Comparing Visual-Analog and Numeric Scales

for Assessing Menstrual Pain

Cristina Lmoy, PhD

Measurements from visual-analog (VAS) and numeric scales were used to

assess menstrual pain in a prevalence study of 1,387 women in Madrid, Spain.
The data obtained from these 2 scales were compared to determine $sign$-
cant differences existed between the 2 rating methods. Findings indicated that
both scales are useful f o r assessing menstrual pain. A high degree of correla-
tion was found between the 2 scales; larger rating di3erences were seen in
only a small percentage of the sample. The numeric scale is easier and more
convenient to use than the VAS and is recommended in epidemiologic and
prevalence studies such as this one.
Index Terms: dysmenorrhea, scales, visual-analog scale

The precise measurement of pain intensity represents one of
the most frequent challenges that healthcare professionals
have to face. Traditionally, numeric scales (almost always
using a total of 6-1 1 points as ratings) have been used.
Patients are asked to quantify their pain by providing a sim-
ple general rating, usually from 0 to 5 or 0 to 10, with 0
equal to no pain and 5 or 10 representing the worst pain the
patient can imagine. Verbal scales (generally with from 5-7
categories) have also frequently been used (for instance, the
famous McGill Pain Questionnaire, which consists basical-
ly of lists of adjectives), although they are not used as often
as the numeric scales.
In the last 10 years, the visual-analog scale (VAS) has
been used more and more frequently. In this method, which
is useful for evaluating variations in pain intensity, the
patient is instructed to indicate the intensity of' his or her
pain by marking a 100-mm line with 2 extremes: no pain
and worst imaginable pain. The VAS is based on the theory
that pain intensity is continuous, without jumps or intervals,
Dr Larroy is profesor titular with the Dpto de Persondidad, Eval-
uacidn y Tratamiento Psicoligico I (Psicologia Clinica), Facuttad
de Psicologia, Universidad Complutense de Madrid, Spain.
and therefore the categorical scales (such as those of the
verbal or numeric types) cannot adequately reflect the
changes produced in this variable. The increase in the use of
the VAS in the last few years has been significant, although
from the beginning different authors such as Jensen and
Karoly,' Jensen and McFarland,* and White? have pointed
out potential problems with its use.
In fact, use of the VAS appears to be mandatory in many
pain clinics to the detriment of numeric and verbal scales4
The latter, despite their disadvantages, seem more adequate
than the visual-analog type when one is working with cer-
tain populations (eg, people whose abstract thinking skills
and capacity to establish analogies are not highly devel-
oped5). Furthermore, the numeric and verbal scales are
more time and cost efficient (ie, for data transcription in
epidemiologic studies that analyze hundreds of partici-
pants). Finally, both these categorical scales have a high,
often significant, correlation with other types of pain mea-
surement and have demonstrated excellent reliability and
~ alidity.In~ this study, I sought to confirm the hypothesis
that the evaluation of primary dysmenorrhea can be accom-
plished with either numeric scales or visual-analog scales
and that the results will be equivalent no matter which scale
is used.

179
ASSESSING MENSTRUAL PAIN

METHOD the Madrid community. All of the participants gave their

This study is part of a larger study that deals with preva- permission to use the data in this study. I rejected incorrect-
lence and symptomatology of dysmenorrhea in the state of ly completed questionnaires. Demographic characteristics
Madrid. A sample of 2,000 women completed a question- of the participants are summarized in Table 1. The final
naire about their menstrual pain. Participants accepted in sample consisted of 1,387 women who answered a ques-
the sample were required to be free of oral contraceptives, tionnaire that asked them to evaluate the average intensity
intrauterine contraceptive devices (IUDs), and gynecologic of their menstrual pain in the last menstrual period by VAS
illnesses. and by a numeric scale (Table 2).
I obtained my sample through advertisements in different RESULTS
schools of the Complutense University of Madrid, in clinics
and hospitals of the city’s sanitary area VII, in public and To compare the measurements from both scales, I multi-
private secondary schools, and in women’s associations in plied the data gathered from the numeric scale (range =
0-10) by 10 so that the new range was from 0 to 100,just as
was the VAS of 100 mm. For the global sample, the average
TABLE 1 pain intensity during the last menstrual period was 45.79
Demographic Characteristics of Participants in a Study points on the numeric scale (with a standard deviation of
Comparing Numeric and Visual-AnalogPain Scales 29.89) and 42.84 points on the VAS (SD = 29.90). The Pear-
son correlation coefficient of the measurements in both
Age range (Y) scales was .957 (p c .OOOl). The Spearman correlation coef-
Variable 13-20 21-30 3140 41-52 ficient of both measurements produced a result of .995 (p >
.OOOl). I believe this result was related to the large number
Percentage 50 25.4 16.3 8.4 of participants (19.3% of the sample) who scored either 0 or
Age (Y) 100 on both scales (in other words, they chose only the
M 16.83 24.63 35.17 43.69 extreme scores). After those scores were eliminated, the new
SLI 1.94 2.97 2.85 2.5 Spearman correlation coefficient was .933 (p c .OOOl). The
Children
M 0.01 0.17 1.09 2.11 difference in the average pain intensity rated by each of the
SD 0.13 0.54 1.02 1.26 scales was 2.95 points, with SD of 8.81 ( t = 12.339; d f =
Education 1357;p c .001), and range from 0 to 64 points.
None 0.4 0 0.4 2.6 Because the average difference was statistically signifi-
Primary school 23.4 12.9 18.8 38.8 cant, I made the following analyses. I determined that
Secondary school 58.3 23.1 38.1 29.3
University 17.9 64 42.6 29.3 21.4% of the women’s scores did not differ, although 19.3%
of the sample scored in the extremes on both scales. The
percentage of women whose scores differed in absolute
value from 0 to 5 points was 62.9%. There were no signifi-
TABLE 2 cant differences between these 2 groups regarding age or
Comparison of Pain Ratings on educationaYprofessional levels. The percentage of women
Visual-Analog (VAS) and Numeric Scales whose differences ranged from 5 to 10 points was 22.9%,

VAS (mm)
I whereas 7.6% of the women had rating differences of 15 to
20 points, and 4.1% had rating differences of 20 to 25
points. Only 2.5% of the sample showed rating differences
0 100 greater than 25 points.
No pain Worst imaginable pain
I also examined the scoring tendencies of these partici-
Numeric scale pants, using the difference in nonabsolute values between
the scores on both scales. The results showed that 52.6% of
0 1 2 3 4 5 6 7 8 9 10 the sample scored pain intensity greater on the numeric
No pain Worst imaginable pain
scale than the mark on the VAS ( M = 8.39; SD = 5.16; range
1-64; 12% of the sample had scoring differences greater
Nore. Participants mark the VAS at a chosen distance from 0 mm
to 100 mm to indicate seventy of pain; those using the numeric than 10 points), whereas 26.7% of the women scored pain
scale indicate a specific number to show pain. intensity with a higher mark on the VAS than on the numer-
ic scale ( M = 5.47; SD = 5.16; range 1-50, and only 2.2%

180 Behavioral Medicine


of the sample had rating differences greater than 10 points).
The participants, therefore, tended to quantify their pain
intensities at higher levels when they used the numeric scale
than they did when they used the VAS.
COMMENT
The VAS and the numeric scale have often been used to
evaluate pain intensity, and both types of scales I used in
this study have previously been shown to be useful in the
evaluation of menstrual pain. Each scale has advantages and
disadvantages. For example, the VAS is very precise, but
some people have great difficulty understanding the princi-
ples behind the analog scale. The numeric scale, on the
other hand, is convenient, but the marks are not continuous.
Despite the inherent differences between the 2 scales, the
results of this study indicate that they correlate in a signifi-
cant and seemingly very important manner because I took
the extreme evaluations, which could potentially have
biased the data, into consideration and eliminated them in
further analyses. Although the average difference in pain
intensity measured in each scale is significant, I found that
a relatively small percentage of women (14.2%) had differ-
ences on both scales that were greater than 10 points. The
significance of the finding may be attributable to the large
difference (as great as 64 points) in marks from ii very small
percentage of participants (0.3%). This discrepancy may be
the consequence of some participants’ having misunder-
stood the VAS because, in fact, the women had more ques-
tions and problems when trying to complete this scale.
The tendency for the women to rate a higher level of pain
on the numeric scale may be partially explained by the non-
continuous type of measurement it uses. Participants are
forced to round their estimations up (in a majority of the
cases) or down. Why some people overestimate and some
do not, as well as the relationship between these tendencies
and other variables, requires further study that is beyond the
Vol 27. Winter 2002
LARROY
scope of my current investigation. A number of studies have
reported that patients significantly overestimate their pain
when asked to recall previous levels of pain, and the results
of this study support this tendency.
In summary, the results of this study afinn that both the
VAS and the numeric scale are useful in evaluating men-
strual pain. However, because of comprehension difficulties
some participants using the VAS reported and because of
the lack of important differences between measurements
taken from both scales, the numeric scale appears to be
more adequate and convenient to use, especially in epi-
demiologic studies requiring analysis of data from a large
number of participants.
NOTE
For further information, please send correspondence to Dr
Cristina Larroy, Profesor Titular, Dpto de Personalidad, Evalu-
aci6n y Tratamiento Psicol6gico I (Psicologia Clfnica), Facultad
de Psicologia, Universidad Complutense de Madrid, 28223
Madrid, Spain (e-mail: clarroy@psi.ucm.es).
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181