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Verbal Rating Scales

Verbal rating scales are powerful tools used to assess pain experiences. Verbal rating scales, also known as verbal pain scores and verbal descriptor scales, are self-reports which consist of a number of statements designed to describe pain intensity and duration (Karcioglu et al., 2018). Such descriptors help patients and clinicians understand the nature of both acute and chronic pain, leading to effective pain assessment and medication management.

Visual Rating ScalesNumerical Rating ScaleEmojinationDue to the complex and subjective nature of pain experiences in both children and adults, objective methods become inapplicable to pain assessment. Pain cannot be directly observed by clinicians or measured via laboratory tests. Consequently, subjective measures become paramount tools in medical research and routine clinical care. Patient-reported outcomes are defined as reports regarding a patient’s health status that come directly from the patient. Patient-reported outcome instruments have numerous applications in today’s digital health industry. To set an example, such measurements can be used to assess clinical trial efficacy endpoints and product differentiation. Thus, the selection of an appropriate pain assessment tool is vital – with verbal rating scales being powerful instruments in pain evaluation and treatment.

Pain assessment is a key factor in the effective treatment of pain. According to the World Health Organization pain is “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Karcioglu et al., 2018).  Although pain has a reproductive and evolutionary meaning, both acute and chronic pain are major health concerns worldwide. Pain is not only a sensory but an emotional experience. Chronic pain, for instance, can lead to disabilities, mental health problems, and financial loss. Moreover, chronic pain in children and adolescents is a significant problem which is often undertreated in clinical settings.

Benefits of Verbal Rating Scales: Verbal rating scales reveal numerous benefits in medical research and clinical practice. Self-reports allow researchers to evaluate an internal and complex experience such as pain, improving pain management and empowering patients. As explained above, verbal rating scales consist of easy to interpret descriptors that range pain. Descriptors can vary from four (e.g., “none”, “mild”, “moderate”, “severe”) to 15. Some verbal rating scales include the following five-point sets of descriptors which facilitate pain evaluation and treatment (Mutebi et al., 2016):

  1. “None”, “mild”, “moderate”, “severe”, “very severe”
  2. “Never”, “rarely”, “sometimes”, “often”, “always”
  3. “Poor”, “fair”, “good”, “very good”, “excellent”
  4. “Not at all”, “a little bit”, “moderately”, “quite a bit”, “extremely”
  5. “Not at all”, “a little bit”, “somewhat”, “quite a bit”, “very much”

Limitations of Verbal Rating Scales: Despite its benefits in clinical care, the verbal rating scale has several limitations. The interpretation of descriptors may be influenced by various factors, such as age, sex, and education. In fact, the use of verbal rating scales can challenge vulnerable participants (e.g., children, patients with mental health problems, people with limited vocabulary), which can lead to under or overestimation of patients’ pain experiences. Patients with limited literacy, for instance, may not be able to express their experiences using a single descriptor. Language barriers can also limit the use of verbal rating scales across populations. Thus, experts recommend adjusting for demographic and clinical factors in data analyses. Another disadvantage is the limited number of choices (compared to numeric and visual analog scales), which might affect precision and sensitivity.

Usage of Verbal Rating Scales: Verbal rating scales, however, can be applied to a wide range of settings. These scales are quick to administer, and descriptors are easy to interpret. Since participants have to read the descriptors to respond, verbal rating scales reveal high compliance. Interestingly, research showed that 60% of patients who had verbal rating scores documented in their health records received analgesia. In addition, those with higher scores were more likely to be treated in a timely and effective manner.

Psychometric Properties of Verbal Rating Scales: The verbal rating scale reveals good psychometric properties (Haefeli & Elfering, 2006). Usually, the selection of an appropriate measurement with high validity, reliability, and responsiveness is fundamental. Research shows that the verbal rating scale correlates well with other pain measurements. Compliance is also high as respondents must read the whole set of descriptors before they rate their pain experience. Although some experts assume that descriptors should provide interval level data, the interpretation of the scale varies between subjects and may be reduced to ordinal data level (Mutebi et al., 2016). Note that in ordinal scales, the order of the values matters, while the distance between each variable is not known (e.g., “unhappy,” “happy,” “very happy”). Interval scales, on the other hand, provide both order of values and significant differences between two variables (e.g., Celsius temperature). In fact, as the verbal rating scale is often interpreted as a categorical ordinal scale, results can be analyzed using non-parametric statistics.

Descriptors and Verbal Assessments: Descriptors allow patients to select a statement that fits their pain experience. Note that descriptors, composed of four or more verbal adjectives, can be assigned a numeric score to facilitate analyses. Interestingly, there’s high variability in the interpretation of the descriptors in the middle of the rating scale. Mutebi and colleagues (2016) showed that when it comes to five-point sets of descriptors, the following sets are interpreted with the least variation: a) “None”, “mild”, “moderate”, “severe”, “very severe”, and “not at all”; b) “A little bit”, “moderately”, “quite a bit”, and “very much”. Interestingly, the study team recruited 6,000 subjects divided into four groups: 1) subjects taking medications for pain and arthritis; 2) subjects prescribed medications for anxiety and depression; 3) patients with cardiovascular problems; and 4) patients with respiratory conditions. Results showed that demographic factors influence the interpretation of descriptors and verbal rating scales.

Digital Verbal Rating Scales: With the increasing use of technologies in health care, the electronic implementation of verbal rating scales is more than desirable. The development of digital verbal rating scales requires some special consideration regarding cognitive load and readability. In case experts implement interactive voice record (IVR) technology, the response choices must be entered in spoken format. Response options should be consistent, short, and presented before the entry value (e.g., “For ‘very much’ press 5.”). Consequently, responses should be confirmed by the subject (e.g., “You entered ‘very much,’ is that correct?”). For tablets and mobile devices, screen size, font size, and orientation (vertical/horizontal) should be considered. Note that the area on the screen that can be tapped to give a response should be identical for each response choice. Despite all the challenges in digital health software development, research shows that electronic and multimedia tools are preferred by patients worldwide.Pain Assessment: Pain assessment is a complex process. It’s not surprising that a large number of pain questionnaires and digital journals are designed to assess factors, such as pain intensity, pain affect, qualities of pain, pain duration, variability, and pain behaviors. As both acute and choric pain experiences are major health concerns, pain assessment is vital. Such evaluation has diagnostic importance and plays a crucial role in decision-making. Pain assessments and reassessments help clinicians monitor the longitudinal course of medical conditions and medication compliance. Note that pain treatment should tackle a wide range of social, psychological, and physiological aspects (Fillingim et al., 2016).

Nonverbal Rating Scales: Although verbal rating scales have numerous applications across settings and populations, nonverbal scales can also improve pain assessment, especially in vulnerable and nonverbal patients. For instance, behavioral pain scales can be used in intubated patients. Such scales use body language and observations to assess a patient’s experience. Behavioral pain scales include aspects, such as facial expression (e.g., relaxed), movements of upper limbs (e.g., partially bent), physiologic signs (e.g., stable vital signs), and compliance with ventilation (e.g., fighting ventilator).

Verbal Rating Scales in Digital Health: Conclusion

            From verbal rating scales to nonverbal self-reports – pain assessment is essential. In fact, pain is an internal and complex phenomenon, which requires the use of patient-reported outcome measurements. Self-reports help patients evaluate their pain experiences and seek adequate pain treatment. Given the multidimensional nature of pain, comprehensive assessments must be implemented in research and practice. Pain assessments should focus on the entire person, with all the emotional, cognitive, and social aspects that affect pain severity and duration. What’s more, subjective measurements are vital tools which have the potential to empower patients and improve doctor-patient communication.

Verbal rating scales, in particular, are popular self-reports used to assess pain experience in both adults and children. They consist of descriptors that facilitate pain assessment. These scales reveal good psychometric properties and high compliance. Electronic verbal rating scales, specifically, are preferred tools in digital health as they support high-quality data and interoperability. With the leveraging use of technologies, electronic assessments and multimedia tools have become essential in medical research and routine clinical care. Verbal rating scales are among the most powerful self-assessments, which can revolutionize health care and improve patient outcomes.Aicher, B., Peil, H., Peil, B., & Diener, H. (2011). Pain measurement: Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS) in clinical trials with OTC analgesics in headache. Cephalalgia, 32 (3), p. 185–197.

Bech, R., Lauritsen, J., Ovesen, O., & Oveegaard, S. (2015). The Verbal Rating Scale Is Reliable for Assessment of Postoperative Pain in Hip Fracture Patients. Pain Research and Treatment.

Fillingim, R., Loeser, J., Baron, R., & Edwards, R. (2016). Assessment of Chronic Pain: Domains, Methods, and Mechanisms. The Journal of Pain, 17 (9).

Haefeli, M., & Elfering, A. (2006). Pain assessment. European Spine Journal, 15 (1).

Hjermstad, M., Fayers, P., Haugen, D., Caraceni, A., Hanks, G., Loge, J., Fainsinger, R., Aass, N., & Kaasa, S. (2011). Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review. Journal of Pain and Symptom Management, 41 (6), p. 1073-1093.

Karcioglu, O. (2018). An Eternal Challenge: Assessment and Documentation of Acute Pain İn the Emergency Setting. Journal of Anesthesia and Intensive Care Medicine.

Karcioglu, O., Topacoglu, H., Dikme, O., & Dikme, O. (2018). A systematic review of the pain scales in adults: Which to use? The American Journal of Emergency Medicine, 36 (4), p. 707-714.

Kliger, M., Stahl, S., Haddad, M., Suzan E., Adler, R., & Eisnberg, E. (2014). Measuring the Intensity of Chronic Pain: Are the Visual Analogue Scale and the Verbal Rating Scale Interchangeable?   Pain Practice, 15 (6), p. 538-547.

Mutebi, A., Slack, M., Warholak, T., Hudgens, S., & Coons, S. (2016). Interpretation of verbal descriptors for response options commonly used in verbal rating scales in patient-reported outcome instruments. Quality of Life Research, 25 (12), p. 3181-3189.

Safikhani, S., Gries, K., Trudeau, J., Reasner, D., Rudell, K., Coons, S., Bush. E., Hanlon, J., Abraham, L., & Vernon, M. (2018). Response scale selection in adult pain measures: results from a literature review. Journal of Patient-Reported Outcomes.