A total of 3 studies evaluated patient factors in scoring pain intensity in the Emergency Department. All studies had level of evidence 4.

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In all studies the study populations consisted of:

- pain of any cause / mixed study populations (2093 patients)

In all studies, NRS was directly compared to VAS pain scores. One study also compared a plastified VAS to the original VAS pain scoring tool. One study compared a Color Analog Scale (CAS) to VAS and NRS. 

Taken together, it can be concluded* that...

1. VAS and NRS pain scores are strongly correlated when used in the Emergency Department.

Level of recommendation C

All studies found excellent correlation. Two remarks have to be made here:

1. Several different statistical methods were used to analyse correlation and agreement. 

2. NRS pain scores had slightly wider limits of agreement in the range of 40-100U in one study and the results of 1 study suggested that NRS overestimated severe pain and underestimated mild pain.

2. CAS is closely correlated with both VAS and NRS pain scores in the Emergency Department.

Level of recommendation C

This was evaluated in one cross-sectional study in 150 patients.

3. NRS is easier to use in the Emergency Department and better reflects actual pain according to patients

Level of recommendation C 

Patients' preferences were evaluated in four studies. The majority found NRS easier to use than VAS (35% and 61%, versus 18% and 22%, respectively in two different studies). Using NRS pain scores led to a lower non-response rate in one study.

In another study, NRS better reflected actual pain than VAS did: 53% versus 26%.


* Disclaimer:

Included studies were different in several items, such as timing and methods of measurement of several endpoints; study population and baseline situation. Due to these large differences in study methodology, results cannot be pooled and the level of recommendation should be regarded as an estimation of the true effect. The levels of recommendation were derived according to the OCEBM levels of evidence

The included studies were found using PubMed (Medline) and Embase with the following search terms and synonyms: pain AND (scale OR score OR measure) AND emergency. The search was updated in September 2020. 

Several studies evaluated convenience samples of patients and ED crowding might have led to missed inclusions (and then probably especially at the extremes of pain intensity). Both factors might have confounded study results.

Some studies used alternated orders in administering pain scores and some studies always used the same order of pain scores. Using the latter technique might bias results, as patients know how to score their pain and understand pain scores better after having recorded the first pain score. This might have influenced study results as well. 


Available literature on comparison of pain scores:


Studies were found using PubMed (Medline) and Embase using the following search terms and synonyms: pain AND (scale OR score OR measure) AND emergency.

The search was updated in September 2020.

This search strategy have eventually led to the following studies that are critically appraised below:

1996 Marco, et al

2005 Kendrick & Strout

2010 Mohan, et al


Marco CA, Kanitz W, Jolly M. Pain scores among emergency department (ED) patients: comparison by ED diagnosis. J Emerg Med 2013;44:46-52.

Study design

Retrospective exploratory chart review



An urban university hospital Emergency Department in the USA



All adult patients (18 years and older) with a self-reported triage pain score of 1 or higher who visited the ED during a 6 month study period.

Exclusion criteria: patients reporting a pain score of 0.


To characterize the distribution of self-reported pain scores among common ED diagnoses


Information was manually collected from the electronic medical records; diagnosis was assigned to one of 19 categories, based on a previous diagnostic reporting method (used in a previous pain study).

Data were collected by trained research assistants.


Distribution of ED pain scores for common diagnosis categories and associations of pain scores with age and number of ED visits and ethnicity.


A total of 1229 patients were included in the study, with a mean age of 43.7 years and a median triage pain score of 7.1 (IQR 6-9).

Most commonly reported diagnoses were:

- minor injuries (10%)

- abdominal pain (8%)

- respiratory infections (8%)


Higher pain scores were significantly associated with a younger age (Spearman correlation coefficient -0.11; p<0.001) and the number of ED visits past 12 months (Spearman correlation coefficient 0.13; p<0.001).

Females reported significantly higher pain scores than males (p<0.001), as did African Americans and patients with Medicaid insurances (p<0.01).


The diagnoses with the highest pain scores were:

- sickle cell disease (8.70)

- back/neck/shoulder (8.62)

- headache/migraine (8.39)

Authors’ conclusions

Demographic factors including younger age, female gender, African American ethnicity, Medicaid insurance status and multiple ED visits in the past year were associated with higher reported pain scores.

Higher pain scores were reported in sickle cell crisis, pain in neck/back and shoulder and headache.


Data collected by trained research assistants.


Retrospective study design and therefore prone to several forms of bias and confounding factors. Although data were collected by research assistants, they were not blinded to study purposes and they did not included patients independently from each other.

Very important limitation was the fact that only 7% of the total of patients who visited the ED during the study visit were included in the study. Therefore, it seems that many patient records were missing (documentation bias), potentially decreasing external validity.

Level of evidence 4


Kendrick DB, Strout TD. The minimum clinically significant difference in patient-assigned numeric scores for pain. Am J Emerg Med 2005;23:828-32.

Study design

Prospective descriptive trial


Emergency Department of an academic hospital in the USA


All patients with acute pain (8 years and older) and able to give IC.

Exclusion criteria: unable to speak English and/or read English instructions or left before being seen by a physician


1. To determine the minimum clinically significant difference in (11-point) NRS pain scores

2. To determine whether this difference varies with age, sex, ethnicity, language or pain etiology


Patients were recruited during 8-hours shifts on 50 non-consecutive days including all days of the week and all shifts. Pain was rated using NRS every 20 minutes during two hours, including contrast-questions with previous measurement using 5-point Likert scales


356 patients signed the Informed Consent and 2 left the ED before being seen, leaving 354 patients for analysis.

Causes of pain were 65.3% non-traumatic and 34.7% traumatic.

The mean NRS at baseline was 6.60.

There were a total of 1515 comparisons of which 338 were ‘a little more’ (94) or ‘a little less’ (244) with a total mean NRS difference of 1.39 NRS points (95%CI 1.27-1.51), without differences between gender or cause of pain.

Authors’ conclusions

The mean minimum clinically significant difference in pain scores was 1.39 NRS points, consistent with previous studies and not dependent of sex or cause of pain.


Trained independent research assistant approached and included patients


Non-consecutive recruitment (but selection bias was minimized as all shifts were included); no sample size was performed

Level of evidence 4


Mohan H, Ryan J, Whelan B, Wakai A. The end of the line? The Visual Analogue Scale and Verbal Numerical Rating Scale as pain assessment tools in the emergency department. Emergency medicine journal : EMJ 2010;27:372-5.


Study design

single center prospective observational study



ED in Ireland


Convenience sample of patients 18 years and older presenting with pain and speaking English.

Exclusion criteria: speaking English insufficiently; altered mental status or to acutely unwell to participate; patients who gave only one pain reading.


- To test agreement between VAS and vNRS in the ED

- To determine whether agreement was altered by patient characteristics


Patients’ pain was recorded using 100mm VAS and with vNRS 0-10 and was reassessed every 30 minutes up to 2 hours. The order of pain scores was alternated between patients and was consistent within patients.


1. Agreement between VAS and vNRS

2. - Patient utility

    - Effect of demographics on pain scores


A total of 123 patients were included, with 531 paired measurements of VAS and vNRS. Causes: trauma in 44.7% and location of pain: limb 50.4%; abdomen 24.4%; chest 8.9%; headache 5.7%; orofacial 4.9%; back 4.1% and testicular 1.6%.


Correlation between VAS and vNRS was significant (rs=0.93 with 95%CI 0.92-0.94). Variability was tested using Bland-Altman method: difference between means VAS – vNRS was -7.1mm (95%CI -7.9 to -6.2). Differences between VAS and vNRS were significant for educational level, gender and increasing age.

Majority (59.4%) of patients found that using a pain scale helped them describe pain severity; 17.9% found VAS easier and 35% found vNRS easier; 47.2% no difference.

The minimum clinically significant difference for VAS was 11.9mm (95%CI 9.7 to 14.9); for vNRS 1.25 (95%CI 1.05 to 1.45). MCSD not influenced by patient demographics.

Authors’ conclusions

There is an almost linear correlation between both pain scores, however, their use is not interchangeable as there is no perfect agreement. Age, gender and level of education affected this agreement, but did not affect the individual measurements or the MCSDs. Therefore self-reported pain does not differ based on age, gender, cause or level of education. vNRS is a good alternative for VAS in the ED.


The study population was a convenience sample

Level of evidence 4