The FLACC scale was developed to guide the assessment of pain in infants and pre-verbal

children, and the pain-related behaviours that form the basis of this tool were identified from studies of children undergoing painful procedures such as circumcision. Some behaviour addressed by this scale such as leg kicking and a quivering Inhibitors,research,lifescience,medical chin does not appear to be relevant when assessing adults. The review of adult pain assessment tools undertaken by Herr and colleagues found that the FLACC has low levels of validity and reliability and as such was not recommended for use in this population[26]. Any tool used by paramedics must be reliable, valid and practical, with the latter influenced by operational requirements to minimise time spent on scene. As such, tools that assess multiple dimensions

Inhibitors,research,lifescience,medical of pain that require observation of behaviour over time during different activities may have less utility than a tool that identifies the presence of pain and attempts to evaluate the severity in a way that parallels tools that are already familiar to paramedics for use in patients without cognitive impairment. In a report published by the Australian Pain Society[34] Inhibitors,research,lifescience,medical that describes the use of best available evidence and the results of a clinical trial of pain assessment tools to inform pain management practice in aged care facilities, the Abbey pain scale (Figure ​(Figure1)1) was recommended as the most appropriate means of assessing pain in residents with severe cognitive impairment. This one-dimensional

scale is designed to rate pain severity. Although this tool Inhibitors,research,lifescience,medical attempts to address acute, chronic and acute-on-chronic pain using six behaviour categories that include physiological and physical changes, vocalisation, facial expressions, and changes in body language Inhibitors,research,lifescience,medical and behaviour, some cues may be non-specific. This is particularly apparent in the facial cue category, where cues such as frowning may not have a strong correlation with pain[35]. The tool takes between two to six minutes to complete[36], and as such this tool may be practical for use in the paramedic practice setting. Figure 1 Abbey Pain Scale. From: Abbey J et al. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia [27]. Following a recent review of available evidence the Abbey Pain Scale was recommended by the Royal College Adenosine of Physicians in the UK for assessment of pain in patients with severe cognitive impairment[37]. The authors of this report recognised that limited clinical data was available to support this decision, but made this recommendation on the basis on ease of use while adding the caveat that no single method of pain assessment could be recommended for this cohort. At this time no pain assessment tools for use in the setting of cognitive TGX-221 molecular weight impairment have been validated for use by paramedics.