CONSTRUCT AND CRITERION VALIDITY, AND RELIABILITY OF

THE FELINE GRIMACE SCALE

EVANGELISTA MC1,2, WATANABE R1,2, LEUNG V1,2, MONTEIRO B2, O'TOOLE E1, PANG DSJ1,2, STEAGALL PV1,2
1Département
de sciences cliniques, Faculté de médecine vétérinaire, Université de Montréal
2Groupe de recherche en pharmacologie animale du Québec, Département de biomédecine vétérinaire, Université de Montréal

INTRODUCTION STATISTICAL ANALYSIS

Facial expression scales (“grimace scales”) have been developed for several Construct (hypothesis testing; Mann-Whitney U test) and criterion validity
species to assess ongoing pain. (Spearman’s rank correlation between rCMPS-f and FGS scores) were
assessed using scores from one observer, blinded to rCMPS-f scores (p <
Our group previously reported the development of a Feline Grimace Scale 0.05 considered significant).
(FGS) in cats with naturally occurring painful states, including five action units
(AU): ears, eyes, muzzle, whiskers and head position (Figure 1).1 Inter- and intra-rater reliability were evaluated with the intraclass
correlation coefficient (ICC) using two-way random effects model for
This study aimed to report the construct and criterion validity, and reliability absolute agreement. The ICC was calculated for the final FGS scores
of the FGS. (average of AU) and for each AU individually.
The hypotheses were: 1) painful cats would score higher that non-painful cats
(construct validation); 2) the FGS would correlate with the Glasgow
composite measure pain scale2 - rCMPS-f (a validated pain scale in cats;
RESULTS
criterion validation); and 3) the agreement between and within observers
would be good to excellent (inter- and intra-rater reliability). FGS scores were higher in painful than in control cats. Median (range): 0.71
(0.18-0.98) and 0 (0-0.1), respectively (Figure 4).
A very strong correlation was observed between scoring systems (Figure 5).
MATERIALS AND METHODS
* p < 0.001
1.0 1.0

Ethics committee protocol number: 17-Rech-1863. 0.9 0.9

0.8 0.8
Animals: Client-owned (6.8 ± 3.8 years, n = 35) and control cats (3.1 ± 1.1 0.7 0.7
years, n = 20) were included in a prospective, case-control study. Cats

FGS scores
FGS scores

0.6 0.6

receiving rCMPS-f scores ≥ 4/16 were considered painful. 0.5 0.5

0.4 0.4
Image capture and scoring: Images of the cats’ faces were extracted from 0.3 0.3
videos (Figures 2 and 3). Four observers unaware of rCMPS-f scores, scored 0.2 0.2

110 images independently twice, 30 days apart (round 1 and 2, respectively). 0.1 0.1

Total AU scores were averaged to produce a final FGS score for each image. 0.0 0.0
0 1 2 3 4 5 6 7 8 9 10
Control Painful
Group rCMPS-f scores
Figure 1 - Feline Grimace Scale: Each facial action unit receives a score from 0 to 2
Figure 4 - Median (solid line) and interquartile Figure 5 - Correlation between FGS and
ranges for FGS scores in control (rCMPS-f = 0; n = rCMPS-f scores (rho = 0.86, p < 0.001) from
20) and painful cats (rCMPS-f ≥ 4; n = 28). The control (rCMPS-f = 0; n = 20) and client-owned
whiskers represent the range. cats (rCMPS-f = 0-10; n = 35).

Inter-rater reliability for FGS scoring was good during both round 1 and 2
[ICC single measures (95% confidence interval): 0.89 (0.85–0.92) and 0.89
(0.84-0.92), respectively]. Inter-rater reliability of single action units ranged
from moderate to excellent (Table 1).

Intra-rater reliability was excellent for all observers [≥ 0.91 (0.81-0.95)].

Table 1 - Inter-rater reliability of the FGS scores for individual action units
[ICC single measures (95% confidence interval)]

Action unit ICC - Round 1 ICC - Round 2

0 = absent 1 = moderately present 2 = markedly present Ears 0.87 (0.82-0.90) 0.85 (0.81-0.89)
Ears facing forward Ears slightly pulled apart Ears flattened and rotated outwards Eyes 0.86 (0.81-0.89) 0.83 (0.77-0.88)
Eyes opened Eyes partially opened Squinted eyes
Muzzle 0.63 (0.53-0.72) 0.67 (0.58-0.75)
Muzzle relaxed (round) Muzzle mildly tense Muzzle tense (elliptical)
Whiskers loose and curved Whiskers slightly curved or straight Whiskers straight and moving forward Whiskers 0.55 (0.43-0.66) 0.60 (0.48-0.70)
Head above the shoulder line Head aligned with the shoulder line Head below the shoulder line or tilted Head position 0.90 (0.87-0.93) 0.88 (0.84-0.91)
Interpretation of ICC: <0.5 = poor; 0.5-0.75 = moderate; 0.75-0.9 = good;
> 0.9 = excellent.3

Figure 2 - Video-recording of cats. A wide-angle
lens camera was placed between the cage bars and
cats were video-recorded undisturbed for 6 min.
Figure 3 - Image cropping and selection.
Assessment of facial expressions were performed
using screenshots obtained from videos.
CONCLUSIONS
The FGS discriminates painful from non-painful cats.
FGS scores showed good inter- and excellent intra-rater reliability.
The FGS is a valid and reliable tool for feline acute pain assessment.

REFERENCES
1. Evangelista MC, Watanabe R, O’Toole E, et al. Facial expressions of pain in cats: development of the Feline Grimace Scale.
Abstract presented at the AVA Spring Meeting – St George’s, Grenada. March 2018
2. Calvo G, Holden E, Reid J, et al. Development of a behaviour-based intervention level for assessing acute pain in cats. J
Small Anim Pract 2014; 55:622–629
3. Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research. J Chiropr
Med 2016;15:155-163
ACKNOWLEDGMENTS
This study received an unrestricted grant by Zoetis.
Fonds en santé des animaux de compagnie, Faculté de médecine vétérinaire - UdeM.
Dr Evangelista is a recipient of the International Veterinary Academy of Pain Management fellowship
and a scholarship from the Merit scholarship program for foreign students from the Ministère de
l'Éducation et de l'Enseignement supérieur du Québec (MEES).