Lack of interchangeability between visual analogue and verbal rating pain scales: a cross sectional description of pain etiology groups

Abstract

Background: Rating scales like the visual analogue scale, VAS, and the verbal rating scale, VRS, are often used for pain assessments both in clinical work and in research, despite the lack of a gold standard. Interchangeability of recorded pain intensity captured in the two scales has been discussed earlier, but not in conjunction with taking the influence of pain etiology into consideration.

Methods: In this cross-sectional study, patients with their pain classified according to its etiology (chronic/idiopathic, nociceptive and neuropathic pain) were consecutively recruited for self-assessment of their actual pain intensity using a continuous VAS, 0-100, and a discrete five-category VRS. The data were analyzed with a non-parametric statistical method, suitable for comparison of scales with different numbers of response alternatives.

Results: An overlapping of the VAS records relative the VRS categories was seen in all pain groups. Cut-off positions for the VAS records related to the VRS categories were found lower in patients with nociceptive pain relative patients suffering from chronic/idiopathic and neuropathic pain. When comparing the VAS records transformed into an equidistant five-category scale with the VRS records, systematic disagreements between the scales was shown in all groups. Furthermore, in the test-retest a low percentage of the patients agreed to the same pain level on the VAS while the opposite hold for the VRS.

Conclusion: The pain intensity assessments on VAS and VRS are in this study, not interchangeable due to overlap of pain records between the two scales, systematic disagreements when comparing the two scales and a low percentage intra-scale agreement. Furthermore, the lower VAS cut-off positions relative the VRS labels indicate different meaning of the rated pain intensity depending on pain etiology. It is also indicated that the scales have non-linear properties and that the two scales probably have different interpretation. Our findings are in favor of using the VRS in pain intensity assessments but if still the VAS is preferred, the VAS data should be analyzed as continuous using statistical methods suitable for ordinal data. Furthermore, our findings indicate a risk to over or under estimate the patient's perceived pain when interpreting condensed VAS data.

Figure 1

Joint distribution of rated pain intensity on the continuous VAS versus the discrete VRS in patients with chronic, nociceptive and neuropathic pain, respectively.

Figure 2

Line plots of recorded rated pain intensity on continuous VAS, 0–100 and on the VRS relative the VAS, for the three pain etiology groups respectively.

Figure 3

Line plots of VAS records condensed into discrete five-category scales relative the VRS – totally ordered (unbiased) and equidistant for the three pain etiology groups respectively.

Figure 4

a–b Contingency tables of frequency distribution of discrete VAS records relative the VRS on a) the unbiased five-category VAS (v0–v4) relative the VRS (0–4) and b) the equidistant five category VAS (v0–v4) versus the discrete five category VRS (0–4) in patients with nociceptive pain. Agreeing pairs of data are shown in the grey shaded main diagonal.