|Year : 2015 | Volume
| Issue : 2 | Page : 86-90
Combination of self-report method and observational method in assessment of postoperative pain severity in 2 to 7 years of age group: A cross-sectional analytical study
Debanjali Ray1, Santanu Ghosh2, Sarbari Swaika1, Ruchi Gupta1, Anamitra Mondal3, Swapnadeep Sengupta4
1 Department of Anesthesiology, Bankura Sammilani Medical College, Bankura, West Bengal, India
2 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
3 Department of Anasthesiology, Kalyani Medical Collge, Kolkata, West Bengal, India
4 Department of Anesthesiology, Calcutta Medical College, Kolkata, West Bengal, India
|Date of Web Publication||15-Apr-2015|
Dr. Debanjali Ray
Shyamantika, 86/3, Sibtala Street, Bhadrakali, Hooghly - 712 232, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Postoperative pain management is based on assessment of severity of pain. Adult patients can express their pain accurately but difficulty occurs in paediatric population. Children between 2 and 7 years of age may give biased response to any scale of pain assessment as they belong to the preoperational stage of cognitive development. Objectives: To establish the agreement between two pain scale, namely Faces Pain Scale-Revised (FPS-R) and Face, Legs, Activity, Cry, Consolability scale (FLACC) regarding assessment of severity of postoperative pain and to find out true negative in terms of specificity of combination of scale for assessment of postoperative pain. Settings and Design: Postoperative recovery unit, cross-sectional analytical study. Materials and Methods: Four hours after short surgical procedure 95 children were assessed by two pain scale and by two observers simultaneously and data submitted to analyser. Statistical Analysis: IBM SPSS (Version 20.0). P < 0.05 was considered as statistically significant. Results: Combination of these two scales show high odds ratio (39%) and kappa coefficient (0.76) suggesting excellent agreement. Specificity of combination of these scales is very high (95.1%) than individual (FPS-R-17.85%, FLACC-2.2%). Spearman's correlation coefficient (ρ) was computed to ascertain the correlation between two scales and a significant positive correlation was found (ρ = 0.727, P = 0.00). Conclusion: FPS-R and FLACC scale has excellent agreement to diagnose the severity of postoperative pain in 2-7 years of age group and combination of these two scales has high specificity to assess the severity of postoperative pain than individual.
Keywords: Face, Legs, Activity, Cry, Consolability scale, Faces Pain Scale-Revised, pediatric pain, postoperative pain assessment
|How to cite this article:|
Ray D, Ghosh S, Swaika S, Gupta R, Mondal A, Sengupta S. Combination of self-report method and observational method in assessment of postoperative pain severity in 2 to 7 years of age group: A cross-sectional analytical study. Indian J Pain 2015;29:86-90
|How to cite this URL:|
Ray D, Ghosh S, Swaika S, Gupta R, Mondal A, Sengupta S. Combination of self-report method and observational method in assessment of postoperative pain severity in 2 to 7 years of age group: A cross-sectional analytical study. Indian J Pain [serial online] 2015 [cited 2020 Feb 17];29:86-90. Available from: http://www.indianjpain.org/text.asp?2015/29/2/86/155176
| Introduction|| |
Pain is defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" by the "International Association for the Study of Pain." Pain, either acute or chronic, is a very common experience by the patients in our day to day practice. Both acute and chronic pain are often under-recognized in children and not treated appropriately, which may lead to both short and long-term negative consequences.  Pain severity assessment, as required by The Joint Commission, is intended to improve the quality of postoperative pain management.  Multiple instruments currently exist to measure and assess postoperative pain in children of all ages. The sensitivity and specificity of these instruments have been widely debated and have resulted in a plethora of studies to establish their reliability and validity. 
In infants, newborns and the cognitively impaired, postoperative pain is assessed by measuring physiological response to nociceptive stimuli, such as blood pressure and heart rate changes, or by levels of adrenal stress hormones. Alternatively, behavioural approaches like facial expressions, body movements are being used as indices of response to nociceptive stimuli.
Self-report measures of pain are preferred over other types of pain measures for use with children capable of verbal communication. There are several advantages of self-report measures. Pain is a subjective experience and self-report measures ask for the individual to articulate their pain experience themselves. Moreover, they are convenient to use in everyday clinical practice. However, self-report measures also have limitations. First, they are dependent on child's social, cognitive, and communicative competence such as his/her ability to match items, to place items in a correct series, and to listen to the instructions of the person administering the measure while looking at materials. , Second, child's reports are also influenced by their context (whom is asking the question, setting). Therefore, it is possible that children may respond in a biased fashion. Many children withdraw or deny their pain if pain relief involves yet another painful experience - the intramuscular injection.  This biasness has been found to be maximum between 2 and 7 years of age group that belongs to Piaget's preoperational stage of cognitive development.  In this age group children try to make balance between animism and transductive reasoning, resulting in inappropriate expression of thought.  We selected two methods to assess severity of postoperative pain in this age group. First is self-report measure, namely Faces Pain Scale-Revised (FPS-R) uses facial expressions to assess pain intensity. Second is Face, Legs, Activity, Cry, Consolability (FLACC) scale, a behavioural measure of pain based on observation of nonverbal clues.
Aims and objectives
The present study was conducted:
- To compare the agreement between two different scales, namely FPS-R and FLACC, in diagnosing severity of postoperative pain among the study population.
- To establish the specificity of combination of these two scales for assessment of severity of postoperative pain in study population.
| Materials and Methods|| |
The study was carried out in Bankura Sammilani Medical College and Hospital from November 2013 to April 2014. After obtaining approval of the Institutional Ethics Committee and written informed consent from the parents, we selected 95 children aged between 2 and 7 years of both sex in the postoperative recovery unit after short surgical procedure (30-45 min) done under balanced general anaesthesia with endotracheal intubation and controlled positive pressure ventilation. Exclusion criteria were children without consent of parents and children with delayed developmental milestones. All children were premedicated with syrup paracetamol orally in a dose of 10 mg/kg body weight 1 h before surgery. Midazolam syrup 0.2 mg/kg oral was given to the study population half an hour before surgery. Intravenous line was established in the operation theatre. After attachment of multichannel monitor and preoxygenation, injection glycopyrrolate was given in a dose of 0.01 mg/kg intravenously. Induction was done by 1 volume percent sevoflurane with oxygen and nitrous oxide, intubation was done with 0.05 mg/kg injection atracurium intravenously. Maintenance was done with injection atracurium 0.1 mg/kg according to response and sevoflurane. After adequate reversal with appropriate dose of injection neostigmine and glycopyrrolate, children were sent to the postoperative recovery unit. They were attended 4 h after surgery to assess the severity of postoperative pain on both FPS-R and FLACC scale by two different observers.
First observer explained the FPS-R to children prior to assessment and recorded the data after assessment. The FPS-R uses facial expression to assess pain intensity. The child was asked to select the face that best reflects the intensity of pain that he or she has from a series of faces depicting different levels of pain intensity in a horizontal orientation. Numeric value from 0 to 10 (0-2-4-6-8-10) can be assigned to each face [Figure 1].
Along with the FPS-R all the children were assessed on FLACC scale by second observer at the same time [Figure 2].
The recorded data by two observers were submitted to analyser who computed the data on severity scale which is a combination of the above mentioned scales based on study of Gregory Garra et al., already prepared prior to the study [Figure 3].  Score '0' was considered as no pain, score 1-4 were considered as mild pain, score 5-8 were considered as moderate pain and score 9-10 were considered as severe pain. Children having score ≥5 were taken into account and designated positive as they required rescue analgesic. Score <5 was considered negative as counselling and proper positioning of children were sufficient for relief of pain.
These faces show how much something can hurt. Left most face shows no pain. The faces show more and more pain from left to right. Scoring was done as 0, 2, 4, 6, 8, 10, counting from left to right, so 0 = no pain and 10 = very much pain.
Face, Legs, Activity, Cry, Consolability was observed for 1-5 min or longer, legs and body were observed uncovered. Children were repositioned and activities were observed. Body was assessed for tenseness and tone. Consoling interventions were initiated when required (FPS-R and FLACC scale were downloaded from the website of IASP, no permission is required to use these scales, and any modification is subjected to permission by IASP).
We rejected data of 2 children due to longer duration of surgery (>45 min). Three of them did not cooperate with the observer and excluded from our study. So data of 90 children were compiled on Microsoft Excel worksheets (Microsoft, Redwoods, WA, USA). Validity of the tests was expressed by sensitivity and specificity by judging severity of pain as gold standard. Cohen's Kappa coefficient was computed to see what extent the reading of two different methods agreed beyond which we would expect by chance alone. Kappa value was 0.76, that is, the two scales have excellent percentage agreement according to the Fleiss's guideline. Spearman's correlation coefficient (ρ) was computed to ascertain the correlation between these two scales and a significant positive correlation between them was found (ρ = 0.727, P = 0.00).
| Results|| |
[Table 1] shows the demographic data of 90 children in the form of male-female ratio, mean and standard deviation of age and duration of surgery. They were comparable in respect to demographic profile. Out of 90 children thirty four had moderate to severe pain (37.7%) according to FPS-R and forty eight had moderate to severe pain (53.3%) according to FLACC scale. Two different tools were assessed on every child and compared with severity scale. For each of the measured parameters odds ratio (OR), kappa coefficient (κ) and confidence interval (CI) were calculated and shown in [Table 2]. Sensitivity, specificity of individual scale and combination of scales are shown in [Table 3].
Individually FPS-R has higher OR (16.06%) and kappa coefficient (0.5) than FLACC scale (OR-2.85%, kappa-0.4%) but combination of these two scales show high OR (39%) and kappa coefficient (0.76).
Sensitivity of FPS-R and FLACC are 42.5% and 53.93% respectively, but combination of these has sensitivity of 66.66%. Specificity of combination of these tools is very high (95.1%) than individual test (FPS-R-17.85%, FLACC-2.2%).
| Discussion|| |
Adult patients can express pain in their own language but it is difficult to assess pain in paediatric population. Children between the ages of 2 and 7 years may be unable to describe their pain or their subjective experiences.  This has led many to conclude incorrectly that these children don't experience pain in the same way as adults. Accurate assessment using reliable and valid measures is the cornerstone of effective treatment of postoperative pain.
When assessing paediatric postoperative pain there are multiple dimensions that can be assessed. These dimensions include:
- Sensory (e.g., intensity, word descriptors, duration, location, and frequency),
- Affective/cognitive (pain unpleasantness), and
- Impact of pain in aspects of everyday life (physical, social, emotional, and role functioning).
While it is important to assess each of these domains, the most commonly used parameter in clinical and research practices is the measurement of the intensity of pain or how much it hurts for giving proper dose of analgesic.  There are three main approaches to the assessment of intensity of pain in children: Physiological, behavioural, and self-report measures. Infants and preverbal children are assessed by physiological or behavioural measures and adult patients reliably can explain their pain by self-report methods. But children between age group of 2 and 7 years who belong to Piaget's preoperational stage of cognitive development give wide variety of response in self-report measures. 
Multiple self-report methods have been developed for the assessment of pain in children. 
Among them we used FPS-R. The FPS-R has several advantages over other existing faces scales. ,, First, it has no smiling and/or tearful faces, which is relevant considering that scales that use a series of faces with expressions from smiling faces (no pain) to tearful (very much pain) can confound the affective component (distress) and the sensory component of pain (pain intensity). ,
Several behavioural scales have potential for clinical assessment and management of postoperative pain. ,,, Most of them are difficult to use in busy clinical settings due to bulk of data sets. We use FLACC scale which incorporates only five categories of pain behaviour so it is practically applicable.  Postoperative pain score is a popular scale to assess postoperative pain in children but it has discriminate validity and reliability is also not established after several studies, so we did not use the tool. ,,
In our study 37.7% have moderate to severe pain in FPS-R which corroborates with the study of Huguet et al. who suggested combining this scale with some observational measure for adequate assessment.  53.3% children had moderate to severe pain on FLACC scale which approximately matches with the study of Merkel et al. 
In our study we got excellent correlation between FLACC and FPS-R (κ-0.76) which corroborates with the study of Cassidy et al. 
Specificity of individual tests are low ((FPS-R-17.85%, FLACC-2.2%) whereas combination of these two tests are significantly high (95.1%). This variety of response in this particular age group can be explained by Piaget's theory.  According to him children in this age group begins to represent the world with words and images. These words and images reflect increased symbolic thinking and go beyond the connection of sensory information and physical action. Children use symbols but have many errors in thinking. These are egocentrism (inability to distinguish between one's own perspective and someone else's perspective), centration (focusing on one characteristic to the exclusion of others) and confuse appearance and reality. This finding is also supported by Wong and Baker who applied several scale and came to the conclusion that no one scale demonstrates superiority in validity or reliability in this age group. 
| Conclusion|| |
Faces Pain Scale-Revised and FLACC scale has excellent agreement to diagnose the severity of postoperative pain in 2-7 years of age group and combination of these two tests are more specific to assess the severity of postoperative pain than individual of test in this age group.
Merit of our study
We aimed to find out the specificity or true negative rather than sensitivity to exclude misuse or abuse of analgesics and to avoid unnecessary adverse effects of analgesic medication in study population.
Limitation of our study
The study was based on assumption that children's ranking of the painful events is a valid estimate of their perception of pain, because there is no way of proving that pain exists other than believing that the person is in pain.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]