/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/questionnaires/,/clinical/cckm-tools/content/questionnaires/related/,

/clinical/cckm-tools/content/questionnaires/related/name-97177-en.cckm

201606168

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires,Related

Reliability and Validity of the Face, Legs, Activity, Cry, Consolability Behavioral Tool in Assessing Acute Pain in Critically Ill Patients

Reliability and Validity of the Face, Legs, Activity, Cry, Consolability Behavioral Tool in Assessing Acute Pain in Critically Ill Patients - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related


By Terri Voepel-Lewis, RN, MSN, Jennifer Zanotti, RN, MS, CCRN, CEN,
Jennifer A. Dammeyer, RN, MSN, and Sandra Merkel, RN, MS
Background Few investigators have evaluated pain assessment
tools in the critical care setting.
Objective To evaluate the reliability and validity of the Face,
Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale in
assessing pain in critically ill adults and children unable to
self-report pain.
Methods Three nurses simultaneously, but independently,
observed and scored pain behaviors twice in 29 critically ill
adults and 8 children: before administration of an analgesic
or during a painful procedure, and 15 to 30 minutes after the
administration or procedure. Two nurses used the FLACC
scale, the third used either the Checklist of Nonverbal Pain
Indicators (for adults) or the COMFORT scale (for children).
Results For 73 observations, FLACC scores correlated highly
with the other 2 scores (ρ= 0.963 and 0.849, respectively),
supporting criterion validity. Significant decreases in FLACC
scores after analgesia (or at rest) supported construct validity
of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P <.001).
Exact agreement and κstatistics, as well as intraclass correla-
tion coefficients (0.67-0.95), support excellent interrater relia-
bility of the tool. Internal consistency was excellent; the
Cronbach αwas 0.882 when all items were included.
Conclusions Although similar in content to other behavioral
pain scales, the FLACC can be used across populations of
patients and settings, and the scores are comparable to those
of the commonly used 0-to-10 number rating scale. (American
Journal of Critical Care. 2010;19:55-62)
RELIABILITY AND VALIDITY
OF THE FACE, LEGS, ACTIVITY,
CRY, CONSOLABILITY
BEHAVIORAL TOOL IN
ASSESSING ACUTE PAIN IN
CRITICALLY ILL PATIENTS
CE
1.0 Hour
Notice to CE enrollees:
A closed-book, multiple-choice examination
following this article tests your under standing of
the following objectives:
1. Describe study findings related to the relia-
bility and validity of the Face, Legs, Activity,
Cry, Consolability (FLACC) Behavioral Scale
in assessing pain in critically ill adults and
children unable to self-report pain.
2. Describe 2 methods for reliable pain assess-
ment of critically ill adults.
3. List 2 advantages that the FLACC tool may
offer for observational pain assessment of
critically ill adults.
To read this article and take the CE test online,
visit www.ajcconline.org and click “CE Articles
in This Issue.” No CE test fee for AACN members.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2010, Volume 19, No. 1 55
©2010 American Association of Critical-Care Nurses
doi: 10.4037/ajcc2010624
Critical Care Evaluation
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from

Frequent and routine assessment of pain
improves pain management for adults and children
10
and is considered essential for optimal care.
11
Addi-
tionally, clinical practice guidelines
9
for the use of
sedatives and analgesics in critically ill patients
highlight the importance of systematically and con-
sistently assessing and documenting pain and
response to therapy by using scales appropriate for
the population of patients. These guidelines, as well
as previous reports,
12,13
suggest that
pain assessment for patients who
cannot communicate their pain
should include subjective observation
of pain-related behaviors (eg, move-
ment, facial expression, posturing).
Despite such recommendations and
pain standards from the Joint Com-
mission, considerable gaps exist in pain assessment
practices in critical care because of the limited
research in this area.
Several investigators
3,14-19
have generated similar,
qualitative descriptors of pain behaviors in adults
and children with cognitive impairment and in crit-
ically ill adults and children. For instance, Mateo and
Krenzischek
17
reported moderate correlations between
the degree of facial grimacing, muscle tension, and
sounds documented by a nurse and the verbal
description of pain reported by patients in the
postanesthesia care unit. In another study, Puntillo
et al
18
compared nurses’ subjective ratings of pain,
number of behavioral indicators (eg, movements,
facial expression, posturing), physiological parame-
ters, and patients’ ratings in 31 critically ill surgical
patients and found moderate correlations between
nurses’ ratings and number of behavior indicators,
and between nurses’ and patients’ ratings.
Such data have led to the development of
behavioral scales, including simple scales such as the
Checklist of Nonverbal Pain Indicators (CNPI),
1
the
Behavioral Pain Scale (BPS),
20
and the Critical-Care
Pain Observation Tool (CPOT).
21
Almost all behav-
ioral pain scales require some grading or scoring of
facial expression, vocalizations, and bodily move-
ments. The CNPI
1
requires simple scoring of each of
6 behaviors (vocalizations, grimaces, bracing, rub-
bing, restlessness, verbal complaint) as present or
absent, to provide a total score of 0 to 6. The BPS
20
requires grading of 3 categories (facial expression,
upper limb movement, and compliance with venti-
lation) to provide a score of 3 to 12. The CPOT
21
requires grading each of 4 behavioral categories
(facial expression, body movements, muscle tension,
and vocalization or compliance with ventilator) on
a scale of 0 to 2 to provide a total score of 0 to 8.
The COMFORT scale,
22
which has been widely stud-
ied in children, contains 8 categories (alertness,
calmness, respiratory response, physical movement,
muscle tone, facial tension, heart rate, and blood
pressure); each category is scored from 1 to 5 to
produce a total score of 8 to 40.
Each of these tools has good interrater agree-
ment and good validity in differentiating nociceptive
stimuli (eg, turning) from rest or pain-free situations.
C
ritically ill patients often cannot self-report their level of pain because of changes
in cognition or physiological status or the presence of an endotracheal tube.
Because of this inability, these patients have been excluded from clinical pain
trials, leaving the patients vulnerable to the undertreatment of pain. In the
absence of self-reports, behavioral observations have been used to detect and
quantify pain in children, cognitively impaired patients, and adults.
1-6
However, testing of
observation pain tools in adult critical care patients has been limited. Several simple tools,
including the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale (Table 1),
4,7,8
have been validated for use in acutely ill children, but limited data are available on pain
assessment in critical care settings.
9
Identification and routine use of a simple yet valid and
reliable observational tool to assess pain in these settings are necessary to ensure adequate
pain management in critically ill patients.
About the Authors
Terri Voepel-Lewis is a research area specialist and
Sandra Merkel is a clinical nurse specialist, Department
of Anesthesiology, and Jennifer A. Dammeyer is a clinical
nurse specialist, Department of Critical Care, in the Uni-
versity of Michigan Health System, Ann Arbor, Michigan.
Jennifer Zanotti is a clinical nurse specialist, Emergency
Services, at Memorial Health System, Colorado Springs,
Colorado.
Corresponding author:Terri Voepel-Lewis, RN, MSN,
Department of Anesthesiology, Section of Pediatrics,
F3900 C.S. Mott Hospital, SPC 5211, 1500 E Medical Center
Dr, Ann Arbor, MI 48109-5211 (e-mail: terriv@umich.edu).
Frequent pain
assessment
improves pain
management.
56 �AJCC�AMERICAN JOURNAL OF CRITICAL CARE, January 2010, Volume 19, No. 1 www.ajcconline.org
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from

adults and children, who were present in any of the
critical care units in the medical center during the
study period (2002-2004). Patients were included if
they could not self-report their pain (eg, because of
intubation with or without change in cognition),
and if they had an underlying condition associated
with pain or were undergoing a procedure known
to cause pain. Patients receiving muscle relaxants
were excluded.
Data Collection
Observations were made by 3 intensive care unit
nurses during the routine care of each patient as
follows: Before administration of an analgesic, or
during a painful procedure such as
turning or suctioning, nurses
observed the patient and simulta-
neously, but independently, scored
pain behaviors during a 1- to 2-
minute period. Nurses had no
knowledge of the scores of their fel-
low nurses. Two of the nurses used
the FLACC tool to score pain
behaviors; the third nurse used
the CNPI for adults and the
COMFORT Scale for children.
22
Each patient was
observed again by the same nurses approximately
15 to 30 minutes after the first observation. Patients’
demographics, illness, type of procedure, and anal-
gesic administered were recorded.
These studies indicate that observing behaviors and
using simple scales can be effective in assessing
pain in nonverbal patients.
To be clinically useful, pain assessment tools
must be readily adaptable in busy settings such as
the intensive care unit. Several characteristics affect
the clinical usefulness of an assessment tool, includ-
ing the tool’s relative advantage compared with
other tools, its compatibility (how similar the instru-
ment is to other tools already used in the setting),
and its complexity (ease of use).
23,24
Furthermore, the
ability to use a single tool in different populations
of patients may improve the clinical usefulness of
the tool.
25
Many observational pain scales lack these qual-
ities. For instance, the most commonly used and
recommended verbal self-report tool is the 0-to-10
number rating scale (NRS),
9
in which 0 indicates no
pain and 10 indicates worst pain. Many observa-
tional tools, including those developed for critical
care, have scales that differ from the 0-to-10 format,
potentially confusing the clinical interpretation of
pain scores. In contrast, with the FLACC tool, each
of 5 behavioral categories, facial expression, leg
movement, bodily activity, cry or verbalization, and
consolability, is rated on a scale of 0 to 2 to provide
an overall pain score ranging from 0 to 10, consis-
tent with the NRS.
The FLACC Behavioral Scale includes behav-
ioral categories and a variety of descriptors that are
reliably associated with pain in children, adults
with cognitive impairment, and critically ill adults,
supporting the content validity of the tool in these
populations. The FLACC tool is widely recognized
and used in the United States and internationally
and has been translated into several languages,
including French, Chinese, Portuguese, Swedish,
and Italian. Last, the tool in a revised form has a
high degree of clinical usefulness in assessing pain
in children with cognitive impairment, attesting to
the tool’s ease of use in the acute care setting.
26
These qualities may make the FLACC Behavioral
Scale a useful instrument in critically ill adults.
We devised this prospective, observational
study to evaluate the reliability and validity of the
FLACC Behavioral Scale in assessing pain in criti-
cally ill adults and children who could not
self-report pain.
Methods
The study was approved by the institutional
review board of the University of Michigan Health
System, Ann Arbor, Michigan, which granted a waiver
of consent. The study sample included patients, both
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2010, Volume 19, No. 1 57
Observation of
behaviors can
be effective in
assessing pain
in nonverbal
patients.
Table 1
Face, Legs, Activity, Cry,
Consolability (FLACC) Behavioral Scale
a
Item 0 1 2
a
Printed with permission © The Regents of the University of Michigan.
Face
Legs
Activity
Cry
Consolability
No particular
expression or
smile
Normal position
or relaxed
Lying quietly,
normal position,
moves easily
No cry
Content, relaxed
Occasional grimace,
frown, withdrawn
or disinterested
Uneasy, restless,
or tense
Squirming, shifting
back and forth,
or tense
Moans, whimpers,
or occasional
complaint
Reassured by occa-
sional touching,
hugging, or
being talked to;
distractible
Frequent to con-
stant frown,
clenched jaw,
quivering chin
Kicking, or legs
drawn up
Arched, rigid,
or jerking
Crying steadily,
screams or
sobs, frequent
complaints
Difficult to con-
sole or comfort
Score
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from

Data Analyses
SPSS software (SPSS Inc, Chicago, Illinois) was
used to analyze the data. Total FLACC and CNPI
scores were treated as ordinal data, and each cate-
gory within the FLACC was treated as ordinal, poly-
chotomous data, as recommended and used by
previous investigators.
27-29
Interrater reliability was
evaluated by using intraclass correlation coefficients,
which determine the strength of association and
measure of chance-corrected agreement. Addition-
ally, exact agreement for scores
within each of the 5 FLACC cate-
gories was evaluated by using κsta-
tistics. In accordance with
well-established criteria,
30
interrater
agreement for total FLACC scores
was considered excellent at an intra-
class correlation coefficient of 0.75.
Because each FLACC category contains only 3 items,
generating comparatively less variance and thereby
limiting the magnitude of correlations,
31
an intra-
class correlation coefficient of 0.41 was accepted as
adequate agreement, and a coefficient of 0.6 was
considered good to excellent agreement.
32
Criterion validity was evaluated by using corre-
lation coefficients to compare FLACC scores with
CNPI scores. Correlation coefficients greater than
0.75 were considered indicative of excellent rela-
tionships. The construct validity of the FLACC tool
was evaluated by using Wilcoxon signed rank tests
for paired data to compare scores before and after
analgesic administration or during and after a
painful procedure. P values less than .05 were
accepted as significant. The internal consistency of
reliability of the items in the FLACC tool was meas-
ured by using Cronbach (coefficient) αvalues.
Cronbach αvalues of 0.7 or greater were consid-
ered indicative of excellent internal consistency.
A principal component and exploratory factor
analysis were performed to identify underlying fac-
tors that explained the variance in the FLACC total
scores; loading factors of 0.45 or greater were con-
sidered acceptable.
Sample Size
The sample size was conservatively based on a
moderate reliability correlation coefficient between
FLACC scores. For α= 0.05 and β= 0.1, a total of 25
observations would be needed to reveal a modest
correlation of at least 0.6.
33
A minimum of 65 obser-
vations with at least 13 paired observations (eg, before
and after analgesia) would be needed to ensure a
sufficient number of FLACC scores across the spec-
trum (ie, mild, moderate, and severe pain scores).
This sample size would be sufficiently large to satisfy
the stronger correlations required for criterion validity
(ie, r= 0.75) and to establish a minimum decrease in
pain scores from a mean of 5.3 (SD, 2.8) to a mean
of 2 (SD, 2.4).
Results
A total of 73 observations were obtained in 29
critically ill adults and 8 children. Table 2 gives a
description of the patients.
Criterion Validity
FLACC scores correlated significantly with CNPI
scores, supporting excellent criterion validity in
adults (ρ= 0.963; P < .01). Additionally, FLACC and
COMFORT scores were highly correlated (ρ= 0.849;
P < .01), supporting criterion validity in critically ill
children.
Construct Validity
FLACC pain scores decreased significantly after
administration of an analgesic or from painful to
nonpainful situations (mean, 5.27; SD, 2.3 vs mean,
0.52; SD, 1.1; P< .001), supporting excellent construct
validity across populations of patients.
Reliability
Agreement was excellent between observers for
each category of the FLACC, as well as for total FLACC
scores, supporting the interrater reliability of the tool
Table 2
Description of the sample
a
Characteristic Adults (n = 29) Children (n = 8)
a
Values are number (%) unless indicated otherwise. Because of rounding, not all
percentages total 100.
b
Data on sex missing for 1 child.
Age, y
Mean (SD)
Range
Sex
b
Male
Female
Race
White
African American
Other
Diagnosis
Medical
Neurological-medical
Neurosurgical
Surgical
Treated with mechanical ventilation
Cognitive impairment
Acute delirium
51 (38)
24 - 70
17 (59)
12 (41)
23 (79)
3 (10)
3 (10)
19 (66)
6 (21)
2 (7)
2 (7)
23 (79)
16 (55)
11 (38)
5.6 (5.6)
0.13 - 13
4 (50)
3 (38)
8 (100)
0
0
1 (12)
0
0
7 (88)
3 (38)
1 (12)
Not applicable
58 �AJCC�AMERICAN JOURNAL OF CRITICAL CARE, January 2010, Volume 19, No. 1 www.ajcconline.org
FLACC scores
showed excellent
criterion validity
in adults.
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from

interrater reliability, criterion validity, and construct
validity, thereby supporting its usefulness in assess-
ing pain in critical care patients.
Indisputably, self-report remains the gold stan-
dard for pain assessment, yet many patients cannot
report their pain, an inability that may make them
vulnerable to poor pain management. Many tools
have been developed to aid in assessing pain for
patients who cannot self-report; however, few of the
tools have been tested in critically
ill patients who cannot self-report.
We found that the FLACC Behav-
ioral Scale has excellent psychome-
tric properties, including reliability,
criterion validity, and construct
validity, in assessing pain in these
patients. Interestingly, 4 categories
(face, legs, activity, and consolabil-
ity) were predictive of most of the
variance (68.5%) in scores. The cry
category correlated poorly with other categories and
slightly lowered the internal consistency of the tool.
These findings are not surprising; many of the
patients in our study were nonverbal and many had
endotracheal tubes.
The COMFORT Scale, BPS, and CPOT, which
were all developed for scoring pain in the intensive
care unit, include a category for assessing respiratory
response or compliance with ventilation, a category
that may be useful for assessing pain in patients
receiving mechanical ventilation.
20-22
In a sample of
sedated adults receiving mechanical ventilation,
20
compliance with mechanical ventilation had a smaller,
in assessing pain in critically ill patients (Table 3).
Agreement was also adequate to excellent when data
on adults, children, and patients receiving mechani-
cal ventilation were analyzed separately (Table 3).
Internal Consistency and Factor Analysis
Internal consistency of the FLACC was excel-
lent, as indicated by Cronbach α= 0.882, when all
items were included. Each category correlated highly
with the others (Spearman ρ=0.69-0.92; P < .001)
except for the cry category (ρ= 0.18-0.36). Addition-
ally, the Cronbach αimproved to 0.934 when the
cry category was removed, but decreased slightly
with removal of other items. In the exploratory fac-
tor analysis, 1 component accounted for 68.9% of
the variance in FLACC scores; 4 items contributed to
this component: face (0.86), legs (0.94), activity
(0.90), and consolability (0.95). These findings indi-
cate that 4 categories of the FLACC reflected the pain
expression factor in this sample of patients.
Discussion
Use of behavioral pain tools may help in
assessing pain in critical care patients, but the tools
must have good reliability and validity and be clini-
cally feasible.
13
Clinical feasibility, or the ability to
readily adapt an instrument for routine assessment
and documentation, may depend on a tool’s sim-
plicity and its compatibility with other tools used in
the clinical setting,
23
as well as on the ability to use
the tool across settings or populations of patients.
25
We evaluated the well-known FLACC behavioral
pain tool and showed that the tool has excellent
Table 3
Measures of interater reliability between scores on the
Face, Legs, Activity, Cry, Consolability Behavioral Scale
a
Face
Legs
Activity
Cry
Consolability
Total score
0.90 [0.83-0.94]
80% (0.68)
0.956 [0.93-0.98]
89% (0.82)
0.91 [0.85-0.95]
82% (0.70)
0.67 [0.44-0.81]
89% (0.69)
0.95 [0.91-0.97]
86% (0.78)
0.96 [0.93-0.97]
0.93 [0.88-0.96]
84% (0.76)
0.97 [0.94-0.98]
91% (0.85)
0.93 [0.87-0.96]
91% (0.74)
0.72 [0.53-0.86]
93% (NA)
b
0.96 [0.93-0.98]
89% (0.82)
0.98 [0.97-0.99]
0.74 [0.10 -0.93]
58% (0.33)
0.92 [0.73-0.98]
83% (0.71)
0.76 [0.17-0.93]
75% (NA)
b
0.43 [-0.97 to 0.84]
75% (NA)
b
0.87 [0.56-0.96]
75% (0.60)
0.85 [0.52-0.96]
0.90 [0.80-0.95]
76% (0.64)
0.94 [0.88-0.97]
79% (0.74)
0.95 [0.89-0.97]
85% (0.76)
0.60 [0.20-0.80]
91% (0.72)
0.96 [0.93-0.98]
88% (0.81)
0.96 [0.92-0.98]
Item
Total observations
(n = 73)
Adults
(n = 60)
Children
(n = 13)
Treated with
mechanical ventilation
(n = 34)
Abbreviation: NA, not applicable.
a
Data are intraclass correlation coefficient [confidence interval]; % exact agreement (κ), where applicable.
b
Unable to calculate κvalues in unequal contingency tables.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2010, Volume 19, No. 1 59
Pain scales
that include
compliance with
ventilation may
be useful in venti-
lated patients.
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from

but significant, coefficient in accounting for variance
in pain expressions, supporting the inclusion of
compliance descriptors in tools used to assess pain
in patients receiving mechanical ventilation. How-
ever, a recent study
34
validating use of the BPS in
sedated patients suggested that newer modes of ven-
tilation that allow for variation in
patients’ needs may reduce the relia-
bility of this category in assessing
discomfort. Interestingly, in our
study, the FLACC had good reliabil-
ity in assessing pain even in the sub-
set of patients receiving mechanical
ventilation. However, the addition of
descriptors (eg, breath holding,
splinting, blocking ventilation) in
the cry category that allow for scoring pain in
patients who are intubated and receiving mechani-
cal ventilation may enhance pain assessment in
these patients. Indeed, similar minor revisions
related to respiratory patterns, in addition to other
revisions, improved the reliability of the FLACC tool
in assessing pain in cognitively impaired children.
16
Several guidelines
9,12,13
suggest that in addition
to observation of behaviors, pain assessment in the
critically ill should include consideration of physio-
logical measures such as heart rate, blood pressure,
and respiratory rate. Importantly, changes in these
measures are nonspecific to pain and may indicate
other pathological changes.
12,13
In a recent study
35
of
the COMFORT scale in the pediatric intensive care
unit, 97% of the variance in pain scores was explained
by 6 behavioral categories, including a category for
scoring respiratory or compliance behaviors, but
not by heart rate or blood pressure. These findings
led the authors
35
to conclude that
these parameters should be removed
from the COMFORT scale.
The fact that behavioral pain
tools provide a score of a patient’s
expressions of distress and discomfort
must be emphasized. In addition to
pain, these behaviors have many
potential underlying sources, includ-
ing physiological abnormalities (eg,
cardiorespiratory compromise) and
anxiety. Such conditions are com-
mon in critically ill patients, and therefore a
patient’s medical condition and current circum-
stances, including response to analgesia, must be con-
sidered when behavioral pain scores are interpreted.
Additionally, most behavioral pain tools, includ-
ing the FLACC, COMFORT, BPS, and CPOT, were
developed to score intensity of acute pain. It has
been suggested that behavioral distress related to
pain lessens over time, despite persistence of pain.
36
Withdrawn or disinterested expressions and immo-
bility may replace behaviors such as grimacing,
vocalizations, and movements. The variety of
descriptors included in the FLACC tool were meant
to indicate some of the differences observed from
patient to patient. However, assessment of chronic
or long-term pain should include other observa-
tions such as activity, quality of sleep, and expres-
sions of depression.
The ability to generalize our findings may be
limited by the following design issues. First, the
same nurses scored pain before and after adminis-
tration of analgesics, a practice that could have
resulted in a reporting bias. However, in previous
studies
5,16
in which nurses were blinded to treatment,
similar changes in FLACC scores occurred, providing
some external validity to our data. Second, we
included a variety of medical and surgical patients
in the sample to indicate usefulness across critical
care settings. However, because of the small sample
size, we could not analyze data separately for each
group. Further study in these subsets of patients
may provide greater insight into behavioral changes
that best describe pain in these groups.
Conclusion
The FLACC behavioral pain tool has excellent
reliability and validity in assessing pain in critically
ill adults and children. Although similar in content
to other observational pain scales, the FLACC tool
may offer an advantage: it can be used across popu-
lations and settings, and FLACC scores are compara-
ble to scores generated by using 0-to-10 number
rating scales.
ACKNOWLEDGMENTS
This study was conducted at the University of Michigan
Health System in Ann Arbor.
FINANCIAL DISCLOSURES
None reported.
eLetters
Now that you’ve read the article, create or contribute to an
online discussion on this topic. Visit www.ajcconline.org
and click “Respond to This Article” in either the full-text or
PDF view of the article.
60 �AJCC�AMERICAN JOURNAL OF CRITICAL CARE, January 2010, Volume 19, No. 1 www.ajcconline.org
Behavioral pain
tools assess the
patient’s expres-
sions of distress
and discomfort.
Behavioral pain
scores must be
interpreted in light
of the patient’s
medical condition,
including response
to analgesia.
SEE ALSO
For more about pain assessment, visit the Critical
Care Nurse Web site, www.ccnonline.org, and read
the article by Kabes et al, “Further Validation of the
Nonverbal Pain Scale in Intensive Care Patients” (Feb-
ruary 2009).
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from

who cannot respond verbally. J Adv Nurs. 1995;22:663-669.
20. Payen JF, Bru O, Bosson JL, et al. Assessing pain in criti-
cally ill sedated patients by using a behavioral pain scale.
Crit Care Med. 2001;29:2258-2263.
21. Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Valida-
tion of the Critical-Care Pain Observation Tool in adult
patients. Am J Crit Care. 2006;15(4):420-427.
22. Ambuel B, Hamlett KW, Marx CM, Blumer JL. Assessing
distress in pediatric intensive care environments: the COM-
FORT scale. J Pediatr Psychol. 1992;17(1):95-109.
23. Hester NO, Foster RL, Jordan-Marsh M, Ely E, Vojir CP,
Miller KL. Putting pain measurement into clinical practice.
In: Finley GA, McGrath PJ, eds. Measurement of Pain in
Infants and Children. Seattle, WA: IASP Press; 1998:179-197.
Progress in Pain Research and Management; vol 10.
24. Dufault MA, Bielecki C, Collins E, Willey C. Changing nurses’
pain assessment practice: a collaborative research utiliza-
tion approach. J Adv Nurs. 1995;21:634-645.
25. Buttner W, Finke W. Analysis of behavioural and physiological
parameters for the assessment of postoperative analgesic
demand in newborns, infants and young children: a com-
prehensive report on seven consecutive studies. Paediatr
Anaesth. 2000;10:303-318.
26. Voepel-Lewis T, Malviya S, Tait AR, et al. A comparison of
the clinical utility of pain assessment tools for children
with cognitive impairment. Anesth Analg. 2008;106:72-78.
27. Kain ZN, Cicchetti DV, McClain BC. Measurement of pain in
children: state-of-the-art considerations. Anesthesiology.
2002;96:523-526.
28. Bartko JJ, Carpenter WT Jr. On the methods and theory of
reliability. J Nerv Ment Dis. 1976;163:307-317.
29. Breau LM, Finley GA, McGrath PJ, Camfield CS. Validation
of the Non-communicating Children’s Pain Checklist-
Postoperative Version [published correction appears in
Anesthesiology. 2002;97(3):769]. Anesthesiology. 2002;
96(3):528-535.
30. Cicchetti DV. The precision of reliability and validity estimates
re-visited: distinguishing between clinical and statistical
significance of sample size requirements. J Clin Exp Neu-
ropsychol. 2001;23(5):695-700.
31. Preston CC, Colman AM. Optimal number of response cat-
egories in rating scales: reliability, validity, discriminating
power, and respondent preferences. Acta Psychol (Amst).
2000;104:1-15.
32. Fleiss JL. Statistical Methods for Rates and Proportions.
New York, NY: John Wiley & Sons; 1981.
33. Browner WS, Black D, Newman TB, Hulley SB. Estimating
sample size and power. In: Hulley SB, Cummings SR, eds.
Designing Clinical Research. Baltimore, MD: Williams &
Wilkins; 1988:139-150.
34. Young J, Siffleet J, Nikoletti S, Shaw T. Use of a behavioural
pain scale to assess pain in ventilated, unconscious and/or
sedated patients. Intensive Crit Care Nurs. 2006;22:32-39.
35. Carnevale FA, Razack S. An item analysis of the COMFORT
scale in a pediatric intensive care unit. Pediatr Crit Care
Med. 2002;3:177-180.
36. McCaffery M, Pasero C. Assessment: underlying complexities,
misconceptions, and practical tools. In: Pain: Clinical Manual.
2nd ed. New York, NY: Mosby; 1999:35-102.
REFERENCES
1. Feldt KS. The Checklist of Nonverbal Pain Indicators (CNPI).
Pain Manag Nurs. 2000;1:13-21.
2. Herr K, Bjoro K, Decker S. Tools for assessment of pain in
nonverbal older adults with dementia: a state-of-the-
science review. J Pain Symptom Manage. 2006;31(2):
170-192.
3. McGrath PJ, Rosmus C, Canfield C, Campbell MA, Hennigar
A. Behaviours caregivers use to determine pain in non-
verbal, cognitively impaired individuals. Dev Med Child
Neurol. 1998;40:340-343.
4. 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.
5. Voepel-Lewis T, Malviya S, Merkel S, Tait AR. Behavioral pain
assessment and the Face, Legs, Activity, Cry and Consola-
bility instrument. Expert Rev Pharmacoecon Outcomes Res.
2003;3(3):317-325.
6. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The
reliability and validity of the Face, Legs, Activity, Cry, Con-
solability observational tool as a measure of pain in chil-
dren with cognitive impairment. Anesth Analg. 2002;95:
1224-1229.
7. Manworren RC, Hynan LS. Clinical validation of FLACC:
preverbal patient pain scale. Pediatr Nurs. 2003;29:140-146.
8. Willis MH, Merkel SI, Voepel-Lewis T, Malviya S. FLACC
Behavioral Pain Assessment Scale: a comparison with the
child’s self-report. Pediatr Nurs. 2003;29:195-198.
9. American College of Critical Care Medicine of the Society
of Critical Care Medicine, American Society of
Health-System Pharmacists, American College of Chest
Physicians. Clinical practice guidelines for the sustained
use of sedatives and analgesics in the critically ill adult.
Am J Health Syst Pharm. 2002;59(2):150-178.
10. Faries JE, Mills DS, Goldsmith KW, Phillips KD, Orr J. Sys-
tematic pain records and their impact on pain control: a
pilot study. Cancer Nurs. 1991;14:306-313.
11. Department of Health and Human Services, Public Health.
Service Acute Pain Management: Operative or Medical Pro-
cedures and Trauma. Department of Health and Human
Services, Public Health Service: Rockville, MD; 1992.
12. Hamill-Ruth RJ, Marohn ML. Evaluation of pain in the criti-
cally ill patient. Crit Care Clin. 1999;15:35-54, v-vi.
13. Herr K, Coyne PJ, Key T, et al. Pain assessment in the non-
verbal patient: position statement with clinical practice rec-
ommendations. Pain Manag Nurs. 2006;7:44-52.
14. Breau LM, McGrath PJ, Camfield C, Rosmus C, Finley GA.
Preliminary validation of an observational pain checklist for
persons with cognitive impairments and inability to com-
municate verbally. Dev Med Child Neurol. 2000;42:609-616.
15. LaChapelle DL, Hadjistavropoulos T, Craig KD. Pain meas-
urement in persons with intellectual disabilities. Clin J
Pain. 1999;15:13-23.
16. 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. 2006;16:258-265.
17. Mateo OM, Krenzischek DA. A pilot study to assess the
relationship between behavioral manifestations and
self-report of pain in postanesthesia care unit patients. J
Post Anesth Nurs. 1992;7(1):15-21.
18. Puntillo KA, Miaskowski C, Kehrle K, Stannard D, Gleeson S,
Nye P. Relationship between behavioral and physiological
indicators of pain, critical care patients’ self-reports of pain,
and opioid administration. Crit Care Med. 1997;25:1159-1166.
19. Simons W, Malabar R. Assessing pain in elderly patients
To purchase electronic or print reprints, contact The
InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax,
(949) 362-2049; e-mail, reprints@aacn.org.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2010, Volume 19, No. 1 61
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from

Name Member #
Address
City State ZIP
Country Phone E-mail address
RN License #1 State
RN License #2 State
Payment by: �Visa �M/C �AMEX �Check
Card # Expiration Date
Signature
CE Test Test ID A1019013: Reliability and Validity of the Face, Legs, Activity, Cry, Consolability Behavioral Tool in Assessing Acute Pain
in Critically Ill Patients . Learning objectives: 1. Describe study findings related to the reliability and validity of the Face, Legs, Activity, Cry, Consolability
(FLACC) Behavioral Scale in assessing pain in critically ill adults and children unable to self-report pain. 2. Describe 2 methods for reliable pain assessment
of critically ill adults. 3. List 2 advantages that the FLACC tool may offer for observational pain assessment of critically ill adults.
Program evaluation
Yes No
Objective 1 was met ��
Objective 2 was met ��
Objective 3 was met ��
Content was relevant to my
nursing practice ��
My expectations were met ��
This method of CE is effective
for this content ��
The level of difficulty of this test was:
�easy �medium �difficult
To complete this program,
it took me hours/minutes.
1. Which of the following patient types have been studied previously for val-
idation of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale?
a. Acutely ill children
b. Adults with dementia and cognitive impairment
c. Critically ill adults and children
d. Adults with expressive aphasia
2. Which of the following is most likely to cause a critically ill patient to be
unable to self-report his or her level of pain?
a. Inability to communicate c. Inadequate nutrition
b. Presence of an endotracheal tube d. Sleep deprivation
3. Which of the following is cited by the authors to explain why gaps exist in
pain assessment practices in critical care?
a. Recommendations of the Joint Commission are not followed.
b. Pain assessment is difficult when the patient is sedated.
c. Limited research has been done on pain assessment practices in critical care.
d. Multiple scales for pain assessment are available to critical care nurses.
4. Which of the following are requirements common to almost all behavioral
pain scales?
a. Some grading or scoring of respiratory rate, heart rate, and blood pressure
b. Some grading or scoring of facial expressions, vocalizations, and body
movements
c. Some grading or scoring of cognition, level of consciousness, and attention span
d. Some grading or scoring of response to painful stimulation by posturing or
withdrawal
5. Which of the following are the categories for assessment in the FLACC
pain tool?
a. Face, activity, compliance with the ventilator, cry
b. Face, limbs, activity, sounds, calmness
c. Face, legs, physical movement, cry, calmness
d. Face, legs, body activity, cry, consolability
6. Which of the following characteristic may af fect the clinical usefulness
of a pain assessment tool?
a. Complexity (ease of use)
b. Unique (uses different factors for evaluation)
c. Electronic (computerized documentation)
d. Reading level (6th grade)
7. How is pain assessed with the Number Rating Scale?
a. Verbal self-report using common descriptive terms for pain
b. Five behavioral categories that are each rated on a scale of 0 to 2
c. Verbal self-report where 0 indicates no pain and 10 indicates worst pain
d. Pain is reported by the nurse on a scale of 0 to 10 based on patient assessment
findings
8. Which of the following patient types were excluded from the study?
a. Intubated patients
b. Patients undergoing a procedure known to cause pain
c. Patients who could not self-report pain
d. Patients receiving muscle relaxants
9. What is considered the “gold standard” for pain assessment?
a. Self-report
b. Use of a behavioral pain assessment tool
c. Wong-Baker faces
d. Use of the Numeric Rating Scale
10. Which of the following behavioral observations would result in a FLACC
score of 0?
a. No expression, relaxed position, lying quietly, no cry, and appears content
b. Grimace, restless, moves easily, no cry, and can be distracted
c. Clenched jaw, kicking, rigid movement, moans, and can be reassured
d. No expression, restless, moves easily, no cry, and can be reassured
11. What conclusion did the investigators reach related to the use of the
FLACC behavioral scale in assessing pain?
a. The FLACC tool has validity in assessing pain in specific populations.
b. The FLACC tool has poor reliability and validity in assessing pain in critically
ill adults.
c. The FLACC tool had excellent reliability and validity in assessing pain in critically
ill adults.
d. The FLACC tool has poor correlation to scores generated by using 0 to 10 number
rating scales.
For faster processing, take
this CE test online at
www.ajcconline.org(“CE
Articles in This Issue”) or
mail this entire page to:
AACN, 101 Columbia,
Aliso Viejo, CA 92656.
Fee: AACN members, $0; nonmembers, $10 Passing score: 8 Correct (73%) Category: Synergy CERP A Test writer: Deborah Lilly, RN, MSN, CCRN
The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN
programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.
Test ID: A1019013 Contact hours: 1.0 Form expires: January 1, 2012. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.
1.�a
�b
�c
�d
9.�a
�b
�c
�d
8.�a
�b
�c
�d
7.�a
�b
�c
�d
6.�a
�b
�c
�d
5.�a
�b
�c
�d
4.�a
�b
�c
�d
3.�a
�b
�c
�d
2.�a
�b
�c
�d
11.�a
�b
�c
�d
10.�a
�b
�c
�d
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from

http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
Personal use only. For copyright permission information:

Published online http://www.ajcconline.org
' 2010 American Association of Critical-Care Nurses
doi: 10.4037/ajcc2010624 2010;19:55-61Am J Crit Care

Terri Voepel-Lewis, Jennifer Zanotti, Jennifer A. Dammeyer and Sandra Merkel
Behavioral Tool in Assessing Acute Pain in Critically Ill Patients
Reliability and Validity of the Face, Legs, Activity, Cry, Consolability


http://ajcc.aacnjournals.org/subscriptions/
Subscription Information
http://ajcc.aacnjournals.org/misc/ifora.xhtml
Information for authors
http://www.editorialmanager.com/ajcc
Submit a manuscript
http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml
Email alerts
by AACN. All rights reserved. ' 2010 Copyright
Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049.
bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
journal of the American Association of Critical-Care Nurses (AACN), published
AJCC, the American Journal of Critical Care, is the official peer-reviewed research
at University of Wisconsin-Madison on April 9, 2015ajcc.aacnjournals.orgDownloaded from