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A systematic review of the pain scales in adults. Which to use?

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A systematic review of the pain scales in adults: Which to use?
Article in American Journal of Emergency Medicine · January 2018
DOI: 10.1016/j.ajem.2018.01.008
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American Journal of Emergency Medicine 36 (2018) 707–714
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage: www.elsevier.com/locate/ajem
Review
A systematic review of the pain scales in adults: Which to use?
Ozgur Karcioglu a,⁎, Hakan Topacoglu b, Ozgur Dikme a, Ozlem Dikme c
a
b
c
University of Health Sciences, Istanbul Training and Research Hospital, Emergency Department, Fatih, Istanbul, Turkey
Duzce University, School of Medicine, Emergency Department, Duzce, Turkey
Koc University, School of Medicine, Emergency Department, Istanbul, Turkey
a r t i c l e
i n f o
Article history:
Received 26 December 2017
Accepted 3 January 2018
Keywords:
Acute pain
Pain score
Pain scale
Pain intensity
Pain management
Emergency department
a b s t r a c t
Objective: The study analysed the Visual Analogue Scale (VAS), the Verbal Rating Scale (VRS) and the Numerical
Rating Scale (NRS) to determine: 1. Were the compliance and usability different among scales? 2. Were any of the
scales superior over the other(s) for clinical use?
Methods: A systematic review of currently published studies was performed following standard guidelines. Online database searches were performed for clinical trials published before November 2017, on the comparison
of the pain scores in adults and preferences of the specific patient groups. A literature search via electronic databases was carried out for the last fifteen years on English Language papers. The search terms initially included
pain rating scales, pain measurement, pain intensity, VAS, VRS, and NRS. Papers were examined for methodological soundness before being included. Data were independently extracted by two blinded reviewers. Studies were
also assessed for bias using the Cochrane criteria.
Results: The initial data search yielded 872 potentially relevant studies; of these, 853 were excluded for some reason. The main reason for exclusion (33.7%) was that irrelevance to comparison of pain scales and scores, followed
by pediatric studies (32.1%). Finally, 19 underwent full-text review, and were analysed for the study purposes.
Studies were of moderate (n = 12, 63%) to low (n = 7, 37%) quality.
Conclusions: All three scales are valid, reliable and appropriate for use in clinical practice, although the VAS is
more difficulties than the others. For general purposes the NRS has good sensitivity and generates data that
can be analysed for audit purposes.
© 2018 Elsevier Inc. All rights reserved.
1. Pain in the emergency department
Acute pain is one of the most common chief complaints reported by
most patients admitted to the ED, while its perception and expression
have great variations between countries [1]. The definition of pain by International Association for the Study of Pain (IASP) as ‘an unpleasant
sensory and emotional experience associated with actual or potential
tissue damage, or described in terms of such damage’ is accepted worldwide [2].
Subjective and multidimensional nature of the pain experience render
pain assessment really challenging. In the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines, implementation of
this standard in clinical practice comprised the addition of pain as the
“fifth” vital sign to be noted in the context of initial assessment; the use
of pain intensity ratings; and posting of a statement on pain management
in all patient care areas. Supplemented with regular pain reassessments,
the schedule of pain reassessment should be driven by patients' pain severity [3].
⁎ Corresponding author at: Dept. of Emergency Medicine, Univ. of Health Sciences,
Istanbul Education and Research Hospital, PK 34098, Fatih, Istanbul, Turkey.
E-mail address: okarcioglu@gmail.com (O. Karcioglu).
https://doi.org/10.1016/j.ajem.2018.01.008
0735-6757/© 2018 Elsevier Inc. All rights reserved.
Pain estimations need to be elicited and recorded to highlight both
the presence of pain and the efficacy of pain treatment. The patients'
perception of pain should be documented during the initial assessment
of a patient. Current evidence provides a general recommendation that
pain needs to be evaluated and managed within 20–25 min of initial
healthcare provider assessment in the ED [4]. Pain treatment should
be targeted to a goal of reducing the pain score (e.g., by 50%, below 4/
10, or referred to as mild/moderate or severe) rather than a specific analgesic dose [5].
2. Pain scores and documentation of pain
The patient's self-report is the most accurate and reliable evidence of
the existence of pain and its intensity, and this holds true for patients of
all ages, regardless of communication or cognitive deficits [6].
In the absence of objective measures, the clinician must depend on
the patient to supply key information on the localization, quality and severity of the pain. Although physicians commonly question the reported
severity and rely on their own estimates, the value of the patients' description of the location and nature of the discomfort has been proved
on the theoretical basis and routine practice [7].
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O. Karcioglu et al. / American Journal of Emergency Medicine 36 (2018) 707–714
Pain scores have gained acceptance as the most accurate and reliable
measure of assessing a patient's pain and response to pain treatment [5].
Scales devised to estimate and/or express the patient's pain can be evaluated in two groups: Unidimensional and multidimensional measures.
It should be noted that unidimensional scales measure only intensity,
they cannot be viewed as a comprehensive pain assessment. Comprehensive pain assessment is expected to encompass both the unidimensional measurement of pain intensity and the multidimensional
evaluation of the pain perception. The unidimensional pain intensity
scales commonly used bedsides are:
• Numeric Rating Scale (NRS),
• Visual Analog Scale (VAS),
• Verbal Rating/Descriptor Scale (VRS/VDS).
• 4–6 = moderate pain
• 7–10 = severe pain
NRS can be used with most children older than 8 years of age, and
behavioral observation scales are required for those unable to provide
a self-report [15]. For patients with cancer-related pain, the NRS is the
most frequently used instrument to measure pain intensity [16]. Goulet
et al. examined the agreement and correlation of electronic medical
record-based ratings of NRS and self-administered NRS in 1643 adult
patients [17]. The correlation was high, but the mean electronic medical
record-based NRS score was significantly lower than the survey score
(1.72 vs. 2.79; p b 0.0001).
2.3. B.3
2.1. B.1
The VAS is the most widely used tool for estimating both severities of
pain and to judge the extent of pain relief [8]. Healthcare worker asks
the patient to select a point on a line drawn between two ends to express how intense he/she perceives pain (Fig. 1). The VAS is a continuous scale comprised of a horizontal (HVAS) or vertical (VVAS) line,
usually 100 mm long, anchored by two verbal descriptors (i.e., “no
pain” and “worst imaginable pain”) [9, 10]. Patients are asked to rate
“current” pain intensity or pain intensity “in the last 24 h”.
The VAS is an easy-to-use instrument which does not warrant
using a sophisticated device. It is also highly sensitive in detecting treatment effects, and its results can be analysed by parametric tests [11]. Minimal translation difficulties have led to an
unknown number of cross-cultural adaptations [10]. Although
this tool is suitable for use with older children and adults, the
need for a marking and for being able to visualize and mark
the line, can make the VAS impractical to use in the emergency
situation. On the other hand, most experts believe that the VAS
offers little practical advantage over verbal reports in the clinical
practice [5].
Verbal Pain Scores (VPSs), Verbal Rating Scales (VRS) or Verbal Descriptor Scales: These tools may discern those patients who are truly
in pain but who may not express their discomfort, as well as influence
the physician to inquire about the patient's pain.
VRS consist of a number of statements describing increasing pain
intensities (Fig. 1). Patients are told to choose the word which best
describes their pain intensity. The number of descriptors used has
ranged from four (none, mild, moderate, severe) to 15 [18]. For patients who have limited literacy or cognitive impairment, use of
these scales may be difficult, and they do not provide the number
of choices available with the VAS or NRS, thus potentially limiting
precision [19].
This article reviews the current literature to provide systematic data
regarding the results from comparative studies on unidimensional assessment of pain intensity using the NRS, VRS, or VAS. The following points
were investigated to determine evidence-based recommendations:
- Were the compliance and usability different among scales?
- Were any of the scales superior over the other(s) for clinical use?
3. Methods
2.2. B.2
The numeric rating scale (NRS) is a single 11-point numeric scale
broadly validated across myriad patient types. Data obtained via NRS
are easily documented, intuitively interpretable, and meet regulatory
requirements for pain assessment and documentation [12]. To date,
findings demonstrated that even in the chaotic prehospital phase
most acute care patients allow evaluation via a simple “zero-to-10
scale” or NRS reliably, respecting their pain levels [13]. Like the pain
VAS, minimal language translation difficulties support the use of the
NRS across cultures and languages [14].
Evidence indicated that patients really want to give a pain number,
rather than simply relate whether they want analgesia. Strengths of
this measure over the pain VAS are the ability to be administered both
verbally (therefore by telephone) and in writing, as well as its simplicity
of scoring. However, similar to the pain VAS, the pain NRS evaluates
only 1 component of the pain experience, pain intensity, and therefore
does not capture the complexity and idiosyncratic nature of the pain experience or improvements due to symptom fluctuations [10].
NRS is a commonly used tool necessitating the patient rate his pain
on a scale from 0 to 10, with 0 indicating no pain and 10 reflecting the
worst possible pain (Fig. 2). NRS are often conducted as a scale from 1
to 10 which does not give the patient a solution to indicate no pain at
all. It can be used with children who are able to understand numbers.
The pain scores are interpreted as:
• 0 = no pain
• 1–3 = mild pain
A systematic review of currently published studies was performed
following standard guidelines. Online database searches were performed for randomized controlled trials published before November
2017, on the comparison of the pain scores in adults and preferences
of the specific patient groups. A literature search via the Cochrane Central Register of Controlled Trials, PubMed/Medline, Clinical Key,
EMBASE, the Cumulative Index to Nursing and Allied Health Literature
(CINAHL), and BIOSIS was carried out for the last fifteen years on English
Language papers. Published studies evaluating the patients' preferences
and usability of the pain intensity scales were targeted. The reference
lists of retrieved articles were used to generate more papers and search
terms. Data were independently extracted by two blinded reviewers.
The discrepancies, on the other hand, were resolved by the primary author. The research protocol to answer these questions was registered in
PROSPERO, the International Prospective Register of Systematic Reviews (registration number is: CRD42017080974).
3.1. Search methodology
A comprehensive literature search was carried out using the following strategy:
Online searches were performed using the following search keywords and terms: (‘pain assessment’ OR ‘pain intensity’ OR ‘pain score’
OR ‘pain comparison’ OR ‘pain scale’ OR ‘acute pain’ OR ‘pain rating’)
AND (‘emergency’ AND ‘acute’ AND ‘score’). The search was limited to
human studies (clinical trials) conducted on adults and published in
English.
O. Karcioglu et al. / American Journal of Emergency Medicine 36 (2018) 707–714
709
A
B
C
D
Fig. 1. A. Visual Analog Scale (VAS). B. The Numerical Rating Scale (NRS) C. Verbal Rating Scale (VRS) or Verbal DescriptorScale (VRS). D. FACES Pain Rating Scale.
3.2. Study selection, data screening and critical appraisal
The study included all comparative trials conducted to assess the use
of commonly used scales measuring acute pain intensity and to compare them with each other on specific patient groups, exclusively in
adults. All RCTs of any duration that investigated pain scores in comparison to each other were identified. All potentially eligible papers were
critically appraised, with the emphasis on evidence from randomized
trials and international guidelines rather than smaller studies, case series and case reports. Reference lists of relevant systematic reviews
and all included studies were checked to identify additional eligible articles. Conference abstracts and proceedings were not deemed eligible
for inclusion in the review. Citation titles and abstracts were independently screened and assessed regarding the methodological quality by
two reviewers (H.T. and O.D.). Any disagreements between the two reviewers were then resolved by consensus or in consultation with a third
reviewer (O.K.) if needed.
3.3. Quality assessment and risk of bias
Eligible clinical studies were rated regarding the quality of evidence
as per GRADE guidelines and assigned to one of four groups: High (A),
moderate (B), low (C) and very low (D) quality [20].
Studies that met the inclusion criteria for the review were assessed
for bias using the risk of bias criteria developed by Cochrane's EPOC
group [21] which is based upon Cochrane's Risk of Bias Tool [22]. Studies
were assessed with regard to selection bias, performance bias, detection
bias, attrition bias, reporting bias, and other sources of bias. Studies
were rated as “low risk of bias (L)”, “high risk of bias (H),” or “unclear
risk of bias (U)” on a general impression after evaluating all criteria
(Table 1).
4. Results
The initial electronic data search yielded a total of 872 potentially
relevant studies; of these, 853 were excluded for some reason, and finally 19 trials fully met the selection criteria based on inclusion of information regarding comparative data on the pain scales, and specific
populations' preferences on the scales (Fig. 2). The main reason for exclusion (33.7%, 288/853) was that irrelevance to comparison of pain
scales and scores, followed by pediatric studies (32.1%, 274/853).
Data collected for the review of the 19 clinical studies included in the
analysis of the pain scales used in the acute setting were tabulated and
summarized (Table 1). With respect to quality of evidence per GRADE
guidelines, there were 12 (63%) moderate quality (B) and 7 (37%) low
quality (C) evidence derived from the studies.
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O. Karcioglu et al. / American Journal of Emergency Medicine 36 (2018) 707–714
Fig. 2. Flow diagram of study selection for systematic review to compare the clinical use of three commonly used pain rating scales, namely the Visual Analogue Scale (VAS), the Verbal
Rating Scale (VRS) and the Numerical Rating Scale (NRS).
5. Discussion
In order to use pain-rating scales well clinicians need to appreciate
the potential for error within the tools, and the potential they have to
provide the required information. Interpretation of the data from a
pain-rating scale is not as straightforward as it might first appear.
Leigheb M, et al. pointed out that there is substantial discordance between NRS and VAS scores which is suggestive of a need for clinical
judgment to be incorporated into assessment of actual pain intensity
and concluded that leaning on pain scale data alone is not a comprehensive approach [23].
In the present study, most of the studies in the analysis indicated a
good correlation between VAS, VRS/VDS and NRS, although some pointed out there is a discrepancy in some situations. One study reported a
moderate agreement between calculated percentage pain reduction
from a VAS or NRS and the difference could range up to 30%.
VDS and NRS were also found to have strong correlation and can be
used in practice depending on the preference. The elderly were found to
prefer VDS to express their pain intensity [24, 25] including those with
mild to moderate cognitive impairment. Accordingly, Ware et al. reported that NRS was the preferred scale in the cognitively intact group while
FPS-R was the preferred scale in the cognitively impaired group [26].
A number of studies cited a considerable difficulty in practical use of
VAS, especially in the elderly and populations with disadvantages. For
example, Yazici et al. noted that the NRS, TPS, FPS, and VDS were appropriate pain rating scales for the participants in this study, and that the
VAS should be used in combination with one of these scales [27].
One of the first reviews on comparison of the three pain scales (VAS,
VRS, and NRS) were published by Williamson and Hoggart in 2005 and
they reported that all three scales were valid, reliable and appropriate
for use, although the VAS had more practical difficulties than the other
two scales [28]. They stressed that for general purposes the NRS has
good sensitivity and produces data that can be analysed for audit purposes. Likewise, Hjermstad MJ, et al. performed a systematic review of
studies to culminate data on the use and performance of unidimensional pain scales [29]. They reported that when compared with the VAS and
VRS, NRSs had better compliance in 15 of 19 studies reporting this, and
were the recommended tool in 11 studies. Overall, NRS and VAS scores
O. Karcioglu et al. / American Journal of Emergency Medicine 36 (2018) 707–714
711
Table 1
Main characteristics of the outstanding human studies that were explained and reviewed in the present study.
Investigator(s), Sample size and
title and
population
date, Ref. #
Quality of Risk
Objectives
evidence of
(GRADE)⁎ bias⁎⁎
Findings
McLean, et al.
2004. [13]
1227
prehospital
patients N13 yrs
old
C
H
To determine the feasibility of
prehospital pain measurement among
patients 13 yrs of age or older using a
VRS and NRS.
Leigheb M,
et al. 2017.
[23]
137 adult ED
patients
B
H
Pereira et al.
2015. [24]
C
101
institutionalized
elderly
U
To evaluate the intensity and location
of pain experienced by patients in the
ED, the time to analgesic therapy in
the ED, and the patient's satisfaction
so to identify potential interventions
to improve management
Correlating two unidimensional scales
for measurement of self-reported pain
intensity for elderly and identifying a
preference for one of the scales.
Herr KA, et al.
2004. [25]
B
175
86 younger (age
25-55) and 89
older (N65)
adults
U
To determine: (1) the psychometric
properties and utility of 5 types of
commonly used pain rating
scaleswhen used with younger and
older adults, (2) factors related to
failure to successfully use a pain rating
scale, (3) pain rating scale preference,
and (4) factors impacting scale
preference.
Ware LJ, et al.
2006. [26]
68 cognitively
impaired
minority
sample
C
H
To determine the reliability and
validity of selected pain intensity
scales including the FPS-R, VDS, NRS,
and Iowa Pain Thermometer (IPT)
with a cognitively impaired minority
sample.
Yazici et al.
2014. [27]
621
postoperative
adult patients
B
L
To determine patient pain scale
preferences and compare the level of
agreement among pain scales
commonly used during postoperative
pain assessment.
Bahreini M,
et al. 2015.
[30]
150 adult ED
patients
C
H
To assess the agreement between
VAS, Color Analog Scale (CAS), and
NRS in the emergency setting.
Aziato L, et al.
2015. [31]
150
post-operative
patients
B
L
To select, develop, and validate
context-appropriate unidimensional
pain scales for pain assessment among
adult post-operative patients.
An 11-point scale is preferable for
prehospital practice and could also be
useful for research applications.
Pain assessment using a VRS and NRS
can be implemented with minimal
paramedic training.
The discrepancy between NRS and
The magnitude of NRS pain
measurements were higher than VAS VAS scores suggests that painintensity
cannot be determined accurately
measurements.
according topainscaledata alone but
should also incorporate clinical
judgment.
Pain measurements among
There were moderate to strong,
institutionalized elderly can be made
positive and statistically significant
by NRS and VDS; however, the
associations between the scores of
NRS and VDS: overall assessment (r = preferred scale for the elderly was the
VDS, regardless of gender.
0.75), the rest (r = 0.92) and
movement (r = 0.87). Higher mean
scores were associated in NRS to
higher categories of pain intensity in
VDS.
The association between the mean
scores of NRS with the categories of
VDS was significant, indicating
convergent validity and a similar
metric between the scales.
Although all 5 of the pain intensity
All 5 pain scales (VAS, FPS, VDS,
rating scales were psychometrically
21-point NRS, 11-point VNS) were
sound when used with either age
effective in discriminating different
levels of pain sensation; however the group, failures, internal consistency
reliability, construct validity, scale
VDS was most sensitive and reliable.
Failure rates for pain scale completion sensitivity, and preference suggest
that the VDS is the scale of choice for
were minimal, except for the VAS.
The scale most preferred to represent assessing pain intensity among older
adults, including those with mild to
pain intensity in both cohorts of
subjects was the NRS, followed by the moderate cognitive impairment.
VDS.
Concurrent validity was supported
In terms of pain scale preference, the
with correlations ranging from 0.56 to NRS (33%) was the preferred scale in
the cognitively intact group and the
0.90. The lowest correlations were
FPS-R (54%) was the preferred scale in
found between the FPS-R and the
other scales, suggesting that the FPS-R the cognitively impaired group.
may be measuring a broader construct African-Americans and Hispanics preferred the FPS-R. Severely,
incorporating pain
moderately, and mildly impaired participants also preferred the FPS-R.
The NRS, TPS, FPS, and VDS were
Patient preference for pain scales
were as follows: 97.4% FPS, 88.6% NRS, appropriate pain rating scales for the
participants in this study, and that the
84.1% VDS, 78.1% TPS, 60.1% SFMPQ,
37.0% BPI, 11.4% VAS, and 10.5% MPQ. VAS should be used in combination
Education was an important factor in with one of these scales.
the preferences for all scales (p b
.000). The level of pain determined by
the VAS did not correlate with the
level of pain identified by the NRS,
TPS, FPS, and VDS (p b .05).
Spearman correlation coefficients
The three pain scales were strongly
between NRS and CAS, NRS and VAS,
correlated at all time periods. The
and CAS and VAS were 0.95, 0.94, and
findings suggest that NRS, CAS, and
0.94, respectively (p b 0.001). On a
VAS can be interchangeably applied
scale of 0 to 10, the 95% limits of
for acute pain measurement in adult
agreement between the paired NRS
patients.
and VAS, VAS and CAS, and CAS and
NRS ranged from −2.0 to 2.6, from
−2.7 to 2.0, and from −2.1 to 2.0,
respectively.
Using a valid tool for pain assessment
(Color-Circle Pain Scale–[CCPS]) had
higher scale preference than NRS and gives the clinician an objective
criterion for pain management.
FPS. Convergent validity was very
Due to the subjective nature of pain,
good and significant (0.70 –0.75).
consideration of socio-cultural factors
Inter-rater reliability was high
(0.923–0.928) and all the scales were for the particular context ensures that
Notes, conclusions
Prehospital pain assessment using a
VRS and NRS was feasible in this
patient population. Further studies are
needed to confirm this in other
settings.
(continued on next page)
712
O. Karcioglu et al. / American Journal of Emergency Medicine 36 (2018) 707–714
Table 1 (continued)
Investigator(s), Sample size and
population
title and
date, Ref. #
Quality of Risk
Objectives
evidence of
(GRADE)⁎ bias⁎⁎
Göransson KE,
et al. 2015.
[32].
217 adult ED
patients
B
L
To compare correlations between
values on the VAS and the NRS in
patients in the ED and to assess the
patients' preference of scale
Edelen MO,
et al. 2010.
[33].
1960 elderly
residents from
71 nursing
homes
B
L
To compare VDS and NRS using item
response theory (IRT) methods to
identify the correspondencebetween
the scales response options by
estimating item parameters for these
and five additional pain items.
Pratici E, et al.
2017. [34]
97 women in
labor
C
H
To determine the level of agreement
between calculated percentage pain
reduction, derived from VAS or NRS,
and patient-reported % pain reduction
in patients having epidural analgesia.
Gagliese L,
et al. 2005.
[35]
504
postoperative
adults.
B
L
To compare the feasibility and validity
of the NRS, VDS, and VAS (horizontal
and vertical line orientation) for the
assessment of pain intensity in
younger and older surgical patients.
Bijur PE, et al.
2003. [36]
108 adult ED
patients
C
H
Herr K, et al.
2007. [37]
97 adults with
chronic joint
pain
B
L
To assess the comparability of the NRS
and VAS as measures of acute pain,
and to identify the minimum clinically
significant difference in pain that
could be detected on the NRS.
To compare the sensitivity and utility
of the new IPT with four other pain
scales: NRS, VNS, FPS, and VAS, using a
naturally occurring pain condition and
a controlled treatment with
rheumatology patients.
Taylor LJ, et al.
2005. [38]
66 cognitively
impaired
elderly
B
L
To determine the reliability and
validity of selected painintensity
scales such as the FPS, VDS, NRS, and
the Iowa Pain Thermometer (IPT) to
assess pain in cognitively impaired
older adults.
Li L, et al. 2007. 173
[39]
postoperative
adults.
B
U
To determine the psychometric
properties and applicability of four
pain scales in Chinese postoperative
adults.
Li L, et al. 2009. 180
[40]
postoperative
elderly.
B
U
To evaluate the reliability and validity
of the FPS-R, NRS, and the Iowa Pain
Thermometer (IPT) for pain
assessment in Chinese elders who
have had surgery.
Findings
Notes, conclusions
sensitive to change in the intensity or
level of pain experienced before and
after analgesia.
The pain scores generated from the
NRS and the VAS were found to
strongly correlate (mean difference,
0.41). Most patients found the NRS
easier to use than the VAS (61% and
22%, respectively; p b .001).
The sample reported moderate
amounts of pain on average.
Examination of the IRT location
parameters for the pain intensity
items indicated the following
approximate correspondence: VDS
mild ≈ NRS 1–4, VDS moderate ≈
NRS 5–7, VDS severe ≈ NRS 8–9, and
VDS very severe, horrible ≈ NRS 10.
There was moderate agreement
between calculated percentage pain
reduction from a VAS or NRS and
patient-reported % pain reduction in
epidural analgesia. The difference
could range up to 30%.
Psychometric analyses suggested that
the NRS was the preferred pain
intensity scale. The VDS also had a
favourable profile with low error rates
and good face, convergent and
criterion validity.
NRS scores were strongly correlated
to VAS scores at all time periods (r =
0.94). The slope of the regression line
was 1.01 and the y-intercept was
−0.34.
The IPT showed the lowest failure rate
of all pain scales evaluated. Other
scale failure rates were relatively low
except for the VNS and the VAS. No
significant difference was noted in
scale failure by age, gender or
education level, but cognitive
impairment was significantly related
to failure on the VAS and the NRS.
Concurrent validity of the VDS, NRS,
and IPT was supported with Spearman
rank correlation coefficients ranging
from .78 to .86 in the cognitively
impaired group. The FPS, however,
demonstrated weak correlations with
other scaleswhen used with the
impaired group, ranging from.48 to
.53. In the cognitively intact group,
strong correlations ranging from.96 to
.97 were found among all of thescales.
All four pain intensity scales had good
reliability and validity when used
with Chinese adults. The ICCs of the
four scales across current, worst, least,
and average pain on each
postoperative day were consistently
high (0.673-0.825), and all scales at
each rating were strongly correlated
(r = 0.71–0.99).
Both the VDS and the FPS-R had low
error rates. Nearly half of the
participants (48.1%) preferred the
FPS-R, followed by the NRS (24.4%),
the VDS (23.1%), and the VAS (4.4%).
The intraclass correlation coefficients
across current, worst, and least pain
on each postoperative day were
consistently high (0.949 to 0.965),
and all scales at each rating were
strongly correlated (r = 0.833 to
the appropriate tool is used.
A majority reported that the NRS
reflected/described their pain better
than the VAS (53% and 26%,
respectively; p b .01). NRS might be
more appropriate to use in the ED
Either scale (VDS and NRS) can be
used in practice depending on the
preference of the clinician and
respondent.
The concordance correlation
coefficient with patient-reported
percentage pain reduction was 0.76
and 0.77 for the VAS and NRS,
respectively.
Difficulties with VAS use among the
elderly were identified, including high
rates of unscorable data and low face
validity
The verbally administered NRS can be
substituted for the VAS in acute pain
measurement.
All five pain scales were sensitive in
detecting changes in pain intensity
pre and post joint injection. All
correlations between the scales were
strong and significant; however, the
intercorrelations for the older cohort
were weaker. The scale most
preferred in both cohorts of patients
was the IPT, followed by the FPS.
When asked about scale preference,
both the cognitively impaired and the
intact groups preferred the IPT and
the VDS. This study revealed that
cognitive impairment did not inhibit
participants' ability to use a variety of
pain intensity scales, but the stability
issue must be considered.
Although all four scales can be options
for Chinese adults to report pain
intensity, the FPS-R appears to be the
best one. No significant differences
were noted in terms of gender, age,
and educational level.
Although all three scales show good
reliability, validity, and sensitivity for
assessing postoperative pain intensity
in Chinese elders, the IPT appears to
be a better choice based on patient
preference.
O. Karcioglu et al. / American Journal of Emergency Medicine 36 (2018) 707–714
713
Table 1 (continued)
Investigator(s), Sample size and
population
title and
date, Ref. #
Quality of Risk
Objectives
evidence of
(GRADE)⁎ bias⁎⁎
Findings
Ismail AK, et al. 133 ambulance
2015. [41]
patients
B
H
To evaluate the agreement between
verbal NRS and VAS in measuring
acute pain in prehospital setting and
to identify the preference among
paramedics and patients.
35 women with
caesarian
section
C
H
To evaluate correlation of pain scores
obtained on the VAS, the Box
Numerical Scale (BNS) and Verbal
Rating Scale (VRS) was studied.
Akinpelu AO,
et al. 2002.
[42]
Notes, conclusions
0.962). The scale mostly preferred was
the IPT (54.7%), followed by the FPS-R
(28.5%) and the NRS (15.6%). No
significant differences were noted in
participant preference by age and
cognitive status, but preference for
the IPT and the FPS-R were
significantly related to gender and
education level.
VAS performs as well as VNRS in
assessing acute pain in prehospital
setting. VAS and VNRS must not be
used interchangeably to assess acute
pain; either method should be used
consistently.
There was a strong correlation
between VNRS and VAS at the scene (r
= 0.865; p b 0.001), as well as on
arrival at the hospital (r = 0.933; p b
0.001). Kappa values and analysis
indicates good agreement between
both scales for measuring acute pain.
The three pain rating scales measure
There was no significant difference
the same construct, and could be used
between the pain scores obtained on
for pain measurement in obstetrically
the 3 pain rating scales. Significant
related conditions in this
correlations existed between pain
scores obtained on the VAS and VRS (r environment.
= 0.48, p = 0.003); VAS and BNS (r =
0.74, p = 0.000); BNS and VRS (r =
0.74, p = 0.000).
Abbreviations: The Faces pain scale (FPS), visual analog scale (VAS), numeric rating scale (NRS), verbal descriptor scale (VDS), thermometer pain scale (TPS), McGill Pain Questionnaire
(MPQ), Short-form McGill Pain Questionnaire (SFMPQ), and Brief Pain Inventory (BPI).
(GRADE system) (GGHO)
Grade A: High level of evidence (The true effect lies close to our estimate of the effect.)
Grade B: Moderate level of evidence (The true effect is likely to be close to our estimate of the effect, but there is a possibility that it is substantially different.)
Grade C: Low level of evidence (The true effect may be substantially different from our estimate of the effect.)
Grade D: Very low level of evidence (Our estimate of the effect is just a guess, and it is very likely that the true effect is substantially different from our estimate of the effect.)
⁎ Quality of evidence and definitions.
⁎⁎ Risk of bias: Studies were assessed for bias using the risk of bias criteria developed by Cochrane [21] which is based upon Cochrane's Risk of Bias Tool [22]. Studies were assessed with
regard to selection bias, performance bias, detection bias, attrition bias, reporting bias, and other sources of bias. Studies were rated as “low risk of bias (L)”, “high risk of bias (H),” or “unclear risk of bias (U)” on a general impression after evaluating all criteria.
corresponded, with a few exceptions of systematically higher VAS
scores.
Limitations of this article are similar to all review articles: the dependence on previously published research and availability of references.
There is also a lack of published Level I and Level II studies specific to
this topic in the world's literature.
6. Summary and conclusion
“Pain cannot be treated if it cannot be assessed”. The most important principle is that clinicians should somehow assess their patients'
pain levels, no matter which method or scale one uses to accomplish
this task. Special scales developed and validated for patients with
difficulties in communication should be made available, and ED physicians should have a plan for assessing pain in different case
scenarios.
The bulk of evidence published to date have demonstrated a gap for
improvement to indicate pluses and minuses of each rating scale used
for acute pain. Reports focus that although all pain-rating scales are
valid, reliable and appropriate for use in emergency setting, the VAS
has somehow appeared more difficult than the others. Elderly patients
and those with cognitive impairment, communication problems and
minorities have found verbal descriptor or rating scales more practical
than others in expression of their pain intensity. Ongoing research in
the area of ED patient pain management along with usability of each
tool should be conducted on specific patient groups and populations before firm conclusions could be drawn.
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