• Tracy Harrison

PreEmpt Pain App. Exercise 3. Pain Scales.

Knowing which pain scale to use for your patients is an important aspect of pain assessment. Consistency in the use of the scales and following the trends in those scales can help to guide your pain management decisions and help you educate your patients.

This post focuses on the various pain scales at our disposal for patients, pediatric or adult, communicative or non-communicative. Some of the scales are observational while others are self-report. Both methods have their benefits and risks. However, all of the scales described here have been validated for the appropriate population.

- Observational Scales


- use specific factors that - open to the interpretation of examiner

can be measured

- pain may be underreported by measure

- Self-Report Scales


- direct communication from patient - other factors can contribute to pain scores

To overcome the potential pitfalls of measures, focus on the following:

- the trends of the pain scores over time

- the relationship of the pain scores to these variables

- activities such as eating, resting, activities of daily living, being

mobile, working with physical therapy

- medications administered

- anxiety, mood, fear

(In a future post, I will address the complexity of the pain experience, that pain is not simply a nociceptive phenomenon (pain caused by tissue damage) but also an emotional experience filtered through complex psychological factors.)

While it is not realistic (or safe) to make the goal of a pain management plan a pain score of '0' or 'no pain', we CAN promise that we will listen to the patient and make adjustments to the plan so they are more comfortable. Meeting the expectations of surgeons or other providers regarding mobility, activities of daily living, resting, recovering and returning to a more typical baseline of functioning is the ultimate goal. Make sure you convey this promise to patients from the beginning of treatment.

Let's now take a closer look at the various pain scales available.


Premature Infant Pain Profile (PIPP)

- an observational measure for premature infants

- scores range from 0 - 21; seven variables

- scores < 6 Absence or minimal pain

- scores > 12 Moderate to severe pain

Neonatal Infant Pain Scale (NIPS)

- an observational measure for neonates

- scores range from 0 - 7; six variables

- scores above 3 indicate pain

- could assume that scores >5 indicate more intense pain

FLACC ( Faces Legs Activity Cry Consolability) Scale

- an observational scale for infants, non-verbal young children, and patients with

cognitive impairment (aged 2 months to 18 years)

- scores range from 0 - 10; five variables

- 0 - 3 mild pain

- 4 - 6 moderate pain

- 7 - 10 intense pain

Bieri FACES Pain Scale-Revised (FACES-R) scale

- a self-report measure (the child should choose the face that matches

their pain)

- scores range from 0 - 10

- 0 - 3 mild pain

- 4 - 6 moderate pain

- 7 - 10 intense pain

- evidence has shown that this scale has good correlation with the 0 - 10

NRS scale

Instruct the child to use the scale in the following way:

'These faces show much something can hurt. This face [point to left-most face] shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to right-most face]. It shows very much pain. Point to the face that shows how much you hurt [right now].


Numeric Rating Scale (NRS)

- a self-report measure

- scores range from 0 - 10

- 0 - 3 mild pain

- 4 - 6 moderate pain

- 7 - 10 intense pain


The manner in which this scale is presented has a direct effect on the patient's understanding. You should consider asking the pain score in the following way:

'With '0' meaning no pain at all and '10' meaning the worst pain possible, what score would you give your pain right now?'

Youth Acute Pain Functional Ability Questionnaire (YAPFAQ)

- a self-report measure

- 20 variables (or 3 variable in the short form)

- Patients rate their perceived level of difficulty performing each activity that day on a 5 - point Likert scale

0 = 'not difficult' and 4 = 'extremely difficult'

Possible total score of 48; the higher the score, the more perceived difficulty performing these actions

However, Dr Rabbitts and colleagues recently studied the utility of a 'short form' of the original scale.

- Three measures correlated highly YAPFAQ total and could be considered the

'YAPFAQ short form'. Individuals rate the difficulty of the following tasks:

- 'Put on or change your hospital gown or clothes'

- 'Wash your body'

- 'Go outside your room'

Caution - this is a self-report measure and is subjective in nature. Although it focuses on the patient's ability to function, the result can be unintentionally exaggerated and might be construed as increased debility if the patient is unsure of their ability or is fearful to return to activity.



Choosing the appropriate pain scale for acute pain is one of the first steps towards development of a thoughtful and effective pain management plan. In some instances, for example with the adolescent population, a combination of these scales, such as NRS and the FLACC scale, can be used to obtain a more comprehensive understanding of the patient's pain experience.

And make certain that as you are recording pain scores, that you document and consider all of the scores over the past 24 hours. Pain can change through the day based on activities performed, sleep, boredom and other factors. You can sometimes make some simple suggestions to improve their pain experience.

Please feel free to comment and let us know about other pain scales that you have found helpful or that are used consistently in your institution.

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