The Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale

Mar 05 2016

The Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale

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A revised version of the FLACC was published in 2006. The bolded items represent updated information.

I. Descriptive Information

Title: The Face, Legs, Activity, Cry, Consolability Scale (FLACC Scale), 1997. Revised in 2006 to include behaviors for children with cognitive impairments.

Authors: Sandra Merkel, MS, RN, Terri Voepel-Lewis, MS, RN, Shobha Malviya, MD, Constance Burke*, BSN RN, and Alan R. Tait*, PhD. (* indicates participation with only the revised FLACC scale).

Source (publisher or distributor, address): C. S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI, 48109.

Costs (booklets, forms, kit): Free; criteria and scoring chart can be found online and printed free of charge. The official revised FLACC chart can be obtained from

Purpose: An observational pain scale used to quantify and guide the management of pain in children who are unable to verbally communicate their pain.

Type of Test: Observational

Target Population & Ages: Young Children (2 months to 7 years old), postoperatively.

Time Requirements: 1 to 5 minutes

II. Administration

Administration and Scoring: Scoring is obtained through observation of the child (body and limbs uncovered) by a clinician. Each category is scored on a scale of 0-2, 0 representing little to no pain and 2 representing intense pain. When adding individual category scores together, the total score can range from 0-10. The score is interpreted as 0 = relaxed and comfortable, 1-3 = mild discomfort, 4-6 = moderate pain, 7-10 = severe discomfort/pain or both.

Type of information resulting from testing (e.g. standard scores, percentile ranks): Quantification of pain behaviors (on a scale of 0-10) leading to clinical decisions regarding pain management by a medical professional.

Environment for Testing: Quiet space where the child’s behavior can be observed by a clinician without distractions.

Equipment/Material: A way to document observations/scores.

Examiner Qualifications: Licensed medical professional, 10 minute training session.

Standardized/Normative Data: None; scores are based on observation of the child’s pain.

Psychometric Properties: The original FLACC scale was revised to obtain improved validity and reliability concerning the Legs and Activity categories. Validity, reliability, sensitivity, and specificity for the Face, Cry, and Consolability categories were established in the original scale, thus these categories remain unchanged. Furthermore, this scale is free to use and easily reproducible.

Evidence of Reliability and Validity: Reliability and validity have been established in various settings and with various patient populations (it has also recently been successfully translated into Brazilian Portuguese and shown to be valid and reliable through multiple research studies of the translated version). Construct validity has been established by demonstrating decreased FLACC scores following administration of analgesics to children. The FLACC scale also has a shown to be highly association with global rating of pain and the OPS scores applied by PACU nurses. The original FLACC demonstrated inter-rater reliability and validity (r=0.94 between 2 observers) within the Face, Cry, and Consolability categories, but not in the Legs and Activity categories. The revised FLACC incorporates parent-identified individualized behaviors of the child, and additional behaviors such as verbal outbursts, tremors, increased spasticity, jerking movements, and respiratory changes. The revised FLACC has been shown as both valid and reliable in all 5 categories, although the number of studies assessing the revised scale have been limited.

Discriminative: Identifies those with and without pain.

III. Summary Comments

Strengths: Clinically applicable, replicable, and contains good validity. This scale can be used free of charge, with children who have various reasons for being unable to communicate their pain verbally. The FLACC has also shown to be successfully translated into other languages (while maintaining its validity and reliability) for expanded use in other countries.

Weaknesses: While test is easily applicable to multiple settings and patient diagnoses, its validity and reliability regarding specific diagnoses has not been studied in detail. Furthermore, observations that a clinician may make in the 5 FLACC categories could be due to motor or cognitive impairments rather than pain in children with certain disorders.

Clinical Application: The FLACC is a frequently used, quickly applicable observational scale used to quantify pain in infants and children postoperatively. The revised scale expands the validity and reliability to include children with cognitive deficits. The results of this scale are intended to guide the medical professional on when and how aggressively they need to manage the child’s pain in a short period of time.

References of Review:

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.

Silva FC da, Thuler LCS. Cross-cultural adaptation and translation of two pain assessment tools in children and adolescents. Jornal de Pediatria. 2008;84(4):344-349. doi:10.2223/JPED.1809.

Manworren R C.B, Hynan L.S. Clinical validation of FLACC: preverbal patient pain scale. Pediatr Nurs. 2003; 29(2).

FLACC Scale Source Information: Accessed March 4, 2016.

Article Summary:

Kjeldgaard Pedersen L, Nikolajsen L, Rahbek O, Uldall Duch B, Møller-Madsen B. Epidural analgesia is superior to local infiltration analgesia in children with cerebral palsy undergoing unilateral hip reconstruction. Acta Orthop. November 2015:1-7.

Management of pain in children with cerebral palsy (CP) after surgery is difficult because many of these children are unable to verbalize their pain due to cognitive impairments from CP. The researchers of this study aimed to determine whether epidural analgesia (EA) or high volume local infiltration analgesia (LIA) would help manage pain better in this patient population after hip reconstruction surgery. The study design included both a randomized, double-blind, placebo controlled design and a prospective consecutive cohort. The revised FLACC (r-FLACC) and the observational visual analog scale (VAS-OBS) were used to assess pain 4 hrs post-op. Observational pain behaviors were also examined after 9 hrs and 21 hrs post-op.

Eighteen out of 24 children (average age 6-8 y.o) screened for the study participated. Participants included both males and females with CP and associated cognitive impairments. Each child was given LIA, EA, or a placebo immediately, 8 hrs and 20 hrs post-op. All 3 groups were additionally given IV and oral analgesics. R-FLACC scores were taken by assessing a standardized, 2-min recorded video at the 4 hr, 9hr, and 21 hr mark. The assessment was performed by a RN trained in the r-FLACC scale, who was blinded to which treatment the participant was receiving. Primary caregivers recorded individual child behaviors in the 5 FLACC categories pre-operatively for comparison.

EA was shown to decrease pain significantly more than both the LIA and the placebo group 4 hrs postoperatively using the r-FLACC (p= 0.01) and the VAS-OBS (p=.02). The Legs, Activity, Cry, and Consolability categories of the r-FLACC all showed significantly lower values in the EA group compared to the LIA group. All 5 r-FLACC categories showed significantly lower values in the EA group compared to the placebo group. R-FLACC and VAS-OBS scores were not significantly different in the LIA group compared to the placebo group. R-FLACC and VAS-OBS scores were also lower in the EA group at the 9 hr and 21 hr post-op mark, however scores were not statistically significant. The researchers concluded that, although EA poses some risk to children with CP, it is the better choice for post-op pain management after hip reconstruction surgery in this population. Furthermore, researchers found that the r-FLACC and VAS-OBS are both validated, independent, comparable scales that can be used together to create more objective pain measurements.

2 Responses to “The Face, Legs, Activity, Cry, Consolability (FLACC) Pain Scale”

  1. csantella Says:

    The revised version of this assessment tool seems to have made vast improvements from the original, improving its reliability and validity among all five categories and incorporating assessment of important additional behaviors such as spasticity and tremors. This appears to be a great informative tool to use because it is simple and efficient to administer, free of charge, and it allows the clinician to construct a specific pain management plan based on the findings. I also found your article to be very interesting, concluding that epidural analgesia may be the more ideal option for these children. I think this is a very cool outcomes assessment tool and the current available research seems to support it.

  2. bmurphy11 Says:

    This is good, clinically beneficial information to know about this test, especially for therapists who might work mostly with the pediatric population in the acute care setting. I was pleasantly surprised that this test has a high inter-rater reliability, at least in the face, cry, and consolability categories of the original test, as well as good validity and reliability in the revised FLACC because it is a test based solely on observations of a child who is unable to verbally communicate their feelings and pain. This was interesting to me because observations of different therapists could always be interpreted in different ways, even with a scoring sheet of descriptions dictating a 0,1, or 2.

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