Aims and objectives.  This review aims to explore the research available relating to three commonly used pain rating scales, the Visual Analogue Scale, the Verbal Rating Scale and the Numerical Rating Scale. The review provides information needed to understand the main properties of the scales.

Background.  Data generated from pain-rating scales can be easily misunderstood. This review can help clinicians to understand the main features of these tools and thus use them effectively.

Method.  A MedLine review via PubMed was carried out with no restriction of age of papers retrieved. Papers were examined for methodological soundness before being included. The search terms initially included pain rating scales, pain measurement, Visual Analogue Scale, VAS, Verbal Rating Scale, VRS, Numerical/numeric Rating Scale, NRS. The reference lists of retrieved articles were used to generate more papers and search terms. Only English Language papers were examined.

Conclusions.  All three pain-rating scales are valid, reliable and appropriate for use in clinical practice, although the Visual Analogue Scale has more practical difficulties than the Verbal Rating Scale or the Numerical Rating Scale. For general purposes the Numerical Rating Scale has good sensitivity and generates data that can be statistically analysed for audit purposes. Patients who seek a sensitive pain-rating scale would probably choose this one. For simplicity patients prefer the Verbal Rating Scale, but it lacks sensitivity and the data it produces can be misunderstood.

Relevance to clinical practice.  In order to use pain-rating scales well clinicians need to appreciate the potential for error within the tools, and the potential they have to provide the required information. Interpretation of the data from a pain-rating scale is not as straightforward as it might first appear.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2702.2005.01121.x

Pain: a review of three commonly used pain rating scales.

Pain assessment in the nonverbal patient: position statement with clinical practice recommendations.

Despite wide usage of the Numerical Rating Scale (NRS) for self-report of pain intensity in clinical practice with children and adolescents, validation data are lacking. We present here three datasets from studies in which the NRS was used together with another self-report scale. Study A compared post-operative pain ratings on the NRS with scores on the Faces Pain Scale-Revised (FPS-R) in 69 children age 7–17 years who had undergone a variety of surgical procedures. Study B compared post-operative pain ratings on the NRS with scores on the Visual Analogue Scale (VAS) in 29 children age 9–17 years who had undergone pectus excavatum repair. Study C compared ratings of remembered immunization pain in 236 children who comprised an NRS group and a sex- and age-matched VAS group. Correlations of the NRS with the FPS-R and VAS were r = 0.87 and 0.89 in Studies A and B, respectively. In Study C, the distributions of scores on the NRS and VAS were very similar except that scores closest to the no pain anchor were more likely to be selected on the VAS than the NRS. The NRS can be considered functionally equivalent to the VAS and FPS-R except for very mild pain (<1/10). We conclude that use of the NRS is tentatively supported for clinical practice with children of 8 years and older, and we recommend further research on the lower age limit and on standardized age-appropriate anchors and instructions for this scale.

Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children's self-reports of pain intensity.

http://www.aspmn.org/documents/PainAssessmentinthePatientUnabletoSelfReport.pdf

Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations.

Summary Background: Difﬁculty with pain assessment in individuals whocannot self-report their pain poses a signiﬁcant barrier to effective painmanagement. However, available assessment tools lack consistentreliability as pain measures in children with cognitive impairment(CI). This study evaluated the validity and reliability of the revisedand individualized Face Legs Activity Cry and Consolability (FLACC)behavioral pain assessment tool in children with CI.Methods: Children with CI scheduled for elective surgery werestudied. The FLACC was revised to include speciﬁc descriptors andparent-identiﬁed, unique behaviors for individual children. Thechild’s ability to self-report pain was evaluated. Postoperatively, twonurses scored pain using the revised FLACC scale before and afteranalgesic administration, and, children self-reported a pain score, ifable. Observations were videotaped and later viewed by experiencednurses blinded to analgesic administration.Results: Eighty observations were recorded in 52 children aged4–19 years. Twenty-one parents added individualized pain behaviorsto the revised FLACC. Interrater reliability was supported by excellentintraclass correlation coefﬁcients (ICC, ranging from 0.76 to 0.90) andadequate j statistics (0.44–0.57). Criterion validity was supported bythe correlations between FLACC, parent, and child scores (q ¼ 0.65–0.87; P < 0.001). Construct validity was demonstrated by the decreasein FLACC scores following analgesic administration (6.1 ± 2.6 vs1.9 ± 2.7; P < 0.001).Conclusions: Findings support the reliability and validity of theFLACC as a measure of pain in children with CI.Keywords: pain assessment; developmentally delayed children; facelegs activity cry and consolability pain tool

/pdf/the-revised-flacc-observational-pain-tool-improved-2wtqpeqlkk.pdf

The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment

Prior to surgery, 47 children (ages 8 to 17) with borderline to profound cognitive impairment were administered tasks to evaluate their understanding of the concepts of magnitude and ordinal position and their abilities to use a 0 to 5 numerical scale to rate pain levels in schematic faces. Of the 111 children (ages 4 to 14) without cognitive impairment, were administered the same tasks. Nurses conducting preoperative evaluations predicted whether children would understand the numerical scale. Fifty percent (n = 3) of children with borderline and 35% (n = 7) of children with mild cognitive impairment (and all children 8 years and older nonimpaired) correctly used the scale. Half of the children with cognitive impairment demonstrated skills (magnitude and ordinal position) that may allow them to use simpler pain rating methods. Nurses overestimated the abilities of cognitively impaired children (and younger children without cognitive impairment) to use the rating scale.

Pain Assessment in Children with Cognitive Impairment: An Exploration of Self-Report Skills

Information about pain in children with cognitive impairment is lacking. To gather pain-relevant information in this population, parents of 145 children with borderline to profound cognitive impairment were interviewed regarding their children's pain expression, experience, treatment, and coping behavior. Descriptions of pain expression and coping behavior were associated with the level of cognitive impairment. Children with mild to moderate cognitive impairment were more likely to be described as directly communicating their pain and exhibiting procedural coping strategies similar to those observed in children without cognitive impairments. More than half of the parents reported that their children experienced pain differently than did children without cognitive impairment, with the majority perceiving decreased pain sensitivity and greater pain tolerance. Finally, one third of parents felt that their children's pain was treated differently than that of other children. Half of these parents believed that health care providers had difficulties assessing and treating their children's pain. Results contribute to the developing foundation of information about pain in this special pediatric population.

Children with cognitive impairment: parent report of pain and coping.

Objective: To gather information about healthcare providers' beliefs regarding pain and its treatment in children with cognitive impairment. Design: A survey consisting of two acute pain vignettes (a child undergoing surgery and a child undergoing an outpatient medical procedure) was completed by 440 nurses and 146 physicians at Arkansas Children's Hospital. Respondents completed one of four different surveys that systematically varied the child's level of cognitive impairment (none, mild, moderate, severe) in both vignettes. Questions addressed expected pain, pain assessment methods, pharmacologic regimens, and nonpharmacologic interventions. Results: In general, provider discipline and level of cognitive impairment did not significantly influence responses about pain experience and treatment. Potent analgesia, regularly scheduled dosing, and nonpainful administration were selected most frequently. Self-report of pain, patient-controlled analgesia, and behavioral interventions requiring higher cognitive skills were selected less frequently for children with more severe cognitive impairment. Conclusions: The presence of cognitive impairment appeared to influence provider decisions regarding the appropriateness of specific pain assessment and treatment methods requiring skills on the part of the child. Overall, healthcare provider views regarding analgesia and sedation were similar for all children, regardless of impairment. Whether these beliefs are consistent with clinical practice is yet to be documented.

R D Harrison

Papers

Pain Assessment in Children with Cognitive Impairment: An Exploration of Self-Report Skills

Children with cognitive impairment: parent report of pain and coping.

Pain Assessment and Treatment in Children with Cognitive Impairment: A Survey of Nurses' and Physicians' Beliefs