardization of FLACC scores, metaanalysis of the scores use suggests it does not significantly affect the reliability, validity, or
internal consistency of the survey [x]. Interestingly, out of the observations measured, the criteria
with the least consistency was the cry factor; when this observation was removed the test results
appeared more strongly correlated, while when other factors removed this correlation slightly
decreased [x].
Although examination of FLACC scores demonstrated excellent compatibility with other
pain assessment scales in quantifying patient pain, studies also revealed that high FLACC scores
had significant association with non-painful procedures too [x]. These findings indicate that
FLACC scores, along with most observational neonate pain assessments measure not only pain,
but also distress. It has been suggested that pain and distress are behaviorally indistinguishable
but to date there has not been sufficient data to support this claim [8]. A clear clinically-universal
definition of distress has not yet been proposed, however it is generally accepted that distress
encompasses pain and also can occur independently of it; in neonate pain it is assumed that
distress can be caused by the invasion of personal space, which is surely not a cause of pain [8].
The convulsion of pain and distress diminish the specific pain utility of FLACC scores. To

James Sherpa
HONORS 222C

circumvent the confounding factor of distress in behavioral neonate pain assessment it is

important to call attention to physiological assessments of pain.

PIPP-R Scores
Overview and Methodology
Designed in Canada by a team lead by clinicians from the University of Toronto and
McGill University (the alma mater and workplace of the influential Ray Metzker) the premature
infant pain profile-revised is a seven item multidimensional assessment of pain. The test includes
three behavioral, two physiological and two contextual measurements; the two contextual
measures, gestational age and baseline behavior state, serve as modifying variables rather than
part of the baseline assessment. Each measurement has corresponding numerical values, these
are then added up to a total quantitative pain score ranging from 0 to 21 (Figure 1). A general
outline illustrates the recommended pain treatment based on the PIPP-R score (Figure 2).

Figure 1 includes an image of the PIPP-R assessment. Clinicians match physiological data and behavioral
observations with assigned scores of the PIPP-R, the scores are intended to reflect increasing changes in each of the

James Sherpa
HONORS 222C
areas from a baseline value, this baseline value is the first measurement of the patient. Scores are then totaled and
added to the Gestational Ages Score and the Behavioral State Score. The final score ranges from 0 to 21; the latter
denoting the patient is in the most pain [x].

Figure 2 shows the recommended treatment route corresponding to given PIPP-R scores. Figure 3 offers an
illustration of a neonate in physical distress or pain, highlighting what to take note of for observing clinicians [x].

Strengths
The greatest strength of the PIPP-R scale is the breadth of pain description the scale
attains; the inclusion of behavioral, physiological and contextual measurements offers a more
holistic measure of pain when self-report is unavailable than the aforementioned FLACC scale.
The measurement of physiological change is particularly important in neonates; patients that
cannot self-report pain fall to variations in behavioral pain expression. The inclusion of
contextual factors further strengthens PIPP-R scores relevance by accounting for different
meaning of behavior depending on the patients age. This is seldom accounted for in other pain
assessments and is crucially important considering the rate of development in neonates, the
nervous system experiences large changes in this short time and these are reflected in its
responses to pain [x]. Using gestational age and behavioral state as additional methods of pain
description rather than baseline assessments removed the possibility of assigning a pain score of
six to a <28 week sleeping neonate without any physiologic or behavioral assessment.
The physiological analysis of these patients offers a new insight into the pain of these
patients that goes beyond the veneer of behavioral inference; absent of the human variations in
expression, physiologic measurements allow for greater standardization and comparison of pain
scores. Framing the results of the PIPP-R scale in relation to other pain assessment scales is
important to asses its validity; a handful of studies asserted that the PIPP-R scale offers results
that are parallel with most other pain scales, only varying from a few purely behavioral pain
assessment methods [x]. The PIPP-R scale in meta-analysis also displayed excellent reliability
scores: results amongst different users were repeated consistently.
Limitations
The PIPP-R is a thorough method of pain assessmentthis thoroughness constitutes the
foundation of its strengths, but also the roots of its limitations.

James Sherpa
HONORS 222C

Despite numerous guidelines and standards mandating the use of validated and standardized pain
assessment measures,2831 only 11%32 to 35%33 of health professionals are reported to use a valid pain
assessment tool in a 24-hour period during their assessments. Researchers argue that there is a lack of good-quality
evidence for the efficacy, effectiveness or cost-benefit of standardized pain assessment tools in relation to
pediatric patient or process outcomes.34 To date, no studies have been conducted to examine whether pain
detection skills or motivation to relieve others pain can be improved by standardized methods of pain assessment.
Further research is needed to understand the intrapersonal and interpersonal factors in clinical neonatal pain
assessment and to test alternative ways of achieving diagnosis and pain management.34

Over the past 2 decades, our understanding of pain and its management has increased dramatically.30 Despite
these advances, optimal pain assessment and management practices have not been realized for many infants. The PIPP
is a well-validated measure used to assess pain in preterm and term infants, but lacks sufficient data on its feasibility
and clinical utility and validity with the ELGA infants. The PIPP-R is reported to be easier to use and score in clinical
practice and has preliminary construct validation and feasibility. The revised measure clearly identifies which infants are
not responding to pain. Although the significance of nonresponse remains unclear, the standardized approach to
assessment is a more accurate reflection of infant response and clinical practice.

Refrences
1.
EstablishingintraandinterrateragreementoftheFace,Legs,Activity,Cry,Consolabilityscale
forevaluatingpainintoddlersduringimmunization.
GomezRJ,BarrowmanN,EliaS,ManiasE,RoyleJ,HarrisonD.

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http://www.ncbi.nlm.nih.gov/pubmed/24308028

8. Berde C, Wolfe J. Pain, anxiety, distress, and suffering: interrelated, but not interchangeable. J Pediatr.
2003; 142: 363.
9.Stevens, B., Johnston, C., Petryshen, P., Taddio A. (1996). Premature infant pain profile: Development
and initial validation. Clinical Journal of Pain, 12 (1): 13-22.