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Journal of Occupational Rehabilitation, Vol. 11, No. 2, June 2001 (

Comparison Between the CR10 Borgs Scale

and the VAS (Visual Analogue Scale) During
an Arm-Cranking Exercise
E. M. Capodaglio1,2

Two subjective assessment scales (VAS and Borgs CR10) are compared in a group of 15
young and healthy subjects performing an arm-cranking incremental steady-state exercise.
Arm-ache and breathlessness were evaluated at each step, together with the measurement
of heart rate (Hr) and blood lactate (Bl). Both arm-ache and breathlessness show a slight
positively accelerating increase with workload as evaluated by CR10, while there exists
a linear increase by VAS. A very good linear correlation (0.99, p < 0.05) was found
between subjective assessments given on the CR10 and a simple combination of Hr and Bl.
Reproducibility of both the scales and of the physiological variables was found to be good.
KEY WORDS: Borgs CR10 scale; VAS; arm-cranking.

INTRODUCTION
Both the CR10 Borgs scale (1) and the VAS (1923) are tolls commonly used for the
measurement of subjective perceptions, especially of pain and perceived exertion. Although
both the scales could benefit from ratio properties (1,2), the statisticians suggest caution with
the treatment of the VAS data and application of nonparametric methods (3,4). Moreover,
this scale tends to restrict the rating behavior into a linear regression, while many psychophysical functions are of logarithmic or exponential nature. According to Neely (5), the
CR10 scale seems better than the VAS with respect to its ability to discriminate among the
most extreme and maximal intensities, and to facilitate communication; moreover, for exercise of a steady-state type with increasing workloads, the incremental curve for perceived
exertion correlates very well with physiological variables (heart rate (Hr) and blood lactate
(Bl)) (6). Other questions arise concerning the semantic and arithmetic abilities required to
use the CR10 scale, and the level of reproducibility and reliability of these and other scales
(79). While in other studies the rating scales were applied during treadmill (10) and cycleergometer (11,12) tests, few studies have been done measuring the subjective feeling of
exertion during arm exercise.
1 Center of the Study of Motor Activity (CSAM), Salvatore Maugeri Foundation, Scientific Institute of Pavia, Italy.
2 Correspondence should be directed to E.

M. Capodaglio, Center of the Study of Motor Activity (CSAM), Salvatore

Maugeri Foundation, Scientific Institute of Pavia via Ferrata, 8-Pavia 27100, Italy; e-mail: ecapodaglio@fsm.it.
69
C 2001 Plenum Publishing Corporation
1053-0487/01/0600-0069$19.50/0

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Capodaglio

MATERIALS AND METHODS

Fifteen young and healthy subjects (aged 31 5) performed an incremental armcranking exercise (Monark, Sweden), at 60 rpm, incrementing 15 W every 4 min, until
exhaustion. The subjects were properly instructed to use both the CR10 and the VAS,
random administrated, to evaluate arm-ache and breathlessness; the rating on the VAS was
done indirectly, with the technician moving a pen slowly along the line, and signing the
notch immediately when the subject stopped him verbally. In the last 30 s of each step Hr
(Polar, Finland) and Bl (Eppendorf, Holland) from ear sample were measured; arm-ache
and breathlessness were evaluated in the last minute of each step. The test was repeated
after 2 weeks with the subjects in the same conditions and varying the order in which the
scales were submitted.
Five steps were considered for analysis, with all the 15 subjects completing 4 min at
75 W. The increasing functions for arm-aches and breathlessness were studied, as evaluated
with VAS and CR10. The correlation between the perceptive and the physiological variables,
and the level of reproducibility were also considered (Statistica for Windows, v. 5.0).

RESULTS
Arm-ache and breathlessness measured by CR10 show a slight positively accelerating
increase with workload, while there exists a linear increase by VAS. The functions calculated
for arm-ache result in exponential increase (f1(x) , with exponent of 1.6) for CR10 and a
linear one (f2(x) ) for VAS (Fig. 1); the same is true for breathlessness. The accelerating

Fig. 1. Functions calculated for arm ache as evaluated by CR10 (f1) and by VAS (f2), and for blood lactate (f3).

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Table I. Subjective Assessments (Means and Standard

Deviations) Given at the Highest Workloads
CR10
60 W
Arm-ache
Breathlessness
75 W
Arm-ache
Breathlessness

VAS

6.8 0.7
4.8 1.0

6.4 0.9
4.4 1.1

9.7 0.7
7 1.1

8.2 0.8
6.3 1.2

Note. Statistical difference between arm-ache and breathlessness: p < 0.005. Statistical difference between CR10 and
VAS: p < 0.05; p < 0.005; p < 0.0005.

curve computed for Bl (f3(x) ) shows an exponent of 2.1 (Fig. 1). Hr linearly increases with
workload.
By CR10, arm-ache (local factor) is rated significantly higher ( p < 0.005) than breathlessness (central factor); in general, both assessments are rated higher on CR10 than on
VAS, especially at the highest workloads (Table I).
A simple combination of Hr and Bl [(Hr% + Bl%)/2], indicated by Borg (1987) as
a new variable, was computed and related to the CR10 assessments, transformed into a
percentage of the variation range; a very good linear correlation was obtained (0.99, p <
0.05), which confirms the reliability of this scale with respect to the psychophysical theory,
that is to say that most of the variation in perceived exertion may statistically be explained
by the variation of the physiological variables.
VAS, rated both with respect to arm-ache and breathlessness, significantly correlates
with Hr (0.95 and 0.94, respectively), though not with Bl.
CR ratings significantly correlate (0.990.98) with VAS, both with respect to arm-ache
and to breathlessness.
Reproducibility of the scales was tested considering the proportion of total variability
explained by the between-subject variability (Anova-repeated measures) in the two sessions (Table II). Reproducibility for arm-ache through CR10 ranges from 99 to 74%, and
through VAS from 83 to 53%; reproducibility for breathlessness through CR10 ranges from
91 to 50%, and through VAS from 81 to 24%. The physiological variables, Hr (9790%) and

Table II. Mean Values Obtained in the Two Sessions for Each Variable

Session I
15 W
30 W
45 W
60 W
75 W
Session II
15 W
30 W
45 W
60 W
75 W

Hr

CR arm

CR breath

VAS arm

VAS breath

Bl

97 (15)
113 (21)
137 (31)
142 (25)
148 (14)

1.8 (0.7)
3.3 (1.6)
5.4 (1.2)
6.8 (0.7)
9.7 (0.5)

1.2 (0.8)
2.2 (1.2)
3.7 (1.0)
4.8 (0.9)
7.0 (0.8)

1.5 (0.6)
2.6 (0.7)
4.7 (1.6)
6.4 (0.9)
8.2 (0.6)

0.9 (0.5)
1.4 (1.0)
3.5 (1.2)
4.6 (1)
6.3 (0.9)

2.2 (0.6)
3.2 (0.7)
4.6 (0.9)
5.9 (1.1)
8.2 (0.9)

90 (15)
106 (21)
125 (31)
138 (30)
146 (19)

1.5 (0.4)
3.1 (0.6)
5.2 (1.1)
6.3 (0.9)
9.7 (0.4)

0.9 (0.2)
2.0 (0.6)
3.6 (1.0)
4.3 (0.7)
7.7 (0.3)

1.2 (0.5)
2.4 (1.2)
4.5 (1.8)
5.8 (0.8)
8.3 (0.9)

0.7 (0.3)
1.6 (0.8)
2.8 (1.4)
3.6 (0.5)
6.4 (0.8)

2.3 (0.8)
3.2 (0.9)
4.5 (1.1)
5.7 (1.2)
8.6 (1.1)

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Capodaglio
Table III. Percent of Total Variability Explained by the Between-Subjects
Variability (ANOVA)

15 W
30 W
45 W
60 W
75 W

Hr

CR arm

CR breath

VAS arm

VAS breath

Bl

90
91
93
96
97

74
77
85
88
99

77
50
73
76
91

69
53
62
81
83

54
24
88
81
81

72
87
79
87
99

Bl (9972%), were highly reproducible. In Table III, the percent of variability is shown for
each variable.
DISCUSSION
Arm-cranking exercise is a mode that is commonly chosen for endurance conditioning
using the upper extremities in rehabilitative medicine. Prescriptions for upper body exercise
are often based on the results of tests involving the lower extremities. Exercise performed
with arms is more strenous than leg exercise, due to the smaller muscle mass involved, and
the cardiovascular strain is greater, which results in a higher systolic and diastolic pressure.
Workload must be established based on the persons response to this form of exercise, and
not from some other exercise stress test, such as bicycling and running.
Relative intensity is usually assigned as some percentage of maximum function, for
example, max VO2 , maximum heart rate, or maximum working capacity. The general
practice for establishing aerobic training intensity is to either directly measure or estimate the
persons max VO2 or maximum heart rate, and then assign a work schedule that corresponds
to some percentage of these maximums.
Levels from 30 to 50% of maximal VO2 for physical work have been given as overall
acceptable limits for avoiding anaerobic metabolism during an 8-h work shift. The available
recommendations are mainly based on development of fatigue in prolonged dynamic work
using large muscle groups (cycling, walking, running, and lifting). The peak VO2 varies
greatly from one work mode to another, and the cardiovascular and subjective responses
are dependent on the active muscle mass and the type of exercise performed. The highest
oxygen consumption achieved by men and women during arm exercise is generally about
7080% of the max VO2 during leg exercise (13); similarly, the maximal values for heart
rate and pulmonary ventilation are lower with arm exercise.
It is yet be demonstrated that regulating exercise intensity, using ratings of perceived
exertion (RPE), is physiologically valid during arm ergometry at both 50 and 70% VO2 peak
(14). It seems also that a facilitated sensory process, due to the smaller muscle mass involved
and the greater localization of muscular fatigue, mediates a more accurate assessment of
exertional intensity during arm than leg exercise.
Both CR10 and VAS have been shown to measure in a reproducible way symptoms
during steady-state exercise, and to be better in respect to the Likert scale (9).
The responses obtained in the study by Borg (15) were about twice as high or more
for arm exercise than for cycling. The biggest difference was found for Bl and the smallest
for Hr and RPE. The incremental functions were similar in both activities (approximately
linear increase in Hr and RPE, and positively accelerating functions for CR and BL). When

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perceived exertion was set as the dependent variable and a simple combination of Hr and
Bl was used as the independent variable, a linear relationship was obtained both for leg and
arm cranking, as had been previously found in cycling, running, walking, etc.
The CR10 scale is therefore particularly indicated when exercise prescription must be
given without performing a maximal test on the patient. The predictive validity of CR10 with
respect to performance allows selection of the training intensity based on the individuals
strain response (Hr and Bl), and the monitoring of the improvement in fitness through a
very simple method.
The exponents in this study are similar to that previously found by Borg (15). CR ratings
increase according to a true psychophysical function, that is an incremental one (1), with
a strong relationship with the physiological variables. As Jensen (16) suggests, although
different scales (numerical, verbal, analogue) for the measurement of pain are valid, the most
recommended is a numerical scale from 0 to 100. A modified CR100 scale (a fine-graded
version of the CR10) has also been proposed by Borg (17) for improving communicability
and intersubjective comparisons.
During arm-cranking exercise, the local factor (arm-ache), related to feelings of strain
in the exercising muscle and/or joints, prevails over the central one (breathlessness), related
primarily to sensations from the cardiopulmonary system, and determines the end of the test.
In conclusion, many advantages make the CR10 scale useful and effective in sports
and clinical medicine applications; the good level of reliability and reproducibility make
it a valid tool for monitoring the intensity of the training and for exercise prescription in
the particular mode of arm-cranking exercise, which is particularly appropriate for selected
subjects, especially paraplegics, amputees, and those with peripheral vascular diseases or
lower extremities disabilities (18). Not only at the highest workload CR10 best represents
the exponential increase of the physiological variables that are related to the development
of local fatigue, but it is also significantly related with a combination of Hr and Bl at each
step of incremental steady-state exercise. CR10 significantly correlates with VAS, which is
already universally accepted as a tool for pain assessement; yet CR10 is reccommended both
for extrapolation of performance to predetermined level of reference, and for comparison
of changes in individuals fitness.
REFERENCES
1. Borg G. A category scale with ratio properties for intermodal and interindividual comparisons. In: Geissler
HG, Petzold P, eds. Psychophysical judgement and the process of perception. Berlin: VEB Deutscher Verlag
der Wissenschaften, 1982, pp. 2534.
2. Price DP, McGrath PA, Rafii A, Buckingham B. The evaluation of visual analogue scale as ratio scales
measures for chronic and experimental pain. Pain 1983; 17: 4556.
3. Syrjala KL, Chapman CR. Measurement of clinical pain: A review and integration of research findings. In:
Benedetti C, Chapman CR, Moricca G, eds. Advances in pain research and therapy, Vol. 7. New York: Raven
Press, 1984, pp. 71101.
4. Scott PJ, Huskisson EC. Graphic representation of pain. Pain 1976; 2: 175184.
5. Neely G, Ljungreen G, Sylven C, Borg G. Comparison between the visual analogue scale (VAS) and the
category ratio scale (CR10) for the evaluation of leg exertion. Int J Sports Med 1992; 13: 133136.
6. Borg G, Van Der Burg M, Hassmen P, Kaijser L, Tanaka S. Relationships between perceived exertion, HR
and HLa in cycling, running and walking. Scand J Sports Sci 1987; 9(3): 6977.
7. Harms-Ringdahl K, Carlsson AM, Ekholm J, Raustorp A, Svensson T, Toresson HG. Pain assessment with
different intensity scales in response to loading of joint structures. Pain 1986; 27: 401411.
8. Grant S, McMurray J, Aitchison T, McDonagh T, Christie J, Davie A, Dargie HJ. The reproducibility of
symptoms during a submaximal exercise test in chronic heart failure. Br J Clin Pharmacol 1998; 45(3):
287290.

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9. Grant S, Aitchison T, Henderson E, Christie J, Zare S, McMurray J, Dargie H. A comparison of the reproducibility and the sensitivity to change of visual analogue scales, Borg scales and Likert scales in normal
subjects during submaximal exercise. Chest 1999; 116(5): 12081217.
10. Noble BJ, Borg G. Perceived exertion during walking and running. In: Piret R, ed. Proceedings of the 17th
International Congress of Applied Psychology, Brussels, 1972, pp. 387392.
11. Ljunggren G, Johansson SE. Use of submaximal measures of perceived exertion during bycicle ergometer
exercise as precidtor of maximal work capacity. J Sports Med 1988; 6: 189203.
12. Borg G, Ljuggreen G, Ceci R. The increase of perceived exertion, aches and pain in the legs, heart rate and
blood lactate during exercise on a bycicle ergometer. Eur J Appl Physiol 1985; 54: 343349.
13. Astrand PO, Ekblom R, Messin R, Saltin B, Stenberg J. Intra-arterial blood pressure during exercise with
different muscle groups. J Appl Physiol 1965; 20: 253256.
14. Kang J, Chaloupka EC, Mastrangelo MA, Donnelly MS, Martz WP, Robertson RJ. Regulating exercise
intensity using ratings of perceived exertion during arm and leg ergometry. Eur J Appl Physiol 1998; 78(3):
241246.
15. Borg G, Hassmen P, Lagerstrom M. Perceived exertion related to heart rate and blood lactate during arm and
leg exercise. Eur J Appl Physiol 1987; 56: 679685.
16. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: A comparison of six methods.
Pain 1986; 27: 177226.
17. Borg G, Borg E. Principles and experiments in category-ratio scaling. In: Reports from the Department of
Psychology, Stockholm University, 1994.
18. Davidoff GN, Lampman RM, Westbury L, Deron I, Finestone HM, Islam S. Exercise testing and training of
persons with dysvascular amputation: Safety and efficacy of arm ergometry. Arch Phys Med Rehabil 1992;
73(4): 334338.