Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: A systematic literature review

Marianne Jensen Hjermstad, Peter M. Fayers, Dagny F. Haugen, Augusto Caraceni, Geoffrey W. Hanks, Jon H. Loge, Robin Fainsinger, Nina Aass, Stein Kaasa

Research output: Contribution to journalReview articlepeer-review

1756 Citations (Scopus)


Context: The use of unidimensional pain scales such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), or Visual Analogue Scale (VAS) is recommended for assessment of pain intensity (PI). A literature review of studies specifically comparing the NRS, VRS, and/or VAS for unidimensional self-report of PI was performed as part of the work of the European Palliative Care Research Collaborative on pain assessment. Objectives: To investigate the use and performance of unidimensional pain scales, with specific emphasis on the NRSs. Methods: A systematic search was performed, including citations through April 2010. All abstracts were evaluated by two persons according to specified criteria. Results: Fifty-four of 239 papers were included. Postoperative PI was most frequently studied; six studies were in cancer. Eight versions of the NRS (NRS-6 to NRS-101) were used in 37 studies; a total of 41 NRSs were tested. Twenty-four different descriptors (15 for the NRSs) were used to anchor the extremes. 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 on the basis of higher compliance rates, better responsiveness and ease of use, and good applicability relative to VAS/VRS. Twenty-nine studies gave no preference. Many studies showed wide distributions of NRS scores within each category of the VRSs. Overall, NRS and VAS scores corresponded, with a few exceptions of systematically higher VAS scores. Conclusion: NRSs are applicable for unidimensional assessment of PI in most settings. Whether the variability in anchors and response options directly influences the numerical scores needs to be empirically tested. This will aid in the work toward a consensus-based, standardized measure.

Original languageEnglish
Pages (from-to)1073-1093
Number of pages21
JournalJournal of Pain and Symptom Management
Issue number6
Early online date27 May 2011
Publication statusPublished - Jun 2011

Bibliographical note

Disclosures and Acknowledgments
The EPCRC is funded by the European Commission’s Sixth Framework Programme (contract no LSHC-CT-2006-037777) with the overall aim to improve treatment of pain, depression, and fatigue through translation research. Core scientific group/work package leaders: Stein Kaasa (project coordinator), Frank Skorpen, Marianne Jensen Hjermstad, and Jon Håvard Loge, Norwegian University of Science and Technology (NTNU); Geoffrey Hanks, University of Bristol; Augusto Caraceni and Franco De Conno, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan; Irene Higginson, King’s College London; Florian Strasser, Cantonal Hospital St. Gallen; Lukas Radbruch, RWTH Aachen University; Kenneth Fearon, University of Edinburgh; Hellmut Samonigg, Medical University of Graz; Ketil Bø, Trollhetta AS, Norway; Irene Rech-Weichselbraun, Bender MedSystems GmbH, Austria; Odd Erik Gundersen, Verdande Technology AS, Norway. Scientific advisory group: Neil Aaronson, The Netherlands Cancer Institute; Vickie Baracos and Robin Fainsinger, University of Alberta; Patrick C. Stone, St. George’s University of London; Mari Lloyd-Williams, University of Liverpool. Project management: Stein Kaasa, Ola Dale, and Dagny F. Haugen, NTNU.


  • Numerical Rating Scale
  • Pain assessment
  • pain intensity
  • review
  • Verbal Rating Scale
  • Visual Analogue Scale


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