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The revised FLACC behavioural pain score: Reliability and validation for pain assessment in children with cerebral palsy Line Kjeldgaard Pedersen, MD Ole Rahbek, MD, Ph.D Lone Nikolajsen, MD, Ph.D, DMSc Bjarne Mller-Madsen, MD, DMSc EP84 No conflicts of interest declared

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Background Pain in children with severe cerebral palsy (CP) is underrecognized and undertreated A self-rating assessment tool is not possible in children with severe cognitive impairments A valid observational or behavioral pain score is needed r-FLACC: revised Face, Legs, Activity, Cry and Consolability behavioural pain score r-FLACC: Incorporates individual typical and atypical pain behaviour

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Background The quality of the r-FLACC can be assessed by the COSMIN Checklist: The quality domain reliability is based on internal consistency (Crohnbachs Alpha, Factoranalysis) and intra- and inter rater reliability (Intra-Class Correlation) The quality domain validity is based on content validity (core pain behaviours), construct validity (expected change in pain) and criterion validity (Pearsons Correlation Coefficient) The aim of this study is to assess reliability and validity of the r-FLACC pain score for use in Scandinavian children with CP.

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Methods 27 children with CP undergoing orthopedic surgery 2 min standardized video recording was made for r-FLACC scoring. Parent-assessed Observational Visual Analog Scale (VAS-OBS) Two nurses r-FLACC scored the recordings independently. Ten of the recordings were reviewed again 1 year later.

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Results Excellent internal consistency with Crohnbachs alpha: 0.93 / 0.98, Factoranalysis indicates unidimensionality Excellent intra-rater reliability (ICC=0.98) and good inter-rater reliability (ICC=0.75) Content validity was tested by the originators of the r-FLACC Construct validity supported by an increase in r-FLACC scores following surgery (p=0.0427) Criterion validity was acceptable when comparing VAS-OBS and r- FLACC scores (Pearsons Correlation Coefficient: 0.76 / 0.59)

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Conclusion The r-FLACC have excellent reliability and validity The translated version of the r-FLACC behavioural pain score is valid for use in postoperative pain assessment in children with CP