Esra DH; Yildirim SA

Research Article

Ann Yoga Phys Ther. 2016; 1(3): 1016.

Examination of Different Pain Scales

Esra DH¹* and Yildirim SA²

¹Department of Physiotherapy and Rehabilitation, Mustafa Kemal University, Turkey

²Department of Physical Therapy and Rehabilitation, Hacettepe University, Turkey

*Corresponding author: Esra DOGRU HUZMELI, Department of Physiotherapy and Rehabilitation, School of Physical Therapy and Rehabilitation, Mustafa Kemal University, Hatay, Turkey

Received: December 05, 2016; Accepted: December 19, 2016; Published: December 20, 2016

Abstract

Aim: There are many pain assessment techniques, and the best scale is not clear. The purpose of this study was to examine a self-report questionnaire, observational scale, and verbal scale; describe physiotherapist–parent– children’s postoperative pain assessment correlation; and address the preference and clinical utility of validated pain scale.

Methods: The participants in the study consisted of 101 children (3–18 years, 75 boys and 26 girls). The assessment was made in the postoperative 30th minute when they were fully awake. Before the assessment, children were asked their demographic datas. Pain was assessed using four validated and standardized pain scales: Oucher, Face, Legs, Activity, Cry and Consolability (FLACC), the Faces Pain Scale, and the Verbal Rating Scale.

Results: To assess the correlation between four pain scales, Spearmen correlation calculations were used. Oucher has a positive and strong correlation with the Verbal Rating Scale (VRS) (0.727) and Faces Pain Scale (FPS) (0.757). VRS has a strong and positive correlation with FPS (0.744). FLACC has a moderate and positive correlation with FPS and Oucher, but a weak correlation with VRS. Oucher was the most preferred scale by the children. Fourteen children could not decide which scale they preferred.

Discussion: Oucher was the most preferred scale by the children and had a uniformly increasing relationship with FPS and VRS. This finding has implications for research on pain management using Oucher, which was a reliable and preferred scale in children. It was found they in case the child could not define pain, parents’ assessments were reliable.

Keywords: Pain; Children; Oucher; Faces pain scale; FLACC

Introduction

Pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life [1]. Babies and people with cognitive deficits feel pain without being capable of describing the pain that they feel. All children normally experience pain from different sources. Pain following surgery in infants and children delays healing and increases morbidity [2-5].

In 1984, Ross, et al. the measurement and evaluation of pain in infants and children had been almost completely ignored claimed [5]. Some developments must have been made during the intervening period, since the past 20 years have brought realization to the clinicians involved in the treatment of children that pain is a real phenomenon in children. There have been significant improvements in awareness, assessment, and treatment of children’s pain in the last 20 years [5-9].

The accurate measurement of pain in children is essential for planning treatment [5]. A large number of measurement techniques have been devised to measure pain in children. These include observational checklists, physiological responses, self-report questionnaires, selections from lists of descriptors, selection from interval scales, Visual Analog Scales (VAS), and projective techniques.

The psychological measures are all based on either domain sampling or psychophysical scaling [6-9]. Thus, there are many pain assessment techniques, and the best scale is not clear. The evaluator should choose tools that are valid and reliable, as well as tools that are informative about children’s pain experiences [6,9-11].

Parents and children’s assessments of children’s pain have been very similar according to earlier studies. Thus, it can be assumed that parents know their children well and can assess their pain in a reliable way [6,12,13].

A perfectly reliable and valid measurement of pain intensity is unattainable. Specifically, a gold-standard pain scale for use with all children is not available.

The purpose of this study was to 1. Examine self-report questionnaire, observational scale and verbal scale and 2. To describe physiotherapist-parent-children’s postoperative pain assessment correlation and 3. To address the preference and clinical utility of validated pain scales.

Methods

The study was conducted at Kutahya State Hospital. The participants in the study consisted of 101 children (3–18 years, 75 boys and 26 girls) (Table 1). Their demographic datas and operation methods were questioned. Ethical clearance was obtained from the Hacettepe University Health Institute’s Ethics Committee, and written informed consent was obtained from parents prior to enrollment in the study. Children who have mental, vision, hearing, neurological, or developmental problems; complications after acute surgery and whose native language was not Turkish were excluded from the study.

Table 1: Demographic data and operation methods.




  
     
     
    N 
    % 
  
  
    Sex 
    Girls
    26
    25.74
  
  
    Boys
    75
    74.25
  
  
    Operation Type 
    Dental operation 
    24
    23.76
  
  
    Inguinal hernia operation
    20
    19.80
  
  
    Tonsillectomy
    10
    9.9
  
  
    Urological operation
    42
    41.58
  
  
    Appendectomy
    2
    1.98
  
  
    Orthopedic problems operation
    3
    2.97



Table 1:  Demographic data and operation methods.

The assessment was made in the postoperative 30th minute when children were fully awake. Before the assessment, children were asked their name, age, etc., to be sure of their wakefulness. Pain was assessed using four validated and standardized pain scales: Oucher, FLACC, the Faces Pain Scale, and the Verbal Rating Scale. The children were asked which scale they preferred the most. FLACC was not included in the preferred scale question because it was an observational scale only.

Assessment of pain in children can be achieved by relying on children’s self-reporting, physiologic parameters, and behavioral changes. Although self-reporting is considered the preferred approach for pain assessment, in many clinical and home settings, the practitioner has to rely on the parental report of children’s pain [6,13]. Parents and physiotherapist scored the children’s pain. Children and parents were blinded from each other’s scores.

Oucher is a poster-like instrument designed to help children provide self-reports of the intensity of their pain. It consists of two scales: a 0–100 numerical scale for older children and a six-picture photographic scale for younger children. The children were asked to choose the face that the best described their pain intensity [6]. FLACC is the acronym for Face, Legs, Activity, Cry, and Consolability. The scale has been validated for children. The patient is assessed in each of these categories, with a score applied to behaviors evaluated. The five scores are totaled, and the severity of pain is determined based on a 0–10 pain scale [9] The Faces Pain Scale (FPS) is a selfreported measure of pain intensity developed for children. There are pictures of some faces on the scale. The faces show how much pain or discomfort individual is feeling. The face on the left shows no pain. Each face shows more and more pain, up to the last face that shows the worst pain possible [10-13]. Verbal Rating Scale (VRS) is a scale uses descriptive words denoting varying intensities of pain. The child chooses the one word that most describes his or her pain, using “No pain,” “Mild pain,” “Moderate pain,” and “Severe pain” [14,15].

Data analysis

SPSS software 2008 was used for the statistical analysis. Descriptive and inferential statistical methods were used. Spearmen correlations were used to examine the correlation between pain scales. The significance of the correlation was defined as 0–0.19 (“very weak”), 0.20–0.39 (“weak”), 0.40–0.59 (“moderate”), 0.60–0.79 (“strong”), and 0.80–1.0 (“very strong”) [16].

Results

Data collection was conducted during a six-month period from January 2010 to July 2010. After enrollment, details of demographics and procedural characteristics were recorded in the subject datasheet. Postop patients that had different operations methods were included in the study (Table 1).

To assess the correlation between four pain scales, Spearmen correlation calculations are presented in (Table 2). Oucher had a positive and strong correlation with VRS (0.727) and FPS (0.757). VRS had a strong and positive correlation with FPS (0.744). FLACC had a moderate and positive correlation with FPS and Oucher, and a weak correlation with VRS (Table 2).

Table 2: Correlation between pain scales.



Table 2:  Correlation between pain scales.

The correlations between parent, physiotherapist, and child in FPS are presented in (Table 3). There was a positive and strong correlation between parent and physiotherapist (0.606) and child and parent (0.604). There was a moderate correlation between physiotherapist and child (0.540).

The correlations between parent, physiotherapist and child in VRS are presented in (Table 3). There was a positive and strong correlation between child and parent (0.623). There was a moderate correlation between physiotherapist and child (0.543) and parent and physiotherapist (0.503).

The correlations between parent, physiotherapist, and child in Oucher are presented in (Table 3). There was a positive and strong correlation between parent and physiotherapist (0.608), child and parent (0.737), and physiotherapist and child (0.648).

Table 3: Correlation between parent, physiotherapist, and child in FPS, VRS, and Oucher.




  
    Faces Pain scale 
    p 
    Rho 
  
  
    Parent-Physiotherapist 
    0.0001
    0.606
  
  
    Physiotherapist-Child 
    0.0001
    0.540
  
  
    Child-Parent 
    0.0001 
    0.604 
  
  
    Verbal Rating Scale 
     
     
  
  
    Parent-Physiotherapist 
    0.0001
    0.503 
  
  
    Physiotherapist-Child 
    0.0001
    0.543 
  
  
    Child-Parent 
    0.0001
    0.623 
  
  
    Oucher 
     
     
  
  
    Parent-Physiotherapist 
    0.0001
    0.608 
  
  
    Physiotherapist-Child 
    0.0001
    0.648 
  
  
    Child-Parent 
    0.0001
    0.737



Table 3:  Correlation between parent, physiotherapist, and child in FPS, VRS,
and Oucher.

Oucher was the most preferred scale by the children. Fourteen children could not decide which scale they preferred (Table 4).

Table 4: The most preferred scale by children.




  
    Scales 
    3–6 years 
    7–10 years 
    11–14 years 
    15–18 years 
    Total 
  
  
     
    n
    %
    n
    %
    n
    %
    n
    %
    n
    %
  
  
    Oucher 
    11
    12.6
    29
    33.3
    19
    21.8
    1
    1.14
    60
    59.40
  
  
    VRS 
    1
    1.14
    3
    3.44
    1
    1.14
    2
    2.18
    7
    6.93
  
  
    FPS 
    8
    9.19
    10
    11.4
    2
    9
    0
    0
    20
    19.80
  
  
    Children couldn’t decide 
    14
    13.86



Table 4:  The most preferred scale by children.

Discussion

Pain severity assessment is intended to improve the quality of pain management. Measures of a patient’s pain must be reliable and accurately reflect the intensity of pain being experienced. The practice of assessing pain as “the fifth vital sign” has become widespread, despite a lack of published evidence demonstrating the accuracy and effectiveness of screening strategies [1,17]. Pain is very common among pediatric populations and is one of the most common factors that impair quality of life [11,17]. Self-report scales should be used for clinical decisions to treat pain in children wherever possible to guide management, but in case the child cannot be assessed, parental pain scores can be reliably used as a surrogate measure. Parents and children’s assessments of children’s pain have been very similar, according to earlier studies. Thus, it can be assumed that parents know their children well and can assess their pain in a reliable way [6,12,13,18,19].

Chamber, et al. investigated 5 different scales with 75 children undergoing venipuncture, and their parents. Following venipuncture, children and parents independently rated the child’s pain using five different face scales and indicated which of the scales they preferred. The level of agreement between child and parent reports of pain was low and did not vary as a function of the scale type used; parents overestimated their children’s pain using all five scales [20]. In our study, we found that parents and children’s pain scores were similar. In case the child cannot define their pain; the child was aggressive, excited, etc.; and communication cannot be established, clinicians can rely on parents’ pain assessment by using self-report scales. Children and physiotherapists’ assessments were similar, but were not as strong as the parent and children’s. Parents understood the feeling of their children better than the health staff.

In a study of four self-report scales that included Oucher, Wong Banker was found to be most preferred [21]. In our study, Oucher was most preferred by children as a rating scale in all age groups. Oucher is a colorful and vertical scale, so describing pain was easier and more attractive for children.

Three commonly used pain scales, the visual analog scale, the Wong-Baker Faces Pain Scale, and the Faces Pain Scale-Revised were administered to 122 Thai children, of whom were HIV-infected, in order to assess their validity. These scales presented moderate to good correlation and moderate agreement, sufficient for valid use in Thai children [22]. Faces scales are ordinal outcome measures consisting of a number of categorical responses ordered in a specific pattern [1,15,23,24]. In our study, there was a good correlation between selfreport scales and we found that those scales can be used with Turkish children.

Preschool children or children who have cognitive and verbal deficits may be unable to describe their feeling of pain or physical discomfort. When children are recovering from anesthesia, it is difficult for them to assess their pain [23-25]. Before they are fully awake, they can be restless, and factors like excitement, agitation, or sedation may influence their outcomes. Therefore, observation of behavior can be an acceptable alternative when valid self-reporting is not possible. Behavioral indicators, such as facial expression, crying, and body movements, are used to estimate the presence of pain and pain intensity in children [23-28]. In our study, we found that FLACC did not a show strong correlation with other self-report scales. So if children are awake and have the mental competence, self-report scales are better for assessment of children’s pain than behavioral scales.

Conclusion

Oucher was found to have an excellent correlation in children with acute pain and had a uniformly increasing relationship with FPS and VRS. This finding has implications for research on pain management using Oucher as a reliable and preferred scale in Turkish children so we suggest to the clinicians in case the children cannot define their pain, parents’ assessment is reliable.

References

Download PDF

Citation:Esra DH and Yildirim SA. Examination of Different Pain Scales. Ann Yoga Phys Ther. 2016; 1(3): 1016.

Instruction for Authors

Submit Your Article

	FLACC		Oucher		VRS		FPS
	rho	p	rho	p	rho	p	rho	p
FLACC	1.000	0.001	0.456	0.001	0.391	0.001	0.496	0.001
Oucher	0.456	0.001	1.000	0.001	0.727	0.001	0.757	0.001
VRS	0.391	0.001	0.727	0.001	1.000	0.001	0.744	0.001
FPS	0.496	0.001	0.757	0.001	0.744	0.001	1.000	0.001

Faces Pain scale	p	Rho
Parent-Physiotherapist	0.0001	0.606
Physiotherapist-Child	0.0001	0.540
Child-Parent	0.0001	0.604
Verbal Rating Scale
Parent-Physiotherapist	0.0001	0.503
Physiotherapist-Child	0.0001	0.543
Child-Parent	0.0001	0.623
Oucher
Parent-Physiotherapist	0.0001	0.608
Physiotherapist-Child	0.0001	0.648
Child-Parent	0.0001	0.737

		N	%
Sex	Girls	26	25.74
Sex	Boys	75	74.25
Operation Type	Dental operation	24	23.76
	Inguinal hernia operation	20	19.80
	Tonsillectomy	10	9.9
	Urological operation	42	41.58
	Appendectomy	2	1.98
	Orthopedic problems operation	3	2.97