Skip to main content


Table 1 Summary of key evidence to support response scale selection in pain

From: Response scale selection in adult pain measures: results from a literature review

Reference Article type, evidence type a, and grade b Article recommendations and rationale
Ong and Seymour 2004 [35] Expert opinion, Direct, D The VAS is simple, widely used, easily understood by most patients, and has strong validity. In general, the VAS is probably the most reliable and sensitive tool for measuring pain.
Dworkin et al. 2005 [9] Consensus guideline, Direct, D VRS and NRS are preferred over VAS by patients. VAS measures typically have greater amounts of missing data and are more difficult for older patients and patients taking opioids to understand. NRS ratings may be difficult in the presence of cognitive impairment; VRS might be easier in these circumstances. An 11-point NRS measure of pain intensity is recommended with 0 meaning “no pain” and 10 meaning “pain as bad as you can imagine.” An additional pain intensity VRS can be considered (none, mild, moderate, severe).
Williamson and Hoggart 2005 [10] Review article, Direct, B All three of the pain-rating scales explored in this review are reliable and valid (VAS, VRS, and NRS). As a tool for pain assessment the NRS is probably more useful than the VRS or the VAS.
Schofield et al. 2006 [36] Review article, Direct, B Among fifteen reviewed papers of pain tools in the adult population, one examined five different scales across a range of care home settings in the UK. It suggests that VRS was the most successful, followed by the NRS.
Litcher-Kelly et al. 2007 [37] Review article, Direct, B Authors researched which pain assessments were most frequently used in clinical trials. The most frequently used assessments were the single-item VAS and the NRS.
Phillips 2007 [38] Review article, Direct, B No recommendation provided: Tailoring the pain assessment to the individual patient and knowing when and how to use different assessment tools will substantially increase the probability of a comprehensive pain assessment. Combining the appropriate tools to identify pain intensity, location, and pain behavior is an appropriate strategy to improve assessment outcome.
Khorsan et al. 2008 [31] Review article, Direct, B The NRS provides intensity estimates relatively quickly, is highly patient-centered, and has the most value when looking at change within individuals. The simplest and least time-consuming measure is the NRS.
Grimmer-Somers et al. 2009 [28] Review article, Direct, B There is considerable detail regarding the psychometric properties of pain severity scales. VAS, VRS, and NRS are useful for quick initial assessment of one pain dimension.
Hjermstad et al. 2011 [29] Review article, Direct, B NRS-11, VRS-7, or VAS work well and are applicable in pain intensity assessment. These response scale types exhibit ease of use, strong psychometric properties, work well in clinical use, and/or are sensitive to symptoms.
Vela et al. 2011 [32] Expert opinion, Direct, D We suggest using the NRS because of its ease of use.
Cook et al. 2013 [30] Review article, Direct, B A 0–10 point NRS (“no pain” to “worst imaginable pain”) was chosen for the National Institutes of Health (NIH) Toolbox to measure pain intensity in adults because it is commonly used in clinical studies and has strong validity.
Riddle 2013 [39] Review article, Direct, B The McGill pain questionnaire and the pain VAS are the two most commonly used pain instruments in the clinical setting. Previous research has shown them to be valid and reliable in measuring acute pain.
Wolters et al. 2013 [33] Review article, Direct, B Our extensive review of pain intensity measures has led us to suggest that the NRS-11 be used to assess this endpoint domain in neurofibromatosis trials. It is brief, reliable, valid, and widely used. Additionally, it is highly recommended in clinical trials from pain experts and other consensus groups, is widely used in research and has strong reliability, validity, sensitivity to change, and feasibility in ages 8 years and older.
Green et al. 2014 [40] Review article, Direct, B The VAS-Usual pain and VAS-Worst pain were moderately correlated (r = 0.63), providing evidence of their structural validity.
  1. a Direct evidence: Primary research that compares different response scales within study. Indirect evidence: Review or expert opinion based on empirical evidence
  2. b Grade Key: A) Primary research; compares different response scales within the study; B) Review or expert opinion; based on an empirical evidence base; C) Primary research; evaluates a single response scale type within the study; and D) Review or expert opinion, based on expert consensus, convention or historical experience