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Faces Pain Scale - Revised (FPS-R)
Please visit this website for more information and to obtain a copy of the instrument: Faces Pain Scale - Revised
Supplemental - Highly Recommended: Myalgic encephalomyelitis/Chronic fatigue syndrome (ME/CFS) for capturing the severity of pain experience in pediatric patients.
Supplemental: Cerebral Palsy (CP), Spinal Cord Injury (SCI)-Pediatric (ages 4-8)
Short Description of Instrument
The FPS-R is a self-report measure of children's pain intensity adapted from the Faces Pain Scale (FPS). The revised scale has six faces, in contrast to the seven of the FPS (Hicks et al., 2001).
The scale uses a picture of a face that represents the child's pain intensity (von Baeyer, 2006).
Set of line drawings or photographs of faces that depict pain states, associated with number designations (free downloads in multiple languages from link above).
Age: 4 years and older
Completes: person with CP
Time to complete: 1 minute
Comments/Special Instructions
The FPS-R is easy to administer and requires no additional equipment besides the pictures of the faces. A short instruction is given, and the child is asked to point to the face that is most like their current level of pain. Each face corresponds to a number between 0 and 10.
Standardization of the anchors (described ends of the scale) as noted in the instructions is important because alternative anchors used in other scales or versions of this test can cause administration bias (Lee et al., 2017). Similarly, asking young people to consolidate pain experienced over a period into a single score ("maximal pain in last month", for example) can also be problematic (Lee et al., 2017) and current pain is the most appropriate use of this tool.  
The scale is easier than visual analog scales (VAS) because subjects are only required to match how they feel to a picture as opposed to quantifying pain, which is simpler and preferred by children (von Baeyer, 2006).
There are other tools that use depictions of faces, notably the Wong-Baker Faces Pain Rating Scale (WBFPRS). The VFS-R does not include confounding emotions with the use of tears or smiles in the images.
CP-specific Pain Category: Intensity
CP-specific ICF Domain: Body Structures (World Health Organization, 2001).
Scoring and Psychometric Properties
Scoring: This is a self-report scale, with scores ranging from 0-10 ("0" equals "no pain" and "10" equals "very much pain").
Psychometric Properties: The scale shows a linear relationship with visual analog pain scales across the age of 4-16 years. There is not extensive data in children with disabilities with FPS-R specifically. Considering six-face scales in general, construct validity is shown from the age of seven (Combes et al., 2017; Baxter et al., 2011; Miro & Huguet, 2004; Stanford et al., 2006; PagÉ  et al., 2012; Gupta et al., 2016). When compared to the Color Analog Scale, there was lower convergent validity noted in children <7 years of age with acute pain (Tsze, 2013), another study showing that children in this age have difficulty in using the middle of the scale. (Hunter et al., 2000; Combes et al., 2021)
In general, faces scales like the FPS-R, tend to be more culturally appropriate for use in international studies where literacy is a concern (Pathak et al., 2018; Atisook et al., 2021).
MCID has not been established, but a score of 4 has been suggested as an intervention line, or the threshold above which some form in pain control strategy is implemented following surgery (Messerer et al., 2010).
The FPS-R has been used to evaluate in children with CP across all GMFCS and MACS levels with both kinetic and dystonic CP. (Harvey et al., 2021; McKinnon et al., 2020; Garzon et al., 2018)
The FPS-R is different than the Wong-Baker Faces Pain Rating Scale (WBFPRS) in the pictures used, but both are 6-image scales, so the features of this scale are also considered in this review. In a study comparing four types of face scales using self-report for pain intensity in children, it was found that although children prefer the WBFPRS, the FPS-R has been recommended based on utility and psychometric features. Psychometric features included construct validity, reliability, and responsiveness (Tomlinson et al., 2010).
In children with disabilities, ages 8 to 20 years, WBFPR-S positively correlated with numeric rating scale-11 and the verbal rating scale-6.
WBFPRS strongly correlates with numeric rating scale-11 and the verbal rating scale-6 regarding pain intensity in children with disabilities (Significant Pearson correlation coefficients ranging from 0.32-0.79). (Miró et al., 2019) It also had a statistically significant positive association with pain interfering with function though nonsignificant positive association to disability due to pain, and statistically significant negative association to psychological functioning in children with disabilities.
Strengths: Rapidly administered. Ease of administration and indication, even for children with disabilities and significant physical or speech impairment. Low cost/resource - a simple paper, laminated card, or computer screen can all be used to display the scale. The use of standardized and consistent visual representations over time may help children to report their discomfort more reliably. The FPS-R test has advantages over other images in that they have images that are less reflective of other emotions such as happiness or sadness.
The FPS-R has been used in children with cerebral palsy.
Weaknesses:  Assumption that children's ranking of painful events is a valid estimate of their perception of pain is a possible limitation. (Wong & Baker, 1988) False positives, negative emotions vs pain; False negatives, positive emotions, and pain.
Key References:
Bieri D, Reeve RA, Champion DG, Addicoat L, Ziegler JB. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain. 1990 May;41(2):139-150.
Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs. 1988 Jan-Feb;14(1):9-17.
Additional References:
Atisook R, Euasobhon P, Saengsanon A, Jensen MP. Validity and Utility of Four Pain Intensity Measures for Use in International Research. J Pain Res. 2021 Apr 21;14:1129-1139.
Baxter AL, Watcha MF, Baxter WV, Leong T, Wyatt MM. Development  and validation of a pictorial nausea rating scale for children. Pediatrics. 2011 Jun;127(6):e1542-9.
Chambers CT, Craig KD. An intrusive impact of anchors in children's faces pain scales. Pain. 1998 Oct;78(1):27-37.
Chambers, C. T., Giesbrecht, K., Craig, K. D., Bennett, S. M., & Huntsman, E. (1999). A comparison of faces scales for the measurement of pediatric pain: Children's and parents' ratings. Pain, 83, 25-35.
Coombes L, Bristowe K, Ellis-Smith C, Aworinde J, Fraser LK, Downing J, Bluebond-Langner M, Chambers L, Murtagh FEM, Harding R. Enhancing validity, reliability, and participation in self-reported health outcome measurement for children and young people: a systematic review of recall period, response scale format, and administration modality. Qual Life Res. 2021 Jul;30(7):1803-1832.
Garzon LC, Switzer L, Musselman KE, Fehlings D. The use of functional electrical stimulation to improve upper limb function in children with hemiplegic cerebral palsy: A feasibility study. J Rehabil Assist Technol Eng. 2018 May 14;5:2055668318768402.
Gupta N, Naegeli AN, Turner-Bowker DM, Flood EM, Heath LE, Mays SM, Dampier C. Cognitive Testing of an Electronic Version of the Faces Pain Scale-Revised with Pediatric and Adolescent Sickle Cell Patients. Patient. 2016 Oct;9(5):433-43.
Harvey A, Waugh MC, Rice J, Antolovich G, Copeland L, Orsini F, Scheinberg A, McKinnon C, Thorley M, Baker F, Chalkiadis G, Stewart K. A pilot feasibility study of gabapentin for managing pain in children with dystonic cerebral palsy. BMC Pediatr. 2021 Aug 28;21(1):368.  
Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain. 2001;93(2):173-183.
Huguet A, Stinson JN, McGrath PJ. Measurement of self-reported pain intensity in children and adolescents. J Psychosom Res. 2010;68:329-336.
Hunter M, McDowell L, Hennessy R, Cassey J. An evaluation of the Faces Pain Scale with young children. J Pain Symptom Manage. 2000 Aug;20(2):122-129.
Lee RR, Rashid A, Ghio D, Thomson W, Cordingley L. Chronic Pain Assessments in Children and Adolescents: A Systematic Literature Review of the Selection, Administration, Interpretation, and Reporting of Unidimensional Pain Intensity Scales. Pain Res Manag. 2017;2017:7603758.
McKinnon CT, White JH, Morgan PE, Antolovich GC, Clancy CH, Fahey MC, Harvey AR. The lived experience of chronic pain and dyskinesia in children and adolescents with cerebral palsy. BMC Pediatr. 2020 Mar 17;20(1):125.
Messerer B, Gutmann A, Weinberg A, Sandner-Kiesling A. Implementation of a standardized pain management in a pediatric surgery unit. Pediatr Surg Int. 2010 Sep;26(9):879-89.
Miró J, Huguet A. Evaluation of reliability, validity, and preference for a pediatric pain intensity scale: the Catalan version of the faces pain scale--revised. Pain. 2004 Sep;111(1-2):59-64.
Miró J, de la Vega R, Gertz KJ, Thong ISK, Jensen MP, Engel JM. Do Commonly Used Measures of Pain Intensity Only Reflect Pain Intensity in Youths with Bothersome Pain and a Physical Disability? Front Pediatr. 2019 Jun 20;7:229.
PagÉ MG, Katz J, Stinson J, Isaac L, Martin-Pichora AL, Campbell F. Validation of the numerical rating scale for pain intensity and unpleasantness in pediatric acute postoperative pain: sensitivity to change over time. J Pain. 2012 Apr;13(4):359-69.
Pathak A, Sharma S, Jensen MP. The utility and validity of pain intensity rating scales for use in developing countries. Pain Rep. 2018 Aug 6;3(5):e672.
Stanford EA, Chambers CT, Craig KD. The role of developmental factors in predicting young children's use of a self-report scale for pain. Pain. 2006 Jan;120(1-2):16-23.
Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010;126(5): e1168-e1198.
Tsze DS, von Baeyer CL, Bulloch B, Dayan PS. Validation of self-report pain scales in children. Pediatrics. 2013;132(4):e971-e979.
von Baeyer CL. Children's self-reports of pain intensity: scale selection, limitations, and interpretation. Pain Res Manag. 2006;11(3):157-162.
World health Organization (2001). International Classification of Functioning, Disability and Health (ICF) Retrieved 19August2021
Document last updated August 2022