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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 67-71

The revised-Face, Leg, Activity, Cry, and Consolability scale: an Egyptian version


Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Web Publication24-Jan-2018

Correspondence Address:
Tarek Shabana
Department of Anesthesia, Faculty of Medicine, Ain Shams University, Cairo, 11865
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_36_17

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  Abstract 

Background Children with cerebral palsy lack the luxury of self-reporting their pain postoperatively. The revised FLACC (Face, Leg, Activity, Cry, and Consolability) pain scale is a behavioral pain assessment tool that is universally accepted for use in children with cognitive dysfunction.
Objective The aim of this study was to cross-culturally adapt and evaluate the validity and reliability of the Egyptian version of the revised FLACC (r-FLACC) scale for use in postoperative pain assessment in children with cerebral palsy.
Patients and methods The study was carried out in Ain Shams University Pediatric Hospital on 30 children with cerebral palsy aged 3–12 years scheduled for open Nissen fundoplication. Pain was assessed at baseline, on arrival to postanesthesia care unit, and 30 min after administration of analgesia using the r-FLACC scale (by two independent caregivers) and the visual analog scale (by the child’s parent).
Results The r-FLACC scores increased postoperatively and decreased after administration of analgesia (P<0.001) supporting good construct validity. Criterion validity was acceptable in view of the positive correlations between r-FLACC scores and visual analog scale scores provided by the parents (P<0.001).
Moderate to significant correlations between observers for total r-FLACC scores (P<0.001), and good agreements for each of the five categories of the r-FLACC scores at baseline (k=0.422–0.627), in postanesthesia care unit (k=0.531–0.737), and after administration of analgesia (k=0.683–0.783) reflected strong inter-rater reliability.
Conclusion The Egyptian version of the r-FLACC scale is a valid and reliable tool for postoperative pain assessment in Egyptian children with cerebral palsy.

Keywords: cerebral palsy, Egypt, pain assessment, r-FLACC, validity


How to cite this article:
Shabana T, Ibrahim AN. The revised-Face, Leg, Activity, Cry, and Consolability scale: an Egyptian version. Res Opin Anesth Intensive Care 2018;5:67-71

How to cite this URL:
Shabana T, Ibrahim AN. The revised-Face, Leg, Activity, Cry, and Consolability scale: an Egyptian version. Res Opin Anesth Intensive Care [serial online] 2018 [cited 2018 Sep 22];5:67-71. Available from: http://www.roaic.eg.net/text.asp?2018/5/1/67/223833


  Introduction Top


Children with cerebral palsy lack the luxury of self-reporting their own pain, rendering their pain highly underestimated. This problem required the development of observational tools that measure pain behaviors to facilitate pain assessment in this group of patients [1],[2],[3].

Among these tools is the revised FLACC (Face, Leg, Activity, Cry and Consolability) pain scale which is universally accepted for use in nonverbal children and children with cognitive dysfunction [4],[5].

The aim of this study is to cross-culturally adapt and evaluate the validity and reliability of the Egyptian version of the revised FLACC (r-FLACC) scale for use in postoperative pain assessment in Egyptian children with cerebral palsy.


  Patients and methods Top


After approval of the ethical committee and obtaining informed consent from the child’s parent or guardian, the study was carried out in Ain Shams University Pediatric Hospital on 30 children with cerebral palsy aged 3–12 years scheduled for open Nissen fundoplication.

In all children, pain was assessed at baseline, postoperatively [on arrival to postanesthesia care unit (PACU)], and 30 min after administration of analgesia (paracetamol 15 mg/kg intravenously). Pain was assessed using the following methods:
  1. The r-FLACC scale was assessed by two independent caregivers (bedside nurse or assistant nurse).
  2. Visual analog scale (VAS) 0–10 cm was completed by the child’s parent or guardian.


Sample size calculation

Based on the results of a previous study [6] that demonstrated correlation coefficients of ∼0.65 between r-FLACC scores and parent rating, it was determined that a sample of 30 observations would be needed to demonstrate a significant correlation between r-FLACC scores and parent VAS scores (α=0.05, β=0.1).

Statistical methods

Pearson’s correlation coefficient was used to correlate between total r-FLACC scores assigned by the first and second observers. Agreements between r-FLACC scores provided by the first and second observers for each of the five categories were assessed using κ statistics. κ values greater than or equal to 0.4 were accepted as good agreement.

The total r-FLACC scores were correlated with the parent VAS pain scores by using Pearson’s correlation coefficient. Median FLACC scores obtained at baseline and before and after analgesic administration were compared using Student’s t-test. SPSS statistics (V. 210.0, 2012; IBM Corp., Armonk, NY, USA) was used for data analysis. The probability of error at 0.05 was considered significant.

Translation

First, permission to translate the r-FLACC scale was obtained from the founders of the original version. The FLACC pain scale was first developed by Merkel et al [7] as a pain assessment tool in nonverbal children. It was revised to include behaviors specific to those with cognitive impairment by Malviya et al [6].

The translation process was performed using foreword–backward translation. The original version of the r-FLACC scale was translated into formal Arabic. The obtained Arabic translations were backtranslated to English. After review of the backtranslations, transformation of some phrases to colloquial Egyptian was needed to overcome discrepancies of words between the original and the backtranslated English versions ([Table 1]).
Table 1 Egyptian version of the revised-Face, Leg, Activity, Cry, and Consolability scale

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  Results Top


Construct validity

There was a significant increase in median r-FLACC scores provided by observers in the PACU compared with baseline scores: 7.3±1.72 versus 3.73±2.44 (P<0.001) for the first rater and 7.76±1.71 versus 3.63±2.07 (P<0.001) for the second rater. After administration of analgesia, there was a significant decrease in median r-FLACC scores provided by observers compared with PACU values: 4.7±2.4 versus 7.3±1.72 (P<0.001) for the first rater and 4.56±2.58 versus 7.76±1.71 (P<0.001) for the second rater. The aforementioned results reflect good construct validity.

Criterion validity

Criterion validity was supported by excellent correlations between VAS scores obtained from parents and r-FLACC scores obtained from the first rater at baseline (r=0.981, P<0.001), in PACU (r=0.935, P<0.001), and after administration of analgesia (r=0.988, P<0.001). There were also positive correlations between VAS scores obtained from parents and r-FLACC scores obtained from the second rater at baseline (r=0.707, P<0.001), in PACU (r=0.65, P<0.001), and after administration of analgesia (r=0.677, P<0.001).

Inter-rater reliability

There were moderate to significant correlations between observers for total r-FLACC scores at baseline (r=0.71, P<0.001), in PACU (r=0.688, P<0.001), and after administration of analgesia (r=0.699, P<0.001).

There were also good agreements for each of the r-FLACC categories at baseline (κ=0.422–0.627, exact agreements: 63.33–80%), in PACU (κ=0.531–0.737, exact agreements: 70–86.66%), and after administration of analgesia (κ=0.683–0.783, exact agreements: 80–86.66%) ([Table 2],[Table 3],[Table 4]).
Table 2 Median revised-Face, Leg, Activity, Cry, and Consolability and visual analog scale scores (cm)

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Table 3 Inter-rater reliability (κ-statistics and percentage of exact agreements)

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Table 4 Correlation between revised-Face, Leg, Activity, Cry, and Consolability and visual analog scale scores

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  Discussion Top


Cerebral palsy is often associated with comorbidities that may require surgical intervention [8]. Selecting an appropriate tool for postoperative pain assessment remains a challenge for the health care provider to ensure that the child is not suffering in silence. Our study demonstrated that the Egyptian version of the r-FLACC tool is both reliable and valid for postoperative pain assessment in Egyptian children with cerebral palsy.

Several pain scores exist for pain assessment in children with cognitive impairment. Such tools focus on nonverbal pain behaviors. However, the pain behaviors of children with cerebral may mimic their baseline behaviors giving a false impression that they are indifferent to pain [9],[10],[11].

The FLACC pain scale was developed by Merkel et al. [7] for use in pain assessment in nonverbal children. It included five categories, each is scored from 0 to 2, with a total score ranging between 0 and 10.

To suit patients with cognitive impairment, the FLACC tool was revised to include more specific behaviors such as ‘constant tremors or jerking’ and ‘head banging’. The authors named it the r-FLACC [6].

Owing to its simplicity and applicability in various settings [12], the r-FLACC pain scale was translated into other languages, namely, Chinese, Danish, Swedish, Hebrew, Thai, and Brazilian Portuguese [13],[14],[15],[16],[17],[18].

In Egypt, not all personnel providing health care to children master the English language, thus language may pose a barrier against proper pain assessment. In this study, the r-FLACC scale was translated to the Arabic language with the use of colloquial Egyptian phrases. The psychomotor properties of this translated version were assessed in Egyptian children (3–12 years) with cerebral palsy.

In the current study, r-FLACC scores increased following open Nissen fundoplication. These scores then decreased after administration of analgesia supporting good construct validity. Criterion validity was acceptable in view of the positive correlations between r-FLACC scores and VAS scores provided by parents.Moderate to significant correlations between observers for total r-FLACC scores, and good agreements for each of the five categories of the r-FLACC scores reflected strong inter-rater reliability.

Several studies examined the validity and reliability of the FLACC scale in children with cognitive impairment. When used for postoperative pain assessment in the study carried by Malviya et al. [6], the original r-FLACC scale showed good construct and criterion validity in 52 children with varying degrees of cognitive impairment. Inter-rater reliability was strong. Reliability and validity of the ‘Legs’ and ‘Activity’ categories improved with the r-FLACC scale when compared with the results of an earlier study carried on the unrevised FLACC scale in the same group of patients [19].

The work of Pederson et al. [14] established validity and reliability of the r-FLACC scale in Danish children with cerebral palsy after orthopedic surgery. Construct validity was supported by a significant increase in r-FLACC scores following surgery. Strong correlations (r=0.76−0.59) between r-FLACC scores and VAS-OBS scores indicated good criterion validity. Inter-rater reliability was acceptable.

In conclusion, this study revealed that the Egyptian version of the r-FLACC scale is a valid and reliable tool for postoperative pain assessment in Egyptian children with cerebral palsy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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