Face, Legs, Activity, Cry, Consolability Scale (FLACC)
Title: The Face, Legs, Activity, Cry, Consolability scale (FLACC Scale)
Author: Sandra Merkel, MS, RN, Terri Voepel-Lewis, MS, RN, and Shobha Malviya, MD, at C. S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI
Source: Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs.1997;23:293–297.
Purpose: An observer rated scale to quantify and assess postoperative (acute) pain in young children (2 months to 7 years) or for those who are unable to communicate their pain.
Type of Test: Observation
Target Population & Ages: Young Children (2 months to 7 years old) postoperatively.
Time Requirements: 1 to 5 minutes
Administration and Scoring: Observe patients body and legs uncovered and score each of the 5 categories (face, legs, activity, cry and consolability) from 0-2, based on the observation, for a total score of 0-10. The score is interpreted as 0 = relaxed and comfortable, 1-3 = mild discomfort, 4-6 = moderate pain, 7-10 = severe discomfort or pain or both.
Type of information resulting: Quantification of pain behaviors, 0-10.
Environment for Testing: Ability to observe the patient
Equipment/Material: A way to document observations/scores
Examiner Qualifications: Trained
Standardized/Normative Data: None, scores are based on observation of the patient’s pain.
Psychometric Properties: Validity, reliability, sensitivity, specificity and clinical applicability
Evidence of Reliability and Validity: Reliability and validity have been established in various settings and with various populations. Validity was established by demonstrating a decrease in FLACC score following administration of analgesics to patients. It also has a high association with the PACU nurses global rating of pain and the OPS score. A high inter-rater reliability (r=0.94) between 2 observers has also been established with the FLACC.
Discriminative: Identifies those with and without pain.
Summary: The FLACC is a frequently used behavioral measure to quantify pain in infants and children postoperatively. Studies have shown adequate validity and reliability for this population.
References of Review:
Hartrick CT, Kovan JP. Pain assessment following general anesthesia using the Toddler Preschooler Postoperative Pain Scale: a comparative study. J Clin Anesth. Sep 2002;14(6):411-415. 14.
Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. Mar 2006;16(3):258-265.
Merkel S, Voepel-Lewis T, Malviya S. Pain assessment in infants and young children: The FLACC Scale. Am J Nurs. 2002 ;102:55–58
Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nurs.1997;23:293–297.
Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002;95(5):1224-1229.
Willis MH, Merkel SI, Voepel-Lewis T, Malviya S. FLACC Behavioral Pain Assessment Scale: a comparison with the child’s self-report. Pediatr Nurs. May-Jun 2003;29(3):195-198. 16.
Article Summary:
Martin S, Smith AB, Newcomb P, Miller J. Effects of therapeutic suggestion under anesthesia on outcomes in children post tonsillectomy. J Perianesth Nurs 2014;29(2). doi:10.1016/j.jopan.2013.03.011.
The purpose of this study is to examine the effects of positive therapeutic suggestions (TS) while patients are emerging from anesthesia post tonsillectomy on distress. There were 94 patients examined, ages 4 to 8. This is a double blinded randomized controlled trial. The children were randomized into a treatment group (n=48) that listened to a TS recording while coming out of surgery, or the control group (n=46) which listened to a control recording. Outcome measures include length of stay (LOS), anxiety via the VAS for parents and Child Rating of Anxiety Scale (CRA) for the children, pain via the FLACC, and once the child was awake the FACES scale was used, IV morphine dose, nausea and vomiting, emergence delirium via the Pediatric Anesthesia Emergence Delirium Scale (PAED) and an implicit memory picture test. The two groups listened to the recording for approximately 15-30 minutes, enough time to hear the recording multiple times during sleep, and outcome measures were taken once the headphones were removed.
There was no significant difference between LOS, nausea and vomiting, emergence delirium or implicit memory. While there was a decreased use of IV morphine in the treatment group, it was not significant. The treatment group did have a lower pain score through 80 minutes after extubation, except during extubation and at 50 minutes, but only a significantly lower score at 30 minutes post extubation. There was also no difference between the VAS, and the CRA was found to not be valid in children ages 4-5 and was not used. The strengths of this study are that it is double blinded randomized controlled trial, easily reproducible and has a relatively large sample size. While the sample size was large, it was smaller than what was required to meet the power and outcome measures weren’t assessed after patients left the PACU to see if there was an extended effect. This study concluded that TS may be beneficial for pain management for children post tonsillectomy, but more research is needed to assess the effectiveness of TS.
5 responses to “Face, Legs, Activity, Cry, Consolability Scale (FLACC)”
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I thought this was an interesting idea and interesting article summary. I wish it had been a bigger study like you said. Did they mention anything about what was specifically on the audio recordings or just that the experimental group was listening to TS and the other was not? Thanks for posting
They did give the exact script of the therapeutic suggestion recording. Generally, it explained that the child would be waking up in a hospital room with a nurse, that everything went well during surgery and that they are already getting better. You can see the full script in the study.
Sometimes pain is a barrier to participation in functional activities and participation in physical therapy. We largely check pain for adults every visit for those reasons and also to monitor effectiveness of treatment to reduce pain. Although this test is most commonly used post-operatively, it would be very helpful to be able to score and track pain for the babies/kids who are unable to voice or understand their pain when pain.
Objectifying pain in pediatric patients is a real challenge! One of your classmates used this measure on clinical, I have never used it but like it after reading more about it. It appears to use it one must be “trained”, Jakki, what does that involve?
I am studying deeply and deeply this Abstract. Surely, as You write ‘… but more research is needed to assess the effectiveness of Therapeutic Suggestions (TS). I have been studying Pain in Preverbal Oncologic and Non-OncologicChildren since 2010, in the Non PharmacologicalCare, and my studies are focusing on the importance of Child’s Eyes in the context of his Face. I practise this Scale also in PreverbalDelirium. In the Prevention. I am a Linguist and I am devoting my studies to All the Children in the World Who Are in Need-and-in Pain, in Memory of my Little Nephew Giampaolo, a PreverbalLeukaemicChild born on 5th March 2009 and died on 17th October 2010.
Luisella Magnani info@luisellamagnani.it http://www.luisellamagnani.it