The Numeric Rating Scale For Clinical Pain Measurement: A Ratio Measure?

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ORIGINAL ARTICLE

The Numeric Rating Scale for


Clinical Pain Measurement:
A Ratio Measure?

Craig T. Hartrick, MD, DABPM; Juliann P. Kovan, BSN, CCRP;


Sharon Shapiro, BSN
Anesthesiology Research Division, William Beaumont Hospital, Royal Oak, Michigan

 Abstract: The Numeric Rating Scale (NRS-11) has been Accreditation of Healthcare Organizations (JCAHO)
widely used clinically for the assessment of pain. Its use for require both routine pain assessment and pain reassess-
clinical research is controversial. Reports differ as to whether ment after analgesic intervention in both inpatient
or not the NRS-11 should be treated as a ratio pain mea-
and outpatient settings. While the Visual Analog Scale
surement tool. This study compared the NRS-11 to a ratio
measure for pain assessment: the visual analog scale (VAS).
(VAS) is a validated ratio measure of pain,1 its admin-
Simultaneous pain measurements using these 2 scales were istration requires additional nursing resources that may
compared in clinical situations commonly encountered in a reduce compliance. The use of complex measurement
tertiary community hospital. Whereas linear relationships tools that preserve scientific validity at the expense of
were noted in laboring patients and in postoperative compliance do not serve patients’ needs. Effective imple-
patients with thoracic or abdominal incisions during cough, mentation of pain measurement initiatives, such as the
no such correlations were noted for the same postoperative “Fifth Vital Sign,” require simple user-friendly tools.
patients at rest or for postoperative orthopedic patients.
The 0–10 verbal numeric rating scale (NRS-11) is a tool
The NRS-11 should not be considered to be interchangeable
with the VAS. Its use for clinical research should be limited
that enjoys widespread clinical use due to its ease of
to situations where it has specifically demonstrated linear administration.
properties.  When using the NRS-11 patients are asked to rate
their pain on a scale from 0 to 10, where 0 represents
Key Words: pain measurement, numeric rating scale, “no pain” and 10 represents “the worst pain possible,”
visual analog scale, psychometrics using whole numbers (11 integers including zero).
Patients may then be questioned as to their goals and
INTRODUCTION
expectations with respect to their pain rating as a
Increasingly, health care professionals are becoming measure of satisfaction with the degree of analgesia.
aware of the importance of pain measurement as an Often the value of “4” is used to confirm clinical nursing
integral component of routine patient assessment. judgment as to the need for further intervention or doc-
Accreditation bodies such as the Joint Commission for umentation that the patient’s goals for analgesia have
Address correspondence and reprint requests to: Craig T. Hartrick, MD,
been achieved.
Director, Anesthesiology Research, William Beaumont Hospital 3601 W. 13 The popularity of the NRS-11as a standard tool for
Mile Road, Royal Oak, Michigan 48073. Tel: 248-551-1907; E-mail: pain measurement has led to its use and perhaps misuse
chartrick@beaumont.edu.
in clinical research. Clearly, the use of pain scores to
© 2003 World Institute of Pain, 1530-7085/03/$15.00
perform mathematical calculations, (such as percent
Pain Practice, Volume 3, Issue 4, 2003 310–316 relief), require measures that exhibit ratio properties.
A Ratio Measure? • 311

Linearity over the clinical range of interest is also desir- performed by four clinical research nurses experienced
able. The VAS has been shown to be linear for mild in analgesic measurement.
to moderate pain.2 Further, while the VAS has been Statistical analysis: Repeated measures analysis of
demonstrated to be a ratio scale, the NRS-11 has not variance using nonparametric methods with Dunn’s
been consistently associated with ratio characteristics.3 multiple comparisons test post hoc was used to examine
Despite this, Breivik et al. have suggested that the choice the effects of static versus dynamic stimulation. Two-
between NRS-11 and VAS for pain assessment in clini- tailed Wilcoxon matched-pairs signed-rank tests and
cal trials be based on subjective preferences.4 This asser- nonparametric Spearman correlations were used to
tion was based upon study of 35 patients having acute compare VAS and NRS-11 collectively and within VRS-
pain following extraction of impacted wisdom teeth. 4 categories for thoracoabdominal, orthopedic and
However, since the VAS and the NRS-11 have very dif- obstetrical pain conditions. Values of p < 0.05 were
ferent psychometric properties, 5 generalization of the considered statistically significant.
results of Breivik et al. for use in other populations may
not be appropriate. RESULTS
This study compares the categorical Verbal Rating NRS-11 and VAS generally trended in the same direc-
Scale (VRS-4), the NRS-11 and the VAS in several com- tion as demonstrated by effective pairing correlations
monly encountered acute pain situations in a hospital for all patients with mild pain at rest (r = 0.38, p <
setting. Both static and dynamic acute pain were 0.0001), mild pain with activity (r = 0.56, p < 0.0001),
assessed in postoperative patients and in laboring moderate pain at rest (r = 0.41, p < 0.0014), moderate
obstetrical patients. The purpose of this study was to pain with activity (r = 0.68, p < 0.0001), and severe pain
determine under which circumstances the NRS-11 with activity (r = 0.50, p < 0.0002). Pairing between the
might behave as a ratio scale. VAS and the NRS-11 was ineffective where small
numbers of arguments were observed as in severe pain
at rest (N = 8; r = 0.53, p < 0.09), severe labor pain with
METHODS activity (N = 12; r = 0.39, p < 0.11), and moderate pain
Two hundred twenty-two patients requiring analgesics at rest following hip arthroplasty (N = 15; r = 0.28,
in a tertiary community hospital following thoracic or p < 0.16).
abdominal surgery (N = 98), total hip arthroplasty (N NRS-11 scores were significantly higher than VAS
= 68), and during labor in the obstetrical suite (N = 54) scores for nearly all pain conditions with the exceptions
were enrolled. Three pain scales were administered in of severe obstetrical pain during contractions (ns) and
sequence, VRS-4, the VAS, and the NRS-11, at rest and in moderate hip pain at rest (p < 0.006) where NRS-11
with activity, as simultaneous measures of static and scores were lower than VAS scores. Pooled data demon-
dynamic pain respectively. No attempt was made to strated no significant difference between NRS-11 and
alter the sequence of testing or to assess the impact the VAS for moderate pain at rest (p = 0.87), but significant
act of sequential measurement might have on the results. differences were apparent for moderate pain with activ-
Initial measurements were made at rest. For the VRS-4, ity (p < 0.019). VRS-4 pain ratings were used to
patients were asked to select from the following pain compare the pain states at rest and with activity (see
intensity descriptors, none, mild, moderate, or severe. Tables 1–5). Results for severe pain at rest are not pre-
Next the VAS was assessed by asking patients to place sented due to insufficient data.
a single vertical mark on a 100 mm vertical line with Scatterplots (Figures 1–6) illustrate the degree of lin-
“No Pain” at the extreme left and “Worst Pain Possi- earity of NRS-11 when compared to VAS. Least squares
ble” at the extreme right. Patients were then asked to best-fit trendlines that were not forced through zero
rate their pain numerically on a 0 to 10 scale where 0 demonstrate relatively linear relationships only for static
represents “no pain” and 10 represents the “worst pain (R2 = 0.86) and dynamic (R2 = 0.79) pain during labor
possible.” These scores were then normalized to a (Figures 1 and 2) and for dynamic thoracoabdominal
0–100 scale to match the VAS. Testing was repeated pain during cough (R2 = 0.76; see Figure 4). NRS-11
during activity. Activities were defined as cough for values in thoracoabdominal pain at rest (R2 = 0.58; see
postoperative thoracic and abdominal incisions, move- Figure 3) and for both static (R2 = 0.40) and dynamic
ment of the extremity for hip arthroplasty and during (R2 = 0.47) orthopedic pain (see Figures 5 and 6) deviate
uterine contraction for laboring patients. Testing was significantly from linearity.
312 • hartrick et al.

Table 1. Moderate Pain with Activity

Pain Condition VAS: Mean ± SEM (CI 95%) NRS-11: Mean ± SEM (CI 95%)

Obstetrical (N = 17) 56.1 ± 4.0 (47.6–64.6) 63.5 ± 5.6 (51.8–75.3)*


Hip arthroplasty (N = 26) 42.9 ± 3.3 (36.1–49.7) 51.2 ± 3.5 (43.9–58.5)**
Thoracoabdominal (N = 33) 49.6 ± 3.3 (42.9–56.2) 49.4 ± 3.7 (41.8–57.0)*** ns

* p < 0.017 (pairing: r = 0.88, p < 0.0001); ** p < 0.032 (pairing: r = 0.44, p < 0.01); *** p < 0.95 (pairing: r = 0.72,
p < 0.0001).

Table 2. Moderate Pain at Rest

Pain Condition VAS: Mean ± SEM (CI 95%) NRS-11: Mean ± SEM (CI 95%)

Obstetrical (N = 8) 52.0 ± 8.5 (31.9–72.1) 57.5 ± 8.2 (38.1–76.9)* ns


Hip arthroplasty (N = 15) 43.2 ± 5.3 (31.9–54.5) 23.7 ± 4.6 (13.7–33.6)**
Thoracoabdominal (N = 29) 41.6 ± 3.0 (35.4–47.8) 49.3 ± 3.1 (42.9–55.7)***

* p < 0.21 (pairing: r = 0.88, p < 0.002); ** p < 0.006 (pairing: r = 0.28, p < 0.16); *** p < 0.033 (pairing: r = 0.38,
p < 0.02).

Table 3. Mild Pain at Rest

Pain Condition VAS: Mean ± SEM (CI 95%) NRS-11: Mean ± SEM (CI 95%)

Obstetrical (none to mild; N = 46) 10.4 ± 2.3 (5.6–15.0) 12.6 ± 3.2 (6.2–19.0)* ns
Hip arthroplasty (N = 31) 20.6 ± 3.0 (14.4–26.8) 26.0 ± 3.1 (19.7–32.2)**
Thoracoabdominal (N = 38) 22.1 ± 2.0 (18.1–26.1) 26.3 ± 2.7 (20.8–31.8)***

* p < 0.47 (pairing: r = 0.85, p < 0.0001); ** p < 0.017 (pairing: r = 0.76, p < 0.0001); *** p < 0.039 (pairing: r = 0.69,
p < 0.0001).

Table 4. Mild Pain with Activity

Pain Condition VAS: Mean ± SEM (CI 95%) NRS-11: Mean ± SEM (CI 95%)

Obstetrical (N = 16) 18.8 ± 3.1 (12.1–25.5) 21.9 ± 3.6 (14.3–29.5)* ns


Hip arthroplasty (N = 24) 21.7 ± 4.3 (12.8–30.5) 29.8 ± 3.5 (22.6–37.0)**
Thoracoabdominal (N = 31) 28.1 ± 2.5 (23.1–33.1) 33.9 ± 2.3 (29.1–38.6)***

* p < 0.53 (r = 052, p < 0.02); ** p < 0.024 (pairing: r = 0.64, p < 0.0003); *** p < 0.049 (pairing: r = 0.30, p < 0.05).

Table 5. Severe Pain with Activity

Pain Condition VAS: Mean ± SEM (CI 95%) NRS-11: Mean ± SEM (CI 95%)

Obstetrical (N = 12) 79.4 ± 4.3 (69.9–88.9) 75.8 ± 7.4 (59.5–92.2)* ns


Hip arthroplasty (N = 9) 58.8 ± 7.4 (41.7–75.8) 68.3 ± 9.4 (46.6–90.1)** ns
Thoracoabdominal (N = 27) 84.9 ± 2.8 (79.2–90.6) 90.7 ± 1.9 (86.8–94.7)*** ns

* p < 0.62 (pairing: r = 0.39, p < 0.11); ** p < 0.40 (pairing: r = 0.22, p < 0.29); *** p < 0.098 (pairing: r = 0.30,
p < 0.061).

DISCUSSION importance of pain management provides to patients,


The “Fifth Vital Sign” Initiative began in the United many have struggled with how to best collect and utilize
States in 1998 when the Veterans Administration this data. Pain measurement, unlike other vital signs, is
announced its innovative policy to incorporate pain vulnerable to bias on the part of both the patient and
assessment into routine vital sign monitoring. The prac- the caregiver. The patient self-report of pain is inher-
tice has since spread nationwide. While few would ques- ently subjective. However, healthcare workers often
tion the added value that heightened awareness of the underestimate patients’ pain for subjective reasons as
A Ratio Measure? • 313

100
90
80
70
y = 0.7747x + 1.6164
60
R2 = 0.8574
VAS

50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100

NRS-11 Figure 1. Static Obstetrical Pain.

100
90
80
y = 0.8408x + 3.8958
70
R2 = 0.7939
60
VAS

50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100

NRS-11 Figure 2. Dynamic Obstetrical Pain.

100
y = 0.6192x + 8.6588
90
R2 = 0.5774
80
70
60
VAS

50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100

NRS-11 Figure 3. Static Thoracoabdominal Pain.

well. A recent study by Marquié et al. detected a “mis- self-report are commonly assessed using the NRS-11.
calibration” in the physician ratings for their patients The NRS-11 is easily administered without the need
and suggested such factors as physician gender, patient for any additional devices or writing materials. This
gender, and “obviousness of the cause of pain” con- permits improved compliance when compared to
tribute to the discrepancy.6 more complex testing procedures. Yet if treatment
Pain is ideally measured using age appropriate self- decisions are to be based upon the results of assessment,
report. Adolescents and adults who are not cognitively the tools employed should be reliable. Moreover, if
impaired or otherwise unable to provide a verbal the tools are being used to assess the efficacy of novel
314 • hartrick et al.

100
y = 0.8316x + 5.7039
90
R2 = 0.7264
80
70
60
VAS

50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100
Figure 4. Dynamic Thoracoabdominal
NRS-11 Pain.

100
90
80 y = 0.6899x + 8.0519
R2 = 0.3962
70
60
VAS

50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100

NRS-11 Figure 5. Static Orthopedic Pain.

100
90
y = 0.6641x + 4.4489
80
R2 = 0.4733
70
60
VAS

50
40
30
20
10
0
0 10 20 30 40 50 60 70 80 90 100

NRS-11 Figure 6. Dynamic Orthopedic Pain.

treatments or algorithms, additional criteria must be information helps to assure that the treatments provided
satisfied. are affecting meaningful change in the primary outcome
Pain measurement scales can have nominal, ordinal, variable, pain, as well as the direction of change, when
interval or ratio characteristics. Nominal (yes or no) the patient’s report moves from one category to another.
scales have little discriminatory value and are problem- Interval scales provide nominal and ordinal informa-
atic when attempting to titrate pain medications to tion, as well as information regarding the degree of
incremental sequential improvement. Ordinal (categor- change affected. Ratio scales also provide nominal,
ical) scales (eg, VRS-4) provide nominal information as ordinal, and interval information. However, the grada-
well as a rank ordering of pain states. This additional tions between discrete measurements in a ratio scale
A Ratio Measure? • 315

have consistent mathematical relationships. Conse- ceral pain, as experienced during uterine contraction,
quently, ratio scales permit the user to perform calcula- may present a different set of psychophysical conditions.
tions such as percent improvement in pain scores. This Strigo et al suggested that visceral pain is more unpleas-
ability, while desirable clinically, is crucial for proper ant, diffuse and variable than cutaneous pain of com-
conduct of clinical trials. Whether the NRS-11 should parable intensities as measured by VAS.7
be considered an interval scale or a ratio scale relates The disparity noted between NRS-11 and the ratio
directly to the circumstances under which it can be measure, VAS, likely reflects differing psychometric
properly used. properties. Clinically, this difference is often seen anec-
In this study the NRS-11 and the VAS, in general, dotally when patients inadvertently place a number on
demonstrated effective pairing, which implies that both the VAS line instead of a vertical mark. Frequently the
measures trend together. Thus the widespread use of the number written is much higher than its corresponding
NRS-11 in clinical situations seems justified. The sim- position on the line might suggest. Similarly, a “moder-
plicity of application of the NRS-11encourages frequent ate” degree of pain in the categorical rating scale is not
assessment of pain, and therefore remains a valuable necessarily appropriately placed at the center of the
tool when used within the context of an individual visual analog scale. Experimentally, when increasingly
patient’s goals as a means of assessing response to treat- intense stimuli are applied, after a level of moderate
ment. The pragmatic need for determining a threshold discomfort is reached, relatively small incremental
value for increasing vigilance presents another chal- increases in stimulation result in exponential (not linear)
lenge. Frequently the NRS-11 score of “4” is given enhancement of pain report.8 This visual-verbal
special significance in this regard. The results for mod- dichotomy may be an expression of an underlying neu-
erate pain (see Tables 1 and 2) support this notion. The rophysiological correlate to neuronal threshold and
absolute NRS-11 values may, however, be unreliable pain tolerance.
when used to perform mathematical computations. Objectively dissecting the subjective complaint of
Observed NRS-11 values were significantly higher pain is a formidable task. Williams et al. examined the
than the respective VAS scores under most circum- differences in patients’ use of visual analog and numeric
stances studied. This finding agrees with previous rating scales in detail.5 They found a large number of
reports for both experimental3 and clinical4 pain mea- factors that patients take into consideration when
surement. Yet, if the NRS-11 displayed similar ratio formulating their responses. These factors may well
properties to the VAS, comparisons between the two provide the patient, especially when numeric rating
scales would still be expected to result in a linear rela- scales are used, with the opportunity to convey global
tionship with a constant slope, even if that slope varied satisfaction and other information embedded within
from unity. This expected consistency was not uni- their pain response. Consequently, the psychometric
formly observed. Agreement was observed in patients properties that cause the NRS-11 to deviate from lin-
having thoracic or abdominal incisions during physical earity may make it unsuitable for research purposes,
exacerbation induced by cough, where VAS scores were including clinical trials, except in specific circumstances
approximately 83% of the respective NSR-11 scores. where this scale has previously demonstrated ratio
This finding was not solely a function of stimulus inten- characteristics.
sity, as it was not observed in pooled data sorted for
severity.
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