Office of Technology Transfer – University of Michigan

Face, Legs, Activity, Cry, Consolability Observational Tool as a Measure of Pain

Technology #6581

FLACC pain scale: A behavioral pain scale used to score pain

Infants, children and persons with cognitively impairment frequently lack the verbal and cognitive skills necessary to report physical discomfort and pain intensity. The assessment and effective management of pain in these populations depends upon the observation and expertise of the care providers. Care providers and care takers frequently have difficulty assessing pain in these individual and this often leads to under-treatment of pain.

Researchers at the University of Michigan developed a behavioral observation tool that can be used to quantify pain behaviors in infants, young children, cognitively impaired young persons and children and adults who are intubated. The tool has been tested in these populations and found to be a reliable and valid measure pain.

Behavioral cues remain the primary indicator of pain in persons who are unable to use a self-reporting pain scale. The FLACC Pain tool incorporates five categories of behaviors. The acronym FLACC ( Face, Legs, Activity, Cry and Consolability), was developed to facilitate recall of the categories included in the tool Each category is scored on 0-2 scale and the numbers are added together which results in a total score between 0 and 10. This range is often found in other clinical pain assessment tools.

A score is obtained by reviewing the descriptions of behavior in each of the 5 categories and selecting the number that most closely matches the observed behavior. To use the scale the clinician or caregiver should observe or interact with the individual for one to five minutes. Behaviors should also be observed during routine care. It may be necessary to touch and reposition the individual to determine if pain is present with movement and to assess tension and rigidity.

The difficulty in using observations to assess pain is that there may be differences in what clinicians expect and observe. It is important to consider the patient’s circumstances, environment and time of the assessment. Parents and family members usually know their child’s/loved one’s typical behavioral response to pain and can identify behaviors unique to the individual that can be included in the assessment of pain.

Keys to the use of behavioral pain tools are to focus on the individual’s behavioral presentation (at both rest and on movement or during procedures known to be painful) and to observe for changes in those behaviors with effective treatment. Increases or decreases in the number or intensity of behaviors suggest increasing or decreasing pain. However, a behavioral pain score is not the same as a self-reported pain intensity rating.


Sandra I Merkel, MS, RN-BC Terri Voepel-Lewis PhD, RN Shoba Malviya, MD


Assist in recognizing, assessing and treating pain in vulnerable populations

  • Infants and young children

  • Children, adolescents, young adults with cognitive impairment (rFLACC)

  • Intubated infants, children, adolescents and adults


  • Easy to use, score and document

  • Readily adopted into clinical practice

  • Promotes consistency and facilitate communication of pain management among care providers

  • Compatibility with other pain tools

  • Compatibility with electronic medical record systems

  • Widely recognized and used in the United States and internationally in clinical care, research and education

  • It has been used in several research studies completed in France, China, Italy, Portugal and India

  • rFLACC includes additional descriptors for children and individuals with cognitive impairment and encourages users to include behaviors unique to the individual patient


Original validation Merkel, S., Voepel-Lewis T., Shayevitz J. & Malviya S. (1997) The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23:293-297.

Validation in children with cognitive impairment Voepel-Lewis, T., Merkel, S., Tait, A.R., Trzcinka, A. & Malviya, S. (2002). The reliability and validity of the face, legs, activity, cry, consolability observational tool as a measure of pain in children with cognitive impairment. Anesthesia & Analgesia, 95:1224-9.

Malviya, S., Voepel-Lewis, T., Burke, C.N., Merkel, S. & Tait, A.R. (2006). The revised FLACC observational pain tool: Improved reliability and validity for pain assessment in children with cognitive impairment. Pediatric Anesthesia,16:258-65.

Validation in intubated children and adults

Voepel-Lewis, T., Zanotti, J., Dammeyer, J. A. & Merkel, S. (2010). Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. American Journal of Critical Care,19(1):1-7.

Other publications Voepel-Lewis, R., Malviya, S. Tait, A. R., Merkel, S., Foster, R. & Krane, E. J. (2008). A comparison of the clinical utility of pain assessment tools for children with cognitive impairment. Anesthesia &Anesthesiology 2008,106(1):72-78

Merkel, S., Voepel-Lewis, T. & Malviya, S. (2002). Pain assessment in infants and young children: The FLACC scale. American Journal of Nursing,102(10):55-57.