Pain scale

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A Chinese pain scale diagram, rating pain on a scale of 1 to 10

A pain scale measures a patient's pain intensity or other features. Pain scales are a common communication tool in medical contexts, and are used in a variety of medical settings. Pain scales are a necessity to assist with better assessment of pain and patient screening. Pain measurements help determine the severity, type, and duration of the pain, and are used to make an accurate diagnosis, determine a treatment plan, and evaluate the effectiveness of treatment. [medical citation needed] Pain scales are based on trust, cartoons (behavioral), or imaginary data, and are available for neonates, infants, children, adolescents, adults, seniors, and persons whose communication is impaired. Pain assessments are often regarded as "the 5th vital sign".[1]

A patient's self-reported pain is so critical in the pain assessment method that it has been described as the "most valid measure" of pain.[2][3] The focus on patient report of pain is an essential aspect of any pain scale, but there are additional features that should be included in a pain scale. In addition to focusing on the patient's perspective, a pain scale should also be free of bias, accurate and reliable, able to differentiate between pain and other undesired emotions, absolute not relative, and able to act as a predictor or screening tool.[2]


Pain is a complex experience with both sensory and emotional elements that typically indicates a potential issue in the nervous system. It alerts organisms to potential injuries and medical conditions that may require medical assistance. The sensation of pain is an unpleasant or discomforting feeling that can manifest as sensations such as pricking, tingling, burning, stinging, shooting, aching, or electric. Pain can vary in intensity, from very mild to very severe; duration, short-lived to chronic; and location, one localized area or all over the body.[4]

There are three different types of pain based on the duration of the sensations: acute, episodic, and chronic. The most common are acute and chronic. Acute pain occurs suddenly, is sharp, and goes away once the issue is treated. Acute pain is caused by things like broken bones, childbirth, strained muscles, or burns.[5] Episodic pain occurs irregularly from time to time. It may be caused by underlying medical conditions or it can come out of nowhere.[5] Chronic pain is pain that is consistent for at least 3 months. Acute pain can become chronic, however, there usually is no known cause for chronic pain. Chronic pain can have negative effects on relationships, daily living, work, extracurricular activities, etc.[5]

The experience of pain is extremely unique for an individual, as all people feel pain differently. As a result of this, self-reporting is the best and most common practice for describing pain to medical personnel.[5]


The practice of measuring pain has been a topic in research since the late 1800s. There were many methods used for assessing the intensity of pain, in humans as well as animals, using electrical, mechanical, and heat stimuli. Over time these methods have evolved; however, there were limitations to these historical methods. The limitations were in addressing the dimensions of pain duration, modality, locus, and response type. The main focus at the time was on acute pain rather than chronic pain. Researchers and clinicians are more interested in information on chronic pain due to its longevity. The locus of pain also differs between clinical and experimental settings; clinical pain is usually deeper while experimental pain is superficial. Furthermore, the response type to pain can contribute to further challenges for interpretation in both preclinical and clinical research.[6][7]

The Dolorimeter, created in 1940 at Cornell University, was one of the first methods used to gather information on pain threshold and tolerance. The instrument applied steady pressure, heat, or electrical stimuli to measure sensations of pain. Beecher was one of the first to suggest something other than the dolorimeter; he suggested that clinical pain be measured by its relief using subjective ratings. Numerical rating scales (NRS), verbal rating scales (VRS), and visual analog scales (VAS) on a 10-cm continuum are the scales used to attain these ratings. Melzack and Torgerson developed the McGill Pain Questionnaire which rates pain quantitatively by sensory, evaluative, and affective descriptors. These are things like burning, shooting, and agonizing.[7]

There have been many methods developed that use observational techniques where pain is evaluated by others. Such a method, for example, is the FLACC scale. It is for young children who are too young to be able to tell anyone how they feel. It measures facial expressions, leg position, activity, crying, and concealability on a 0–2 scale.[7]

Pain assessment[edit]

There are many different instruments used to assess both the intensity of pain as well as the effect of pain. A few are listed below:

Numeric rating scale[edit]

The Numeric Rating Scale (NRS-11) is an 11-point scale for patient self-reporting of pain. It is based solely on the ability to perform activities of daily living (ADLs) and can be used for adults and children 10 years old or older.[8]

Rating Pain Level
0 No Pain
1–3 Mild Pain (nagging, annoying, interfering little with ADLs)
4–6 Moderate Pain (interferes significantly with ADLs)
7–10 Severe Pain (disabling; unable to perform ADLs)

Pain interferes with a person's ability to perform ADLs. Pain also interferes with a person's ability to concentrate, and to think. A sufficiently strong pain can be disabling on a person's concentration and coherent thought, even though it is not strong enough to prevent that person's performance of ADLs. However, there is no system available for measuring concentration and thought.

Verbal rating scale[edit]

The verbal rating scale (VRS) is a pain measurement tool that uses adjectives to express various levels of pain. The scale is rated similarly from no pain at all to the most extreme pain ever felt. When doing clinical trials there is usually a four-to six-point VRS. There are a few limitations to this scale. Some people might find it hard to accurately express their pain with the limited number of options to choose from. Interpretation of the options is also a potential issue, as people could interpret them all differently.[9]

Visual analog scale[edit]

The visual analog scale is a visual scale that has two endpoints: "no pain" and "pain is as bad as it could be". When it was first created people had to physically write their answers on the scale. There are mechanical ones now to make the scoring of them easier.[9]

Examples of pain scales
Self-report Observational Physiological
Infant Premature Infant Pain Profile; Neonatal/Infant Pain Scale
Child Faces Pain Scale – Revised;[10] Wong-Baker FACES Pain Rating Scale; Coloured Analogue Scale[11] FLACC (Face Legs Arms Cry Consolability Scale); CHEOPS (Children's Hospital of Eastern Ontario Pain Scale)[12] Comfort; Wharton PAIN Scale
Adult Visual Analog Scale (VAS); Verbal Numerical Rating Scale (VNRS); Verbal Descriptor Scale (VDS); Brief Pain Inventory Wharton Impairment and Pain Scale Wharton PAIN Scale

Partial list of pain measurement scales[edit]

Specialized tests[edit]

  • Abbey pain scale for people with end-stage dementia[46]
  • AUSCAN: Disease-Specific, to assess hand osteoarthritis outcomes.[30]
  • Colorado Behavioral Numerical Pain Scale (for sedated patients)[47]
  • CPOT For those who can't self report[48]
  • Osteoarthritis Research Society International-Outcome Measures in Rheumatoid Arthritis Clinical Trials (OARSI-OMERACT) Initiative, New OA Pain Measure: Disease-Specific, Osteoarthritis Pain[30]
  • Oucher Scale for Pediatrics[49]
  • Pain Assessment in Advanced Dementia (PAINAD)
  • Pediatric Pain Questionnaire (PPQ)[50] for measuring pain in children
  • Premature Infant Pain Profile (PIPP)[51] for measuring pain in premature infants
  • Schmidt Sting Pain Index[52] and Starr sting pain scale[53] both for insect stings
  • WOMAC : Disease-Specific, to assess knee osteoarthritis outcomes.[30]

In endometriosis[edit]

The most common pain scale for quantification of endometriosis-related pain is the visual analogue scale (VAS). A review came to the conclusion that VAS and numerical rating scale (NRS) were the best adapted pain scales for pain measurement in endometriosis. For research purposes, and for more detailed pain measurement in clinical practice, the review suggested use of VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the clinical global impression (CGI) and a quality of life scale.[17]

See also[edit]


  1. ^ "Pain: current understanding of assessment, management and treatments" (PDF). Joint Commission on Accreditation of Healthcare Organizations and the National Pharmaceutical Council, Inc. December 2001. Retrieved 2018-01-20.
  2. ^ a b "Pain Assessment Tools".
  3. ^ Adams P (May 2017). "Supporting the Self-Management of Chronic Pain Conditions with Tailored Momentary Self-Assessments". Proceedings of the 2017 CHI Conference on Human Factors in Computing Systems. Vol. 2017. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. pp. 1065–1077. doi:10.1145/3025453.3025832. ISBN 9781450346559. PMC 6176683. PMID 30310887.
  4. ^ "Pain". Retrieved 2024-04-04.
  5. ^ a b c d "Pain | National Institute of Neurological Disorders and Stroke". Retrieved 2024-04-04.
  6. ^ "Pain | National Institute of Neurological Disorders and Stroke". Retrieved 2024-04-04.
  7. ^ a b c Mogil, Jeffery. "The History of Pain Measurement in Humans and Animals".
  8. ^ "Pain Intensity Instruments" (PDF). National Institutes of Health – Warren Grant Magnuson Clinical Center. July 2003. Archived from the original (PDF) on 2011-12-15.
  9. ^ a b Haefelfi, Mathias; Elfering, Achim. "Pain Assessment".
  10. ^ "The Faces Pain Scale – Revised". Pediatric Pain Sourcebook of Protocols, Policies and Pamphlets. 7 August 2007.
  11. ^ Stinson, JN; Kavanagh, T; Yamada, J; Gill, N; Stevens, B (November 2006). "Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents". Pain. 125 (1–2): 143–57. doi:10.1016/j.pain.2006.05.006. PMID 16777328. S2CID 406102.
  12. ^ von Baeyer, C.L.; Spagrud, L.J. (2007). "Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years". Pain. 127 (1–2): 140–150. doi:10.1016/j.pain.2006.08.014. PMID 16996689. S2CID 207307157.
  13. ^ Stewart B, Lancaster G, Lawson J, Williams K, Daly J (July 2004). "Validation of the Alder Hey Triage Pain Score". Arch. Dis. Child. 89 (7): 625–630. doi:10.1136/adc.2003.032599. PMC 1720010. PMID 15210492.
  14. ^ Payen, JF; Bru O; Bosson JL (2001). "Assessing pain in critically ill sedated patients by using a behavioral pain scale". Critical Care Medicine. 29 (12): 2258–2263. doi:10.1097/00003246-200112000-00004. PMID 11801819. S2CID 7656090.
  15. ^ Cleeland CS, Ryan KM (March 1994). "Pain assessment: global use of the Brief Pain Inventory". Ann. Acad. Med. Singap. 23 (2): 129–38. PMID 8080219.
  16. ^ Feldt, KS (2000). "The Checklist of Nonverbal Pain Indicators (CNPI)". Pain Management Nursing. 1 (1): 13–21. doi:10.1053/jpmn.2000.5831. PMID 11706452. S2CID 23917628.
  17. ^ a b Bourdel, N.; Alves, J.; Pickering, G.; Ramilo, I.; Roman, H.; Canis, M. (2014). "Systematic review of endometriosis pain assessment: how to choose a scale?". Human Reproduction Update. 21 (1): 136–152. doi:10.1093/humupd/dmu046. ISSN 1355-4786. PMID 25180023.
  18. ^ Ambuel, B; Hamlett KW; Marx CM; Blumer JL (1992). "Assessing distress in pediatric intensive care environments: the COMFORT scale". Journal of Pediatric Psychology. 17 (1): 95–109. doi:10.1093/jpepsy/17.1.95. PMID 1545324.
  19. ^ "Use color-coded scale to assess children's pain". Retrieved 2019-03-20.
  20. ^ Gélinas, C; Fillion L; Puntillo KA; Viens C; Fortier M (2006). "Validation of the Critical-Care Pain Observation Tool in adult patients". American Journal of Critical Care. 15 (4): 420–427. doi:10.4037/ajcc2006.15.4.420. PMID 16823021.
  21. ^ "Dallas Pain Questionnaire" (PDF). Workforce Safety. Retrieved 21 May 2017.
  22. ^ Ozguler A, Guéguen A, Leclerc A, Landre MF, Piciotti M, Le Gall S, Morel-Fatio M, Boureau F (2002). "Using the dallas pain questionnaire to classify individuals with low back pain in a working population". Spine. 27 (16): 1783–9. doi:10.1097/00007632-200208150-00018. PMID 12195072. S2CID 24544669.
  23. ^ Gracely RH, Kwilosz DM (December 1988). "The Descriptor Differential Scale: applying psychophysical principles to clinical pain assessment". Pain. 35 (3): 279–88. doi:10.1016/0304-3959(88)90138-8. PMID 3226757. S2CID 9801177.
  24. ^ Hardy, J.D.; Wolff, H.G.; Goodell, H. (1952). Pain Sensations and Reactions. Baltimore: The Williams & Wilkins Co. ASIN B0006ASZ92.
  25. ^ Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K (1991). "The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients". J Palliat Care. 7 (2): 6–9. doi:10.1177/082585979100700202. PMID 1714502. S2CID 26165154.
  26. ^ Nekolaichuk C, Watanabe S, Beaumont C (March 2008). "The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991--2006)". Palliat Med. 22 (2): 111–22. doi:10.1177/0269216307087659. PMID 18372376. S2CID 41926711.
  27. ^ Richardson LA, Jones GW (January 2009). "A review of the reliability and validity of the Edmonton Symptom Assessment System". Curr Oncol. 16 (1): 55. doi:10.3747/co.v16i1.261. PMC 2644623. PMID 19229371.
  28. ^ Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B (August 2001). "The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement". Pain. 93 (2): 173–83. doi:10.1016/S0304-3959(01)00314-1. PMID 11427329. S2CID 31086827.Instructions in many languages and images
  29. ^ Doctor, Pain. "Global Pain Scale". Pain Doctor. Retrieved 2019-03-20.
  30. ^ a b c d e "OARSI Initiatives, Pain Indexes". OARSI. Retrieved 1 March 2010.
  31. ^ Lequesne M, Mery C, et al. (1987). "Indexes of severity for osteoarthritis of the hip and knee". Scand J Rheumatol. 65 (Supplement 65): 85–89. doi:10.3109/03009748709102182. PMID 3479839. S2CID 13138269.
  32. ^ Lequesne M (1991). "Indices of severity and disease activity for osteoarthritis". Seminars in Arthritis and Rheumatism. 20 (Supplement 2): 48–54. doi:10.1016/0049-0172(91)90027-w. PMID 1866630.
  33. ^ Lequesne MG (1997). "The algofunctional indices for hip and knee osteoarthritis". J Rheumatol. 24 (4): 779–781. PMID 9101517.
  34. ^ "Pain Scale". Retrieved 2019-03-20.
  35. ^ Melzack R (September 1975). "The McGill Pain Questionnaire: major properties and scoring methods". Pain. 1 (3): 277–99. doi:10.1016/0304-3959(75)90044-5. PMID 1235985. S2CID 20562841.
  36. ^ "Multiple Pain Rating Scales - back, leg, neck, migraine". Retrieved 27 June 2017.
  37. ^ Jensen MP, Karoly P, O'Riordan EF, Bland F, Burns RS (June 1989). "The subjective experience of acute pain. An assessment of the utility of 10 indices". Clin J Pain. 5 (2): 153–9. doi:10.1097/00002508-198906000-00005. PMID 2520397. S2CID 31102020.
  38. ^ Hartrick CT, Kovan JP, Shapiro S (December 2003). "The numeric rating scale for clinical pain measurement: a ratio measure?". Pain Pract. 3 (4): 310–6. doi:10.1111/j.1530-7085.2003.03034.x. PMID 17166126. S2CID 40284276.
  39. ^ Hearn J, Higginson IJ (December 1999). "Development and validation of a core outcome measure for palliative care: the palliative care outcome scale. Palliative Care Core Audit Project Advisory Group". Qual Health Care. 8 (4): 219–27. doi:10.1136/qshc.8.4.219. PMC 2483665. PMID 10847883.
  40. ^ Paul W Stratford; Jill M Binkley; Daniel L Riddle; Gordon H Guyatt (1998). "Sensitivity to Change of the Roland-Morris Back Pain Questionnaire: Part 1". Phys Ther. 78 (11): 1186–1196. doi:10.1093/ptj/78.11.1186. PMID 9806623.
  41. ^ Schulte TL, Schubert T, Winter C, Brandes M, Hackenberg L, Wassmann H, Liem D, Rosenbaum D, Bullmann V (2010). "Step activity monitoring in lumbar stenosis patients undergoing decompressive surgery". European Spine Journal. 19 (11). 1855–64. doi:10.1007/s00586-010-1324-y. PMC 2989265. PMID 20186442.
  42. ^ Higginson IJ, McCarthy M (1993). "Validity of the support team assessment schedule: do staffs' ratings reflect those made by patients or their families?". Palliat Med. 7 (3): 219–28. doi:10.1177/026921639300700309. PMID 7505183. S2CID 23476645.
  43. ^ "Wharton Impairment and Pain Scale". January 2023.
  44. ^ "Wong-Baker FACES Pain Rating Scale Foundation". Retrieved 6 December 2009.
  45. ^ Huskisson EC (1982). "Measurement of pain". J. Rheumatol. 9 (5): 768–9. PMID 6184474.
  46. ^ Abbey, Jennifer (January 2004). "The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia". International Journal of Palliative Nursing. 10 (1): 6–13. doi:10.12968/ijpn.2004.10.1.12013. PMID 14966439.
  47. ^ Salmore R (2002). "Development of a new pain scale: Colorado Behavioral Numerical Pain Scale for sedated adult patients undergoing gastrointestinal procedures". Gastroenterol Nurs. 25 (6): 257–62. doi:10.1097/00001610-200211000-00007. PMID 12488689. S2CID 22569187.
  48. ^ "Critical Care Pain Observation Tool (CPOT)". MDCalc. Retrieved 2019-03-20.
  49. ^ "How to use the Oucher". Retrieved 2019-03-20.
  50. ^ Varni JW, Thompson KL, Hanson V (January 1987). "The Varni/Thompson Pediatric Pain Questionnaire. I. Chronic musculoskeletal pain in juvenile rheumatoid arthritis". Pain. 28 (1): 27–38. doi:10.1016/0304-3959(87)91056-6. PMID 3822493. S2CID 246622.
  51. ^ Ballantyne M, Stevens B, McAllister M, Dionne K, Jack A (December 1999). "Validation of the premature infant pain profile in the clinical setting". Clin J Pain. 15 (4): 297–303. doi:10.1097/00002508-199912000-00006. PMID 10617258.
  52. ^ Schmidt, Justin O.; Evans, David (1990). Hymenopteran venoms: striving toward the ultimate defense against vertebrates; chapter in Insect defenses: adaptive mechanisms and strategies of prey and predators. Albany, N.Y: State University of New York Press. pp. 387–419. ISBN 0-88706-896-0.
  53. ^ Starr, C.K. (1985). "A simple pain scale for field comparison of Hymenopteran stings". Journal of Entomological Science. 20 (2): 225–231. doi:10.18474/0749-8004-20.2.225.