438 Journal of Pain and Symptom Management Vol. 18 No.

6 December 1999

Original Article

A Descriptive Study of the Use of Visual

Analogue Scales and Verbal Rating Scales for
the Assessment of Postoperative Pain in
Orthopedic Patients
Michelle Briggs, BSc, MSc, RGN, and José S. Closs, BSc, RGN, MPhil, PhD
Centre for the Analysis of Nursing Practice (M.B.), Leeds Metropolitan University, Leeds; and Division
of Nursing (J.S.C.), School of Healthcare Studies, University of Leeds, Leeds, UK

Abstract
Visual analogue scales (VAS) and verbal rating scales (VRS) are widely used to assess pain.
This paper presents a secondary analysis of a subsection of data collected as part of an
evaluation of an intervention to improve nighttime pain. The aims were to describe the
relationship between the VAS and VRS; to compare characteristics of the noncompliant groups
in terms of age, gender, type of surgery, and analgesics; to explore the reasons for
noncompletion of the VAS or VRS; and to determine the noncompliance rates with each
assessment scale. Worst and average pain scores were obtained for the second postoperative
night for 417 patients. Fifty-nine patients (14.2%) did not complete the VAS. In contrast, two
patients did not complete the VRS (0.5%). The scores generated from the VAS and VRS
correlated well, although the range of VAS scores corresponding to each VRS category was
wide. We conclude that the VRS was more suitable for use in this clinical setting. J Pain
Symptom Manage 1999;18:438–446. © U.S. Cancer Pain Relief Committee, 1999.

Key Words
Pain assessment, pain measurement, visual analogue scales, verbal rating scales, orthopedics,
postoperative pain

Introduction Karoly described a Pain Context Model in which

Pain is a complex, private experience and at-
tempts to make valid assessments of it have been
fraught with difficulties. This was experienced by
the authors when they conducted a recent hospi-
tal-based clinical trial.1 Pain is also influenced by
numerous intrinsic and extrinsic factors, and the
multiple aspects of pain have been assessed in
many different ways. For example, Jensen and
Address reprint requests to: Ms. Michelle Briggs, CANP,
Leeds Community and Mental Health Trust Headquar-
ters, The Mansion, Meanwood Park, Tongue Lane,
Leeds LS6 4QB, UK.
Accepted for publication: February 4, 1999.
pain is considered to be a construct consisting of
dimensions such as verbal reports of pain, pain
behavior, pain intensity, pain location, and pain
affect. The construct is not directly observable,
but rather inferred from the observations of oth-
ers.2 It is important to acknowledge the multidi-
mensional nature of this construct, but it compli-
cates attempts to provide a simple quantitative
measure of the pain experience.
Multidimensional pain questionnaires, such
as the McGill Pain Questionnaire3,4 and the
Wisconsin Brief Pain Questionnaire,5 have
been developed, but successful completion de-
pends on good verbal skills. This can create a

© U.S. Cancer Pain Relief Committee, 1999 0885-3924/99/$–see front matter

Published by Elsevier, New York, New York PII S0885-3924(99)00092-5
Vol. 18 No. 6 December 1999 Postoperative Pain in Orthopedic Patients
strong cultural and educational bias, as pa-
tients may choose words with which they are fa-
miliar rather than those that reflect the quality
of their pain. Such questionnaires are also con-
sidered by some researchers to be too long, re-
quiring sustained concentration by the pain
sufferer.6
As a result, unidimensional scales which
measure only the sensory component of the
pain experience are still used in acute pain re-
search. In these studies, investigators are inter-
ested in a change in the severity of pain from a
sensory perspective.7–9 Two of those most com-
monly used scales are the visual analogue
scale (VAS) and the verbal rating scale (VRS).
Both are considered to have good reliability
and construct validity when patient self-re-
port is used as the method of data collec-
tion.2,10,11 This paper considers the relative util-
ity of these two scales in the acute orthopedic
setting.
Verbal Rating Scales
The VRS consists of a list of adjectives de-
scribing different levels of pain intensity. An
adequate VRS should include adjectives that
describe the extremes of the dimension.2
There are many examples of verbal rating
scales. They range from simple 4-point scales
(e.g., from none to severe)12 to 15-point ratio
scales.13,14 There is good evidence of their con-
struct validity.2,10,11 The main advantages of
such scales are that patients, particularly the
elderly,11,15,16 appear to prefer the VRS to the
VAS, finding them easier to use. Researchers
consider them to be easy to administer and
score, and they achieve high compliance
rates.2
However, the use of VRSs for research pur-
poses generates a number of concerns due to
their psychometric properties.17,18 Because
they separate the pain experience into distinct
categories, they provide simple ranked data,
which means that the intervals between each
category can not be assumed to be equal. For
example, the difference between moderate
and severe pain may not represent the same
magnitude of change as a movement from no
pain to no slight pain.19 Because the intervals
of a VRS are unlikely to be equally spaced, the
data are ordinal. This is sometimes considered
a weakness of this method, because it limits the
statistical analysis to nonparametric methods.
439
VRSs can be transformed into approximate ra-
tio scales if cross-modality matching methods
are used or if a VRS has been developed using
these methods.13,14 Cross-modality matching
involves asking the participants to indicate the
severity of pain represented by each word us-
ing other modalities, for example, the length
of line or hand-grip force.
As a consequence of the fixed number of re-
sponse categories, VRSs are considered to be
less sensitive to treatment effects than VASs, on
which patients can mark anywhere on a line
from 0–100 mm.20 However, sensitivity to
change is dependent on the number of adjec-
tives used.2 For example, it appears that a scale
with more than 11 items is likely to be as sensi-
tive as a VAS to treatment effects, although if a
VRS has less than 5 categories this may reduce
its sensitivity in some situations.2,19
Further limitations of VRSs are that the
scales rely on patient ability to read and inter-
pret the words outlined. This may prove diffi-
cult for those with limited vocabulary. Patients
are also required to select from a finite num-
ber of descriptors and may not find a word that
accurately reflects their experience, or they
may feel that they lie between two categories.
For these reasons, some researchers hesitate to
recommend VRSs as the sole method of pain
measurement in studies.2
Visual Analogue Scales
The VAS is widely used to investigate many
kinds of subjective experience, including
pain.21 The technique has also been applied to
alertness after sleep, quality of life, anxiety,
breathlessness, nausea, and attitudes towards
the environment.20,22
When using a VAS to assess pain, subjects are
asked to indicate intensity by marking a (usu-
ally) 100-mm-long horizontal line that is la-
beled “no pain” at one end and “worst pain
possible” at the other end. This requires the
patient to be able to equate the length of the
line (as measured from the left-hand side to
the point marked) with the amount of pain
they are experiencing. Like the VRS, there is
evidence to support the construct validity of
VAS. The scales correlate with pain intensity
measured by other methods.23,24 They are con-
sidered to be sensitive to interventions that al-
ter the pain experience.25
440 Briggs and Closs
The main benefit of the VAS over the VRS is
that the scores appear to have the qualities of
ratio data and may be treated as such statisti-
cally, providing that the data are normally dis-
tributed. 26,27 The VAS also has a large number
of response categories, which means that it is
considered to be more sensitive to changes in
pain intensity than measures with limited num-
bers of responses. However, it has been noted
that while the VAS may be sensitive to treat-
ment effects if the same individual scores his or
her pain before and after the intervention, it
may not produce reliable ratings across differ-
ent groups of patients because each patient
may interpret the scale differently.11
Another limitation of the VAS is that it is con-
ceptually complex and requires the ability to
translate a sensory experience into a linear for-
mat. Some patients find the concept too abstract
or difficult to grasp,17,22 with reported noncom-
pliance rates ranging from 7–26%.6,15,16,28,29
The difficulties with the use of the VAS are pre-
dominantly attributed to a lack of understand-
ing on the part of the patient or poor instruc-
tion on behalf of the researcher, and these
problems appear to be more prevalent in eld-
erly patient populations.11,28
A further source of error is the use of a pho-
tocopier to reproduce the VAS. Some photo-
copiers tend to enlarge an image slightly each
time they provide a copy. Therefore, if copies
of the VAS are produced, the resulting VAS
may be longer than 100 mm.30
Despite these limitations, the VAS is still
used in a variety of clinical and research set-
tings and is favored for its ease of use and the
Table 1
Strengths and Weaknesses of the VAS and VRS
Scale Strengths
Visual Analogue Scale Rapid completion
by respondent
Produces ratio data
High sensitivity to change
Easy to score
Good construct validity
Verbal Rating Scale Rapid completion
Can be completed by
respondent, or read
out by interviewer
Conceptually simple
High compliance rates
Easy to score
Good construct validity
Vol. 18 No. 6 December 1999
minimal demands it places on ill patients.17 It
is sometimes advocated in preference to a
VRS.31
It is thus clear from the literature reviewed
that the VRS and VAS have a number of
strengths and weaknesses. These are summa-
rized in Table 1. Both measures were used in a
study of acute pain, and a secondary analysis
was performed to compare them.
Methods
The study evaluated a nursing intervention
designed to optimize overnight pain manage-
ment and sleep following orthopedic surgery.1
The design was a before/after trial with a con-
trol ward for comparison. The choice of design
was pragmatic because the trial involved mea-
suring aspects of sleep, analgesic provision, and
nurses’ pain assessment, as well as patients’ re-
ports of pain. Because sleep would be affected
by the ward environment, it was not possible to
randomize patients within wards. In addition,
the trial involved nurses following a protocol
for pain assessment during the night and provi-
sion of information. It was clear during discus-
sions about protocol development that the
nurses would be reluctant to use the protocol
with some patients on the ward and not others.
Two matched wards within one hospital were
therefore chosen and the intervention ward was
assigned randomly by tossing a coin.
When planning the study, it was agreed that
both the VRS and VAS would be used as there
was uncertainty in the literature about the
most appropriate measure for a group of or-
Weaknesses
Significant proportion of respondents
are noncompliant (especially
elderly patients)
Conceptually complex
Repeated photocopying can produce
inaccuracies in scoring (increases
length of line)
Produces ordinal data
Fewer response categories, therefore
lower sensitivity to changes. Debate
exists about adequacy of sensitivity
Relies on patients’ vocabularies
Vol. 18 No. 6 December 1999 Postoperative Pain in Orthopedic Patients
thopedic patients undergoing surgery (both
trauma and elective). A subsidiary set of aims
for the intervention study, therefore, was con-
cerned with the use of VAS and VRS within this
clinical setting.
The aims of this secondary analysis were: (1)
to describe the relationship between the VAS
and VRS; (2) to compare characteristics of the
noncompliant groups in terms of age, gender,
type of surgery, and analgesic consumption;
(3) to explore the reasons for noncompletion
of the VAS or VRS; (4) to determine the non-
compliance rates with each assessment scale.
Sample
The sample size was calculated by assuming
that a clinically significant reduction in pain
scores would be a 10-mm reduction on the
VAS. The number of patients required to pro-
vide a study of 95% power (assuming the 5%
level of significance) was 427. Only 417 pa-
tients were recruited in the time available.
Patients admitted to two orthopedic wards in
a large teaching hospital were invited into the
study on a voluntary, informed basis. The fol-
lowing inclusion criteria were used: (1) consec-
utive orthopedic patients admitted to two
matched orthopedic wards (both elective and
trauma patients); (2) aged over 18; (3) not
working permanent night shifts; (4) not suffer-
ing from concomitant terminal disease; (5) not
confused/cognitively impaired.
Data Collection
The study was conducted in two phases: a
baseline phase (phase 1) during which data
were collected from two matched wards, and
phase 2, during which an intervention de-
signed to improve pain at night was introduced
on one of the wards. The majority of patients
were recruited on the day of admission (or as
soon as possible thereafter). The patients were
interviewed on the morning of the second
postoperative day by a research nurse. The five-
page semistructured interviews were con-
ducted by two research nurses and one of the
authors. The nurses involved in the data collec-
tion were provided with standard information
about how to conduct the pain assessments.
During the pilot phase, the pain assessments
were conducted jointly to allow for discussion
about any differences in interpretation.
441
A structured questionnaire was used. This in-
cluded retrospective assessments of overnight
pain (worst and average) using the VAS and the
5-point VRS already in use on the wards (Table
2). The reported average and worst overnight
pain scores were obtained using both scales.
The method of retrospective pain scoring has
been shown to produce reliable ratings by Lui
and Aitkenhead,32 and Babul et al.33 Lui and
Aitkenhead assessed patients undergoing total
abdominal hysterectomy using repeated hourly
contemporaneous and single retrospective
scores over 24 hours. The two measures demon-
strated good correlation and the authors con-
cluded that average VAS scores were a reliable
method of pain assessment.32 Babul et al. con-
ducted a similar study in postoperative orthope-
dic patients and provided evidence that the
memory for acute pain is reliable and that the
use of an average pain score can have advan-
tages over hourly pain scores which can be cum-
bersome, intrusive, and expensive, and would
have been unethical and impractical at night.33
Because these data were collected as part of
a broader intervention study, patients were
asked to complete both scales. It would have
been inappropriate to assign different scales to
different patients because that would have pre-
sented difficulties in determining whether the
changes in outcomes seen were due to the in-
tervention or the scale used.13
First, patients were asked to mark the VAS to
represent the average pain they had experienced
during the previous night and then to indicate
their pain intensity using the VRS. As a measure
of reliability, patients were asked to score their
pain at the beginning of the interview and this
Table 2
Corresponding VRS Categories and
VAS Scores (in mm)
VAS VAS VAS
VRS (categories) (median) (mean) (range)
0 5 no pain 0 0.5 0–10
1 5 no pain at rest,
slight pain
on movement 20 20.3 2–50
2 5 slight pain at rest,
moderate pain
on movement 35 36.8 0–92
3 5 moderate pain at rest,
severe pain
on movement 63 59.7 21–92
4 5 severe pain at rest
and on movement 70 72.6 35–100
442 Briggs and Closs
was then repeated at the end of the interview
(15–30 minutes later). Pain scores were accepted
if they agreed to within 5 mm for the VAS. All pa-
tients who were able to complete the VAS scores
repeated them reliably (i.e., within 5 mm).
The VRS scores were obtained using a lami-
nated A4 size sheet with the adjectives displayed
in large print. Patients could point to categories
of pain response as well as having them read out
by the interviewer if preferred. Patients were
asked to point to or state which category most
closely described their worst and average pain
during the previous night. The scores were ob-
tained at the beginning and the end of the inter-
view in line with the VAS data collection. The VAS
scores were obtained first and the VRS scores sec-
ond to minimize bias caused by patients trying to
match the word chosen with a mark on the VAS.
The data were analyzed using descriptive statistics
and Spearman rank correlations were used to as-
sess the relationship between VAS and VRS.
Results
Description of the Relationship between VAS
and VRS
The mean, median, and range of VAS and
VRS scores for worst pain are outlined in Table
2. Spearman’s rank correlation coefficient for
the two scales was 0.79, P , 0.00001 (worst
pain) and for average pain it was 0.70, P ,
0.00001. This indicates that the VAS and VRS
scores were highly positively correlated, al-
though this association may have been artifi-
cially high because both scales were used at the
same time. Despite this correlation, the wide
ranges of VAS scores chosen in relation to the
Table 3
A Comparison of Age and Gender of Total Sample, Compliers and
Noncompliers (VAS Only)
Group Gender
Whole sample Male n 5 219
(n 5 417)
Female n 5 198
Compliers Male n 5 197
(n 5 358)
Female n 5 161
Noncompliers Male n 5 22
(n 5 59)
Female n 5 37
Vol. 18 No. 6 December 1999
VRS categories represent significant individual
patient variability. For example, the study par-
ticipants who selected “severe” (i.e., a score of
4 on the VRS) to describe pain, marked any-
where from 35–100 mm on the VAS.
Characteristics of the Noncompliant Groups
The age and sex distribution of patients un-
able to use the VAS is outlined in Table 3. Due
to the high compliance rate for the VRS, the
age and sex distribution for noncompliers for
VRS is not shown. The mean age for noncom-
pliers was 70.2 (SD 17.3) years, while it was 52.7
(SD 20) for the compliers. A Mann-Whitney U
test showed this difference to be statistically sig-
nificant (Z 5 26.46, P , 0.0001). Cross-tabula-
tions of compliance with sex and with type of
surgery also showed some significant differ-
ences. Chi-square tests showed that noncompli-
ers were more likely to be female than male
(x2 5 6.39, 1 df, P , 0.02) and to have had
trauma rather than elective surgery (x2 5 4.35,
1 df, P , 0.04). The sample contained a large
proportion of elderly women who had sus-
tained orthopedic trauma and it appears likely
that this group had the greatest difficulty using
the VAS.
Finally, noncompliers were less likely to have
received analgesics during the night (x2 5 6.47,
1 df, P , 0.02), but their pain scores (as elicited
by the VRS) were not significantly different from
the compliers (average pain: Z 5 20.71, P .
0.4; worst pain: Z 5 0.53, P . 0.5).
Reasons for Noncompliance
Fifty-six percent (n 5 33) of noncompliers
could not complete the VAS due to lack of un-
Age (yrs)
Mean 5 47.2 (SD 6 20.2)
Range 5 18–91
Mean 5 63.9 (SD 6 17.2)
Range 5 18–94
Mean 5 45.8 (SD 6 19.5)
Range 5 18–91
Mean 5 61 (SD 6 17.4)
Range 5 18–94
Mean 5 59.5 (SD 6 22.4)
Range 5 18–87
Mean 5 76.4 (SD 6 8.9)
Range 5 53–90
Vol. 18 No. 6 December 1999 Postoperative Pain in Orthopedic Patients
derstanding. Almost one-third (n 5 17) could
not complete the VAS due to a physical restric-
tion (for example, fractures in their hands or
elbow replacements) or communication diffi-
culties, such as a visual or hearing impairment.
The reasons for noncompletion are displayed
in Table 4.
Noncompliance Rates
Fifty-nine patients could not complete the
VAS. This represents a 14.1% noncompliance
rate for the whole sample. In contrast, only 2
patients could not use the VRS, a 0.5% non-
compliance rate.
Discussion
Comparison of the VAS and VRS showed
high positive correlations. Although consis-
tent with other findings,15,18,23,34 this result may
be due in part to the way the scales were ad-
ministered. Because the scales were adminis-
tered concurrently, it could be argued that pa-
tients may have tried to match the two scores.
Therefore the correlation should be inter-
preted cautiously. Despite this limitation, it is
interesting to note that the ranges of the scores
are very wide (see Table 2), which suggests that
it is misleading to assume that VAS scores cor-
respond simply with VRS scores, such as no
pain (0 mm), mild pain (0–30 mm), moderate
pain (30–65 mm), severe pain (65–100 mm).
Indeed, from the findings presented in this pa-
per, the patient who marks the pain as 40 mm
on a VAS could define his or her pain as either
slight, moderate, or severe (see Table 2).
These findings follow a similar pattern to those
reported by Collins et al.35 who conducted a
meta-analysis of individual patient data from
11 controlled double-blind randomized trials,
in which VAS and VRS were used to measure
pain. This demonstrates that the patients have
Table 4
Reasons for Noncompletion of the VAS (n 5 59)
Reason for noncompletion Number (%)
Unable to understand 33 (56%)
Visual impairment 10 (17%)
Physical restriction 7 (12%)
Refused 4 (7%)
Reason not documented 4 (6%)
Hearing impairment 1 (2%)
443
an individual interpretation of the VAS line
which may not be communicated to the re-
searcher or clinician. The reason for these
large ranges could partly be attributed, in this
study, to the use of a combination of “at rest”
and “on movement” verbal descriptors. Al-
though this may in part provide an explana-
tion, it does not explain the variation for the
“no pain” category or the “severe pain” cate-
gory, or the findings of Collins et al. when sin-
gle descriptive adjectives were used.35
This study suggests that for orthopedic surgi-
cal patients, compliance is better with VRSs.
Noncompliance figures for the VAS in this
study were within the range of those quoted in
other reviews and studies,6,16,17 and represent a
significant proportion of the overall sample.
Despite reported noncompliance rates of at
least 7% of a sample, it is rare for studies using
VAS scores to reveal noncompliance rates and,
therefore, rendering critical review of these re-
search papers is difficult.
In addition to those who were recruited into
this study, a further 190 patients could not be
recruited. The reasons for the nonrecruitment
of these patients are outlined in Table 5 and
broadly reflect the inclusion criteria. Patients
were approached prior to surgery, with the ex-
ception of some trauma patients who went di-
rectly from Accident and Emergency to theatre.
The most common reasons for not recruiting
patients were when patients were cognitively
impaired or too ill to communicate verbally.
These patients could not be included in the re-
search, as they were unable to complete the
five-page structured questionnaire and there-
fore they were not given the opportunity to
complete the pain scales. These patients may or
may not have been able to complete the pain
score section of the interview. For example, in a
study of a random sample of 325 people with
substantial cognitive impairment, Ferrell et al.36
reported compliance rates of 44% for a VAS
and 59–65% for VRSs. In light of this finding,
we are unable to say with certainty that this
group of patients were unable to comply with
the pain scales in this clinical setting; rates of
noncompliance would be higher than 14% if
these patients were included.
Reasons for noncompliance were not solely
due to lack of understanding or increasing age
(see Table 4). A significant proportion could
not complete the VAS due to a physical restric-
444 Briggs and Closs
tion or communication difficulties. Some prob-
lems may be unique to the research setting.
For example, in the orthopedic wards, patients
with upper limb trauma (fractures of the wrist,
shoulder, hand, and elbow), those having el-
bows and shoulder joint replacements, those
with arthritis in the hands, and those restricted
to flat bed rest/traction found the VAS particu-
larly problematic to complete.
When selecting pain measurement instru-
ments for research, investigators need to be
aware of the strengths and weaknesses of each
instrument and the practical problems associ-
ated with administering the scales. It would
seem that the VAS provides useful data for se-
rial measurements in the same individual when
movement from the patient’s own baseline is
the important outcome measure. In this situa-
tion, the VAS has the benefits of increased sen-
sitivity, provision of ratio data, and analysis
using parametric statistics. However, some au-
thors discourage the use of the VAS as the pri-
mary (or sole) measure of pain intensity in
postoperative populations and suggest the use
of more than one scale.2 In postoperative pain
studies, the risk of high noncompliance rates
with the VAS could be avoided by using a VRS.
The sensitivity and ratio properties of the VRS
could be enhanced by using a VRS with a
greater number of adjectives developed using
methods like cross-modality matching, for ex-
ample, the 15-point verbal scale developed by
Gracely et al.13,14
From a clinical practice perspective, the use
of reliable and valid methods to aid the commu-
nication of the level of pain experienced by pa-
tients is an essential part of good quality nursing
care.28 However, the use of more than one pain
measurement method would be time-consum-
Table 5
Reasons for the Inability to Recruit
to the Study (n 5 190)
Reason for not recruiting Number (%)
Patient was confused/
cognitively impaired 76 (40%)
Too ill to communicate verbally 43 (23%)
Declined invitation to participate 24 (13%)
Other (poor English, CVA,
discharged before 2nd
postoperative day) 22 (11%)
Recruited during previous admission 18 (9%)
Suffering from terminal disease 7 (4%)
Vol. 18 No. 6 December 1999
ing and impractical in most acute settings. In
clinical practice, the assessment of pain involves
an overall appraisal of an individual’s experi-
ence and represents a contextual judgment to
guide clinical decision making. This contrasts
with the use of pain measurement methods in
research where, often, the aim is to quantify the
extent and degree of pain experienced to pro-
vide a bias-free comparison of outcomes be-
tween patients or groups of patients.37 It would
appear from the findings presented in this pa-
per and the literature reviewed that verbal rat-
ing scales may be more practical for use in clini-
cal practice postsurgery because they allow a
rapid overall appraisal of pain by the patient,
have higher compliance rates, and the issues re-
garding sensitivity to change are less relevant.
Conclusion
The ability to evaluate pain experiences is an
essential feature of high-quality nursing prac-
tice and research.28 There are numerous meth-
ods of measuring and assessing pain. All tend
to rely on the self-report as the most direct way
to access the information required.2,11,37–39
Each method has strengths and limitations.
This paper has highlighted practical and con-
ceptual problems regarding the use of VASs in
postoperative orthopedic patients. Researchers
and clinicians should be aware of the proper-
ties of the relevant instruments when selecting
a method of pain appraisal for their patient
group. This paper provides useful data to
guide decision making for professionals caring
for patients undergoing orthopedic surgery.
Acknowledgment
We would like to acknowledge the support
of the NHS Executive, Northern and York-
shire, who funded this project. In addition, we
thank Viv Everitt and Jo Regan for their invalu-
able help in completing the data collection. Fi-
nally, we are extremely grateful to all the nurs-
ing staff on the two orthopedic wards and John
Kelly and Jane Nixon whose commitment and
support made the project possible.
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