A systematic review of the pain scales in adults: Which to use?
a b s t r a c t
Objective: The study analysed the Visual analogue scale (VAS), the Verbal rating scale 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. On- line 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 data- bases 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 methodolog- ical 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 rea- son. 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.
(C) 2018
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 In- ternational 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 world- wide [2].
Subjective and multidimensional nature of the pain experience render pain assessment really challenging. In the Joint Commission on Accredita- tion 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 se- verity [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: [email protected] (O. Karcioglu).
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 an- algesic dose [5].
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 se- verity of the pain. Although physicians commonly question the reported severity and rely on their own estimates, the value of the patients’ de- scription of the location and nature of the discomfort has been proved on the theoretical basis and routine practice [7].
https://doi.org/10.1016/j.ajem.2018.01.008
0735-6757/(C) 2018
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 eval- uated 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. Compre- hensive pain assessment is expected to encompass both the unidimen- sional 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 ,
- Verbal Rating/Descriptor Scale (VRS/VDS).
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 ex- press how intense he/she perceives pain (Fig. 1). The VAS is a continu- ous 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 detect- ing treatment effects, and its results can be analysed by paramet- ric 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].
B.2
The Numeric rating scale 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 ex- perience 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
- 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).
B.3
Verbal Pain Scores (VPSs), Verbal Rating Scales (VRS) or Verbal De- scriptor 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 pa- tients 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 assess- ment 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?
Methods
A systematic review of currently published studies was performed following standard guidelines. Online database searches were per- formed 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 Cen- tral 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 au- thor. The research protocol to answer these questions was registered in PROSPERO, the International Prospective Register of Systematic Re- views (registration number is: CRD42017080974).
Search methodology
A Comprehensive literature search was carried out using the follow- ing strategy:
Online searches were performed using the following search key- words 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.
A
B
C
D
Fig. 1. A. visual analog scale . B. The Numerical Rating Scale (NRS) C. Verbal Rating Scale (VRS) or Verbal DescriptorScale (VRS). D. FACES Pain Rating Scale.
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 com- pare them with each other on specific patient groups, exclusively in adults. All RCTs of any duration that investigated pain scores in compar- ison 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 se- ries and case reports. Reference lists of relevant systematic reviews and all included studies were checked to identify additional eligible ar- ticles. Conference abstracts and proceedings were not deemed eligible for inclusion in the review. Citation titles and abstracts were indepen- dently screened and assessed regarding the methodological quality by two reviewers (H.T. and O.D.). Any disagreements between the two re- viewers were then resolved by consensus or in consultation with a third reviewer (O.K.) if needed.
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).
Results
The initial electronic data search yielded a total of 872 potentially relevant studies; of these, 853 were excluded for some reason, and final- ly 19 trials fully met the selection criteria based on inclusion of informa- tion regarding comparative data on the pain scales, and specific populations’ preferences on the scales (Fig. 2). The main reason for ex- clusion (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.
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 , the Verbal Rating Scale (VRS) and the Numerical Rating Scale (NRS).
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 be- tween 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 comprehen- sive 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 point- ed 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. report- ed 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 appro- priate 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 pur- poses. Likewise, Hjermstad MJ, et al. performed a systematic review of studies to culminate data on the use and performance of unidimension- al 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
Main characteristics of the outstanding human studies that were explained and reviewed in the present study.
Investigator(s), title and
date, Ref. #
Sample size and population
Quality of evidence (GRADE)?
Risk of bias??
Objectives Findings Notes, conclusions
McLean, et al. 2004. [13]
Leigheb M, et al. 2017.
Pereira et al. 2015. [24]
Herr KA, et al. 2004. [25]
Ware LJ, et al. 2006. [26]
Yazici et al. 2014. [27]
Bahreini M, et al. 2015.
Aziato L, et al. 2015. [31]
1227
prehospital patients N 13 yrs old
137 adult ED patients
101
institutionalized elderly
175
86 younger (age
25-55) and 89
older (N 65) adults
68 cognitively impaired minority sample
621
postoperative adult patients
150 adult ED patients
150
post-operative patients
C H To determine the feasibility of prehospital pain measurement among patients 13 yrs of age or older using a VRS and NRS.
H 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
U Correlating two unidimensional scales
for measurement of self-reported pain intensity for elderly and identifying a preference for one of the scales.
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.
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.
-
- L To determine patient pain scale preferences and compare the level of agreement among pain scales commonly used during postoperative pain assessment.
- H To assess the agreement between VAS, Color Analog Scale (CAS), and NRS in the emergency setting.
B L To select, develop, and validate context-appropriate unidimensional pain scales for pain assessment among adult post-operative patients.
Prehospital pain assessment using a VRS and NRS was feasible in this patient population. Further studies are needed to confirm this in other settings.
The magnitude of NRS pain measurements were higher than VAS measurements.
There were moderate to strong, positive and statistically significant associations between the scores of NRS and VDS: overall assessment (r = 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.
All 5 pain scales (VAS, FPS, VDS, 21-point NRS, 11-point VNS) were
effective in discriminating different levels of pain sensation; however the VDS was most sensitive and reliable. Failure rates for pain scale completion were minimal, except for the VAS. The scale most preferred to represent pain intensity in both cohorts of subjects was the NRS, followed by the VDS.
Concurrent validity was supported with correlations ranging from 0.56 to
0.90. The lowest correlations were found between the FPS-R and the other scales, suggesting that the FPS-R may be measuring a broader construct incorporating pain
patient preference for pain scales were as follows: 97.4% FPS, 88.6% NRS, 84.1% VDS, 78.1% TPS, 60.1% SFMPQ,
37.0% BPI, 11.4% VAS, and 10.5% MPQ.
Education was an important factor in 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).
The three pain scales were strongly correlated at all time periods. The findings suggest that NRS, CAS, and VAS can be interchangeably applied for acute pain measurement in adult patients.
(Color-Circle Pain Scale-[CCPS]) had higher scale preference than NRS and FPS. Convergent validity was very good and significant (0.70 -0.75).
Inter-rater reliability was high (0.923-0.928) and all the scales were
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 VAS scores suggests that painintensity cannot be determined accurately according topainscaledata alone but should also incorporate clinical judgment.
Pain measurements among institutionalized elderly can be made by NRS and VDS; however, the preferred scale for the elderly was the VDS, regardless of gender.
Although all 5 of the pain intensity rating scales were psychometrically sound when used with either age group, failures, internal consistency reliability, construct validity, scale sensitivity, and preference suggest that the VDS is the scale of choice for assessing pain intensity among older adults, including those with mild to moderate cognitive impairment.
In terms of pain scale preference, the NRS (33%) was the preferred scale in the cognitively intact group and the FPS-R (54%) was the preferred scale in the cognitively impaired group.
African-Americans and Hispanics pre- ferred the FPS-R. Severely, moderately, and mildly impaired par- ticipants also preferred the FPS-R. 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.
Spearman Correlation coefficients between NRS and CAS, NRS and VAS, and CAS and VAS were 0.95, 0.94, and 0.94, respectively (p b 0.001). On a scale of 0 to 10, the 95% limits of agreement between the paired NRS 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 gives the clinician an objective criterion for pain management.
Due to the subjective nature of pain, consideration of socio-cultural factors for the particular context ensures that
(continued on next page)
Table 1 (continued)
Investigator(s), title and
date, Ref. #
Sample size and population
Quality of evidence (GRADE)?
Risk of bias??
Objectives Findings Notes, conclusions
Goransson KE, et al. 2015.
[32].
Edelen MO, et al. 2010.
[33].
Pratici E, et al. 2017. [34]
Gagliese L,
et al. 2005.
Bijur PE, et al. 2003. [36]
Herr K, et al. 2007. [37]
Taylor LJ, et al. 2005. [38]
Li L, et al. 2007. [39]
Li L, et al. 2009. [40]
217 adult ED patients
1960 Elderly residents from 71 nursing homes
97 women in labor
504
postoperative adults.
108 adult ED patients
97 adults with chronic joint pain
66 cognitively impaired elderly
173
postoperative adults.
180
postoperative elderly.
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
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.
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.
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.
C H 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.
B L 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.
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.
B U To determine the psychometric properties and applicability of four pain scales in Chinese postoperative adults.
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.
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.
Investigator(s), title and
date, Ref. #
Sample size and population
Quality of evidence (GRADE)?
Risk of bias??
Objectives Findings 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.
Ismail AK, et al. 2015. [41]
Akinpelu AO, et al. 2002.
35 women with caesarian section
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.
H To evaluate correlation of pain scores
obtained on the VAS, the Box Numerical Scale (BNS) and Verbal Rating Scale (VRS) was studied.
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 no significant difference between the pain scores obtained on the 3 pain rating scales. Significant correlations existed between pain scores obtained on the VAS and VRS (r
= 0.48, p = 0.003); VAS and BNS (r = 0.74, p = 0.000); BNS and VRS (r =
0.74, p = 0.000).
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 the same construct, and could be used for pain measurement in obstetrically related conditions in this environment.
Abbreviations: The Faces pain scale (FPS), Visual Analog Scale , Numeric Rating Scale , 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 “un- clear 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 depen- dence 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.
Summary and conclusion
“Pain cannot be treated if it cannot be assessed”. The most impor- tant 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 phy- sicians 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 be- fore firm conclusions could be drawn.
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