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Commentary

The Journal of Clinical Pharmacology


Assessing Pain Intensity With the Visual Analog 54(3) 241–244
© 2014, The American College of
Scale: A Plea for Uniformity Clinical Pharmacology
DOI: 10.1002/jcph.250

Michael D. Reed, PharmD, FCCP, FCP1,2,3 and William Van Nostran, BS1

Keywords
Visual analogue scale (VAS), pain scale, VAS validity, pain assessment

“Those who do not feel pain seldom think that frequently used assessment instrument5,8,9–11 to evaluate
it is felt.” analgesic effects of various therapies and detect minute
Dr. Samuel Johnson (circa 1750) pain changes during analgesic administration. Structurally,
we find the VAS a simple tool to use by anyone cognitively
The sensation of pain is undeniably subjective. capable of understanding the parameters and responding to
Personality, recollections of painful events, emotional clinician instructions. Indeed its popularity is frequently
state, age, culture, context, and other factors influence an attributed to the ease and convenience of the VAS in a fast‐
individual’s responses to, and description of, pain.1–5 paced clinical setting.4
Linguistically, the word “pain” encompasses multidimen- PI may be the most convenient dimension to assess
sional attributes well beyond a single sensation varying quickly, but interpreting a VAS reading is no simple
only in intensity.2,3 Every patient’s “pain vocabulary” matter.12 Context plays an important role when translating a
contains nuanced connotations: aching, pulling, burning, VAS score into an evidence‐based treatment. One specialty
stinging, stabbing, or radiating, to name a few.6 Quantify- treats nociceptive pain; another focuses on relieving patients
ing “how much it hurts” eludes visual documentation (X‐ suffering neuropathic pain.13 Hodgins2 and other authori-
ray, MRI) or objective physiologic measurement (heart ties8 suggest that identical scores on a pain scale may be
rate, blood pressure, hormone response, or other empirical treated differently based on the specialty and individual
information). patient.2 High pain scores may be termed acceptable
No matter the clinical setting or circumstance, however, immediately following traumatic injury, yet unacceptable if
adequate pain management requires precise, thorough pain they persist over time.2,3 The underlying cause of pain
assessment—an individualized approach.4,7–9 Assessing, (surgery vs. migraine headache), and clinical setting (acute
treating, and monitoring pain is germane to every care vs. hospice) illustrates that no “one size fits all.”
discipline—from general clinical practice through all Because VAS is an extremely common means of
subspecialties.10 Likewise, research assessing novel estimating and monitoring PI, it raises this conundrum: is
therapies and treatments pose additional challenges, VAS really the most effective assessment tool? Could
particularly when changes in pain represent the primary flaws within the tool itself contaminate results? Or, might
outcome variable. The most credible expression of pain clinical interpretation of pain scores rob the VAS of
comes via each patient’s self‐report using their unique pain consistency and reliability? We posit the tool and its
vocabulary.4,6,8 When cognitively and physically capable,
the patient is the best source for accurately communicating
the extent to which pain moderates, worsens, or varies over 1
Rebecca D. Considine Research Institute, Akron Children’s Hospital,
time.4,6,8 Akron, OH, USA
2
Division of Clinical Pharmacology and Toxicology, Department of
Pediatrics, Akron Children’s Hospital, Akron, OH, USA
3
College of Medicine, Northeast Ohio Medical University (NEOMED),
VAS Used to Assess Pain Intensity in Rootstown, OH, USA
Diverse Clinical Settings
Submitted for publication 28 October 2013; accepted 17 December
The European Palliative Care Research Collaborative, and 2013.
scores of others charged with pain measurement, agree the
Corresponding Author:
most clinically relevant dimension to pain assessment,
Michael D. Reed, PharmD, FCCP, FCP, Director, Rebecca D.
regardless of disease or condition, is pain intensity (PI).5,7 Considine Research Institute, Akron Children’s Hospital, One Perkins
A preponderance of evidence demonstrates that the Square, Akron, OH 44308, USA
100 mm visual analog scale (VAS) is by far the most Email: mreed@chmca.org
242 The Journal of Clinical Pharmacology / Vol 54 No 3 (2014)

clinical application combine to produce undependable, Ironically, these investigators cannot reach consensus on
sometimes capricious results. Moreover, this variability which precise tick‐mark on the 100 mm continuum
and imprecision inherent in the standard VAS confounds corresponds to clinically relevant “moderate pain.” 3,5,9,14
extrapolation of findings from differing research inves- Studies differ on what is considered a moderate pain
tigations when applied to a global patient population. Ours threshold, beginning with >30 mm, up to >60 and even
is not an especially new or novel perspective. Authors >75 mm.14,17 Similarly, Stinson et al15 question whether a
representing diverse clinical and research domains have difference of 10 mm represents a meaningful change in PI.
reported similar concerns over the decades.1,2,4,7–16 Williams et al8 report the meaning of identical tick‐marks on
a scale vary by patient. One individual’s number expresses
“average, everyday pain.” A second patient considers the
Clinical Interpretation Issues same VAS location as “barely tolerable.”18 Several studies
Many clinicians and investigators consider the 100 mm describe a “ceiling and floor” effect—a clustering of results
continuum of the VAS (Figure 1A and B) superior in around lower and higher endpoint descriptors.1,8,18 Our own
capturing subtle differences (sensitivity) compared to the recent use of the VAS19 supports the interpretive difficulties
few discrete points of categorical pain scales that limit Stinson and colleagues cite.17,18 This is further supported by
responses to 4, 5, 7, or 11 choices8 (Figure 2A and B). investigators who point out that pain is not a linear

A)) Traditional VAS Sca


ale: B) Vertic
cal VAS Sca
ale:

The
e Worst Imag
ginable Pain
__
_______
_______
_______
_______
______
0 100
No
o Pain Worst Pain
Possiblee

No Pain

C)) Typical Numeric Paiin Scale D: Iowa


a Pain Therrmometer Scale

0 1 2 3 4 5 6 7 8 9 10
No
o Pain uciating
Excru
P
Pain

Figure 1. (A) The conventional 100 mm Visual Analog Scale with two commonly used end point descriptors. (B) Vertical VAS (note yet another high
end‐point descriptor variation). (C) The 11‐point Numerical Rating Scale (NRS). Studies show this scale is less sensitive in detecting pain intensity
changes over time. (D) The Iowa Pain Thermometer employs a vertical format and visual metaphor to suggest pain intensity rises or falls in a manner
analogous to how a thermometer registers heat. (Used with permission of Keela Herr, PhD, RN, College of Nursing, The University of Iowa).
Reed and Van Nostran 243

phenomenon.15 For this reason, one may not assume a score must be interpreted as “no change” even if that person’s
of 50 is precisely two times that of 25.17,18 pain steadily increased.1 In fact, Williams quotes one
study subject as saying, “having to put 100 would make
me feel worse.”8
Unnecessary Variations Several less finite anchor labels are already in use:
Granted that at the bedside, the patient’s report of “unbearable pain,” “excruciating pain,” “very intense
increasing or decreasing PI trend should provide data on pain,” and others. Even “no pain,” although finite, is
which to base individual clinical pain management affected by each patient’s pain threshold and subjective
decisions. Nevertheless, the advantages of more consis- distinction between what they deem simply an unpleasant
tent, universal VAS score comparisons in clinical and sensation versus clinically relevant pain.1
research settings would broaden this assessment tool’s This lack of uniformity, precision, and consensus in the
accuracy and reliability. Equally important, greater format and application of VAS within institutions,
consistency among VAS values enhances the scale’s between medical practitioners, and even among two
comparative applicability across pain treatment study clinicians working side‐by‐side in the same department,
publications. renders relative clinical comparison extremely difficult.
Many have attempted to enhance the precision and With the increasing demand for provision of evidence‐
broader applicability of the standard VAS (Figure 2). based medicine, collaborative interdisciplinary care
Design and formatting variables among VAS pain scale models, and trend toward comparative effectiveness
versions include: (1) anchor terminology, (2) presence/ research—we can, and must, do better in assessing PI.
absence of line markers, (3) interpreting the baseline and
successive measures, and (4) the units of measurement Can We Improve the VAS and Its
and length of the scale, and (5) horizontal or vertical
orientation.11 Some of these “modified VAS” instruments Clinical Application?
are shown in Figure 1C and 1D. We posit that clinicians and researchers would be better
We believe some modifications can and do enhance the served with a universal VAS construct and more
value of the data derived. However, for extrapolation consistent interpretive practices within the context of
across differing patient populations and accounting for the each specialty. We believe such consistency will bring
tremendous heterogeneity in patient sensations and clarity to published findings and yield more clinically
descriptions of PI, incorporating a few basic changes relevant pain assessment data for investigators and
should result in a universally accepted VAS. One clinicians alike and, most importantly, foster more
especially constructive modification would result from accurate, and thus, clinically relevant data extrapolation
adopting identical and clinically universal anchoring across studies for applicability to the individual patient.
terminology—the descriptive terms that provide user Our vision of a universal VAS (Figure 2) includes three
reference points. minimal revisions:
A review of published VAS tools reveals a spectrum of
anchor descriptor terms. The differing, seemingly arbi- 1. We advocate identifying and labeling a relative
trary, anchor point label verbiage interjects an important mid‐point descriptor to denote “moderate pain.”
variation for patient and clinician. Universally accepted In our opinion this will not significantly diminish
definitions or numerals to quantify PI beginning with the instrument’s ability to detect subtle PI
“no pain” and escalating to “worst pain ever” (or other changes. This will, however, provide a relative
nomenclature) do not exist. In reality “worst pain ever” locale that patients and clinicians can agree upon
is infinite. It is always possible for a patient to to represent pain‐varying degrees of “moderate”
experience more pain than they deemed the “worst pain.
ever” just 60 min ago.1 By forcing patients into selecting 2. We recommend all clinical practitioners and
“worst pain ever” a second or third time, their response researchers adopt identical end point labels to

Figure 2. Depiction of the 100 mm horizontal VAS model we recommend. We propose a 100 mm VAS with generic end point descriptors and an
additional mid‐point descriptor to establish an approximate area of moderate pain. Unlike high end descriptors such as “the most intense pain
imaginable,” or “maximal amount of pain,” the descriptors “mild,” “moderate,” and “severe” are neutral in their connotation. Minimal visual cues
delineating general mild, moderate, and severe areas directs the eye to a relative area of the scale, yet still offers patients a 100 mm range to mark a
discrete point for each successive pain measurement. A uniform patient instruction might be: “Rate your pain on a scale of zero to 100. Zero is equal
to no pain. Make a mark anywhere on the line to show me how much pain you have right now.”
244 The Journal of Clinical Pharmacology / Vol 54 No 3 (2014)

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