Home Medicine Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain
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Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain

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Published/Copyright: April 1, 2016
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 11 Issue 1

In this issue of the Scandinavian Journal of Pain David Dorfman and his co-authors focus on limitations of changes in pain-intensity as outcome measure of management of patients with chronic pain [1].

1 Multidimensionality of chronic pain makes pain intensity inadequate as sole outcome metric of chronic pain management

The Dorfman et al. paper is one of several recent publications questioning the usefulness of pain-intensity as an only measurement in chronic pain. Thus, Jane Ballantyne and Mark Sullivan late last year (2015) in the New England Journal of Medicine asked whether intensity of chronic pain is the wrong metric [2] and again this year (2016) in PAIN they state that it is not necessary to reduce pain-intensity in order to treat chronic pain well [3]. Fayers et al. [4] on behalf of the European Palliative Care Research Collaboration focus on the differences in reports of pain intensity and pain interference among chronic pain patients and palliative care patients in pain. In 2015 in the journal Quality of Life Research Cooket al. [5] call for establishing a common metric for self-reported pain by linking scales for pain interference with SF-36 bodily pain subscale.

2 VAS – the Visual Analogue Scale: after 50 years there is no better way to measure subjective experience of the intensity of pain [6]

The neurosurgeon and psychiatrist Michael Bond and Issy Pilowsky had knowledge of the method used in the science of psychology for visualizing and measuring subjective psychophysical phenomena, and they were the first to apply a Visual Analogue Scale for creating a mental picture of and measure the subjective experience of pain-intensity [6]. Unfortunately, when VAS was next used in a publication on pain a few years later, the original, first ever, publication on VAS for pain-intensity by Bond and Pilowsky was not cited. Not until very recently has the Bond and Pilowsky paper [6] been correctly cited as the origin of pain-VAS [7,8]. Considering how much the pain-intensity-VAS has meant in pain research, for clinical management of pain, and the policy of pain, this is astonishing, indeed.

3 Practical performance of pain-intensity measurements: numeric rating scale (NRS), and categorical verbal rating scale (VRS) as alternatives to VAS [9,10]

In the vitally important tissue-injury-alarm system, the intensity of the subjective experience of acute pain is, among other factors, related to the seriousness of the tissue-injury [11].

For a Visual Analogue Scale (VAS)-measurement to be possible, the patient must be able to see and handle paper and pencil, marking on a line from 0 = no pain, to 10 cm (or 100 mm) = worst pain imaginable, where on this line the patient’s present pain intensity is located.

When the patient cannot handle pen and paper, a verbal Numeric Rating Scale (NRS) – is a good alternative: The patient must be able to hear and understand the researcher’s or clinician’s voice asking where on a scale from 0 (no pain) to 10 (worst pain imaginable) his pain is at the moment of asking [9,10].

These two scales, the VAS and the NRS, are equally sensitive in detecting changes in intensities of acute pain [10,12], but the NRS is often easier to use and more practical in a busy clinical praxis.

Categorical Verbal Rating Scales (VRS), with categories of pain-intensity varying from mild, moderate, severe, to very severe (or unbearably severe), such VRS-scales are easy to use, but less sensitive to changes in pain intensities than the VAS and NRS scales are [9,10,12].

4 Intensity of pain RIGHT NOW versus making estimates of average pain during a past time period: we cannot remember pain intensity well

As pointed out by Michael Bond and Issy Pilowsky 50 years ago [6] and emphasized by pain-researchers again and again, pain intensity estimates using VAS or NRS are reliable only for pain intensities experienced and reported right now, at the present moment, when he/she is interviewed for a NRS-score or is marking the VAS-line [9,12].

If patients are asked to make an estimate of the average pain intensity during the last 12 h, the last 24 h, the last few days, or the last two weeks, variability in responses increases, making the VAS/NRS-numbers less valid, even meaningless.

How can you make a mental average of intensities that vary from low during long and varying periods with high pain intensities during varying length periods? Dorfman et al. made this observation as well [1]: Patients cannot remember accurately what the varying pain intensity was and have great difficulties making an average number for pain intensity during a past period.

5 Intensity of acute pain during movements is a highly sensitive outcome measure of management of pain after surgery or trauma

Increased focus during the last 3 decades on monitoring and treating pain intensity during movement, dynamic pain, have improved management of acute pain after surgery and trauma [13]. When intensity of dynamic pain after thoracotomy or major abdominal surgery is reduced by epidural analgesia so that patients are able to breath freely and move around easily, this not only reduces risk of postoperative morbidity, but even 30 days mortality after such surgery is reduced significantly [14].

6 For patients with chronic pain condition with varying pain intensity: patient’s global impression of change – PGIC – is a more appropriate outcome measure than the pain intensity alone

The following is an illustrative example of how changes in pain intensity can be misleading, while the patient’s impression of change indicates a definite benefit of a treatment of osteoarthritis. Osteoarthritis (OA) of hip and knee joints causes a chronic pain condition that interferes with movements and activities of daily living.

The WOMAC questionnaire is often used to evaluate outcome of treatment of OA. There are three sub-scales in the WOMAC score-sheet: One for pain, one for stiffness, and one for disabilities caused by the OA-condition.

In the WOMAC-Pain scale the patient is asked to make estimates of pain intensity during the last 24 h. A treatment that reduces pain intensity allows the patient to move around more, the interference of daily activities will be less as the pain decreases. However, more movement with an OA-extremity will provoke more pain. Therefore, the patient will mark his pain average intensity during the last 24 h as unchanged, but his global impression of change is positive because he/she will have been able to move around more, to be more active. Therefore she/he will have a better global impression of her condition.

This is exactly what happened in a 6 months long double blind comparison of a low dose (median 10 microgram/h) buprenorphine patch compared with a placebo-patch: Pain intensity changed equally in the two groups, but the patients’ global impression of change was significantly more positive in the active group [15].

7 Why pain-intensity measure alone is NOT appropriate outcome measure for treatment of chronic pain, when for acute pain this is a sensitive outcome measure?

Chronic pain, pain that is there week after week, month after month, pain that interferes with activities of daily living, pain that reduces ability to have a work to go to, regular income disappears, patients have catastrophizing thoughts about never getting back to normal life, they plunge into mental fatigue, depression and suicidal ideas appear. In such circumstances, the intensity of pain is only one part of the total burden of suffering.

The IMMPACT project has focused on this problem: We need to assess several outcome-measures when studying how to help chronic pain patients better. A group of experienced pain clinicians and pain researchers in 2008 published the paper: “Analyzing multiple endpoints in clinical trials of pain treatments: IMMPACT recommendations. Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials” [16]. Follow-up papers have indicated areas of progress based on this project.

However, Jane Ballantyne and Mark Sullivan are correct in their strong statements in New England Journal of Medicine and in PAIN that we still have a long way to go before outcome measures of chronic pain management are optimal. Reliance on pain intensity as an outcome measure for trials on chronic pain, is not appropriate: While good for acute pain, pain intensity is unreliable as outcome measure for chronic pain.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.12.004.

Oslo University Hospital, Department of Pain Management and Research, P. Box 4950, Nydalen, 0424 Oslo, Norway. Tel.:+47 23073691

  1. Conflict of interest: None declared.

References

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Published Online: 2016-04-01
Published in Print: 2016-04-01

© 2016 Scandinavian Association for the Study of Pain

Articles in the same Issue

  1. Editorial comment
  2. Psychophysiological effects of threatening a rubber hand that is perceptually embodied in healthy human subjects
  3. Original experimental
  4. A preliminary investigation into psychophysiological effects of threatening a perceptually embodied rubber hand in healthy human participants
  5. Editorial comment
  6. Analysis of C-reactive protein (CRP) levels in pain patients – Can biomarker studies lead to better understanding of the pathophysiology of pain?
  7. Clinical pain research
  8. Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders
  9. Editorial comment
  10. Importance of early diagnosis of complex regional pain syndrome (CRPS-1 and CRPS-2): Delayed diagnosis of CRPS is a major problem
  11. Clinical pain research
  12. Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)
  13. Editorial comment
  14. Associative learning mechanisms may trigger increased burden of chronic pain; unlearning and extinguishing learned maladaptive responses should help chronic pain patients
  15. Original experimental
  16. When touch predicts pain: predictive tactile cues modulate perceived intensity of painful stimulation independent of expectancy
  17. Editorial comment
  18. Low back pain among nurses: Common cause of lost days at work and contributing to the worldwide shortage of nurses
  19. Observational study
  20. Pain-related factors associated with lost work days in nurses with low back pain: A cross-sectional study
  21. Editorial comment
  22. Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?
  23. Clinical pain research
  24. Characterization of persistent pain after hysterectomy based on gynaecological and sensory examination
  25. Editorial comment
  26. Transmucosal fentanyl for severe cancer pain: Nasal mucosa superior to oral mucosa?
  27. Original experimental
  28. Facilitation of accurate and effective radiation therapy using fentanyl pectin nasal spray (FPNS) to reduce incidental breakthrough pain due to procedure positioning
  29. Editorial comment
  30. Why do we have opioid-receptors in peripheral tissues? Not for relief of pain by opioids
  31. Clinical pain research
  32. Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial
  33. Editorial comment
  34. Chronic pain and psychological distress among long-term social assistance recipients – An intolerable burden on those on the lowest steps of the socioeconomic ladder
  35. Clinical pain research
  36. The co-occurrence of chronic pain and psychological distress and its associations with salient socio-demographic characteristics among long-term social assistance recipients in Norway
  37. Editorial comment
  38. Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain
  39. Clinical pain research
  40. Patient reported outcome measures of pain intensity: Do they tell us what we need to know?
  41. Editorial comment
  42. Postoperative pain documentation 30 years after
  43. Topical review
  44. Postoperative pain documentation in a hospital setting: A topical review
  45. Editorial comment
  46. Aspects of pain attitudes and pain beliefs in children: Clinical importance and validity
  47. Observational study
  48. The Survey of Pain Attitudes: A revised version of its pediatric form
  49. Editorial comment
  50. The role of social anxiety in chronic pain and the return-to-work process
  51. Clinical pain research
  52. Social Anxiety, Pain Catastrophizing and Return-To-Work Self-Efficacy in chronic pain: a cross-sectional study
  53. Editorial comment
  54. Advances in understanding and treatment of opioid-induced-bowel-dysfunction, opioid-induced-constipation in particular Nordic recommendations based on multi-specialist input
  55. Topical review
  56. Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group
  57. Observational study
  58. Opioid-induced constipation, use of laxatives, and health-related quality of life
  59. Editorial comment
  60. Migraine headache and bipolar disorders: Common comorbidities
  61. Systematic review
  62. Migraine headache and bipolar disorder comorbidity: A systematic review of the literature and clinical implications
  63. Editorial comment
  64. The role of catastrophizing in the pain–depression relationship
  65. Clinical pain research
  66. The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: A longitudinal analysis
  67. Announcement
  68. May 26-27, 2016 Scandinavian Association for the Study of Pain, Reykjavik, Iceland May 25, 2016 PhD course
https://doi.org/10.1016/j.sjpain.2016.02.004

Articles in the same Issue

  1. Editorial comment
  2. Psychophysiological effects of threatening a rubber hand that is perceptually embodied in healthy human subjects
  3. Original experimental
  4. A preliminary investigation into psychophysiological effects of threatening a perceptually embodied rubber hand in healthy human participants
  5. Editorial comment
  6. Analysis of C-reactive protein (CRP) levels in pain patients – Can biomarker studies lead to better understanding of the pathophysiology of pain?
  7. Clinical pain research
  8. Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders
  9. Editorial comment
  10. Importance of early diagnosis of complex regional pain syndrome (CRPS-1 and CRPS-2): Delayed diagnosis of CRPS is a major problem
  11. Clinical pain research
  12. Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)
  13. Editorial comment
  14. Associative learning mechanisms may trigger increased burden of chronic pain; unlearning and extinguishing learned maladaptive responses should help chronic pain patients
  15. Original experimental
  16. When touch predicts pain: predictive tactile cues modulate perceived intensity of painful stimulation independent of expectancy
  17. Editorial comment
  18. Low back pain among nurses: Common cause of lost days at work and contributing to the worldwide shortage of nurses
  19. Observational study
  20. Pain-related factors associated with lost work days in nurses with low back pain: A cross-sectional study
  21. Editorial comment
  22. Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?
  23. Clinical pain research
  24. Characterization of persistent pain after hysterectomy based on gynaecological and sensory examination
  25. Editorial comment
  26. Transmucosal fentanyl for severe cancer pain: Nasal mucosa superior to oral mucosa?
  27. Original experimental
  28. Facilitation of accurate and effective radiation therapy using fentanyl pectin nasal spray (FPNS) to reduce incidental breakthrough pain due to procedure positioning
  29. Editorial comment
  30. Why do we have opioid-receptors in peripheral tissues? Not for relief of pain by opioids
  31. Clinical pain research
  32. Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial
  33. Editorial comment
  34. Chronic pain and psychological distress among long-term social assistance recipients – An intolerable burden on those on the lowest steps of the socioeconomic ladder
  35. Clinical pain research
  36. The co-occurrence of chronic pain and psychological distress and its associations with salient socio-demographic characteristics among long-term social assistance recipients in Norway
  37. Editorial comment
  38. Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain
  39. Clinical pain research
  40. Patient reported outcome measures of pain intensity: Do they tell us what we need to know?
  41. Editorial comment
  42. Postoperative pain documentation 30 years after
  43. Topical review
  44. Postoperative pain documentation in a hospital setting: A topical review
  45. Editorial comment
  46. Aspects of pain attitudes and pain beliefs in children: Clinical importance and validity
  47. Observational study
  48. The Survey of Pain Attitudes: A revised version of its pediatric form
  49. Editorial comment
  50. The role of social anxiety in chronic pain and the return-to-work process
  51. Clinical pain research
  52. Social Anxiety, Pain Catastrophizing and Return-To-Work Self-Efficacy in chronic pain: a cross-sectional study
  53. Editorial comment
  54. Advances in understanding and treatment of opioid-induced-bowel-dysfunction, opioid-induced-constipation in particular Nordic recommendations based on multi-specialist input
  55. Topical review
  56. Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group
  57. Observational study
  58. Opioid-induced constipation, use of laxatives, and health-related quality of life
  59. Editorial comment
  60. Migraine headache and bipolar disorders: Common comorbidities
  61. Systematic review
  62. Migraine headache and bipolar disorder comorbidity: A systematic review of the literature and clinical implications
  63. Editorial comment
  64. The role of catastrophizing in the pain–depression relationship
  65. Clinical pain research
  66. The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: A longitudinal analysis
  67. Announcement
  68. May 26-27, 2016 Scandinavian Association for the Study of Pain, Reykjavik, Iceland May 25, 2016 PhD course
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