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Numeric Pain Rating Scale (NPRS)
Availability
Please visit this website for more information about the instrument: Numeric Pain Rating Scale
Classification
Supplemental: Cerebral Palsy (CP)
Short Description of Instrument
The Numeric Pain Rating Scale (NPRS) is a segmented numeric version of the visual analog scale (VAS) in which a respondent selects a whole number (0-10 integers) that best reflects the intensity of his/her pain.
  • The common format is a horizontal bar or line.

  • Like the VAS, the NPRS is anchored by terms describing pain severity extremes.

There are various iterations of the NPRS, the most used is the 11-item NPRS or NRS-11.
Comments/Special Instructions
The NRS is a 11-, 21-, or 101-point self-report scale where the end points are the extremes of no pain and pain as bad as it could be, or worst pain. The NRS can be graphically or verbally delivered. When presented graphically the numbers are often enclosed in boxes and the scale is referred to as an 11- or 21-point box scale depending on the number of levels of discrimination offered to the patient. (Williamson, 2005)

The NRS takes less than a minute to complete, is easy to administer and score, and is a valid and reliable scale to measure acute and chronic pain intensity in adults, children and adolescents (Ferraz et al., 1990; Hawker, 2005; Jensen et al 1989; Castarlenas, 2017).
 
CP-specific Pain Category: Pain Intensity
 
CP-specific ICF Domain: Body Functions (World health Organization, 2001).
Scoring and Psychometric Properties
Scoring: Scores range from 0-10 points, with higher scores indicating greater pain intensity.
 
Reliability: High test-retest reliability has been observed in both literate and illiterate adult patients with rheumatoid arthritis (r = 0.96 and 0.95, respectively) before and after medical consultation. (Ferraz et al., 1990). One study demonstrated the NRS-11 shows high levels of test-retest stability in an 8- to 17-year-old sample of children with acute pain (Bailey et al, 2010).
 
Validity: For construct validity, the NPRS was shown to be highly correlated with the VAS in adult patients with rheumatic and other chronic pain conditions (pain>6 months): correlations range from 0.86 to 0.95. (Ferraz et al., 1990).  In children and adolescents, convergent validity of the NRS-11 has been supported by the moderate-to-high correlations between the NRS-11 pain intensity scores and the Faces Pain Scale-Revised (FPS-R) scores (r range across studies=0.75 to 0.93) (Castarlenas, 2013; von Baeyer, 2009;Miro, 2009; Connelly, 2010)  and the VAS (r range across studies=0.73 to 0.95) (Castarlenas, 2013; von Baeyer, 2009; Connelly.2010).   
Rationale/Justification
Strengths: "The literature shows that NRSs provide sufficient discriminative power for chronic pain patients to describe their pain intensity" (Jensen et al, 1994). The NRS-11 is one of the most widely used scales to assess self-reported pain intensity in children and the NRS is preferred by the majority of patients in different languages.  A recent study (Miro et al, 2016) comparing the validity of the Numerical Rating Scale (NRS-11), the Wong Baker FACES Pain Rating Scale (FACES), and a 6-point categorical Verbal Rating Scale (VRS-6) for assessing pain intensity among 113 youths aged 8-20 with physical disabilities (n=39 [35%] with CP) found strong positive associations between these pain assessments, supporting their validity as measures of pain intensity in children with disabilities. The NRS-11 out-performed both the VRS-6 and the FACES scale with respect to: (1) associations with the validity criterion (i.e., pain interference, disability and psychological functioning) and (2) a lack of any moderating effect of age on the association between the measure and the criterion variables.
 
Strengths of this measure over the VAS are the ability to be administered both verbally and in writing, as well as its simplicity of scoring (Hawker, 2011). The NRS is preferred by the majority of patients in different cultures (Caraceni et al., 2002; Paice & Cohen, 1997); Caraceni et al., 2005).
 
Weaknesses: The NPRS evaluates only 1 component of the pain experience and intensity, and therefore does not capture the complexity and idiosyncratic nature of the pain experience or improvements due to symptom fluctuations.
Limited published research exists on the NRS-11 psychometric properties for assessing pain in pediatric populations, especially in children less than 8 years.
References
Key References:
Castarlenas E, Jensen M, von Baeyer, Carl L; Miró J. Psychometric Properties of the Numerical Rating Scale to Assess Self-Reported Pain Intensity in Children and Adolescents, The Clinical Journal of Pain: April 2017; 33 (4):376-383.
 
Jensen MP, McFarland CA. Increasing the reliability and validity of pain intensity measurement in chronic pain patients. Pain 1993;55: 195-203.
 
Additional References:
Bailey B, Daoust R, Doyon-Trottier E, et al. Validation and properties of the verbal numeric scale in children with acute pain. Pain. 2010;149:216-221.
 
Caraceni A, Cherny N, Fainsinger R, et al. Pain measurement tools and methods in clinical research in palliative care: recommendations of an Expert Working Group of the European Association of Palliative Care. J Pain Symptom Manage 2002;23:239e255.
 
Caraceni A, Brunelli C, Martini C, Zecca E, De Conno F. Cancer pain assessment in clinical trials. A review of the literature (1999-2002). J Pain Symptom Manage 2005;29:507e519.
 
Castarlenas E, Miró J, Sánchez-Rodríguez E. Is the verbal numerical rating scale a valid tool for assessing pain intensity in children below 8 years of age? J Pain. 2013;14:297-304.
 
Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976). 2005 Jun 1;30(11):1331-4.
 
Connelly M, Neville K. Comparative prospective evaluation of the responsiveness of single-item pediatric pain-intensity self-report scales and their uniqueness from negative affect in a hospital setting. J Pain. 2010;11:1451-1460.
 
Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann Rheum Dis. 1978 Aug;37(4):378-81.
 
Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J, Cowan P, Dionne R, Galer BS, Hertz S, Jadad AR, Kramer LD, Manning DC, Martin S, McCormick CG, McDermott MP, McGrath P, Quessy S, Rappaport BA, Robbins W, Robinson JP, Rothman M, Royal MA, Simon L, Stauffer JW, Stein W, Tollett J, Wernicke J, Witter J; IMMPACT. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005 Jan;113(1-2):9-19.
 
Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P, Goldsmith CH. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. J Rheumatol 1990;17:1022-4
 
Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole MR. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001 Nov;94(2):149-158.
 
Hawker GA. Measures of Adult Pain. Arthritis Care & Research 2011; 63,S240-S252.
 
Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, Fainsinger R, Aass N, Kaasa S; European Palliative Care Research Collaborative (EPCRC). Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011 Jun;41(6):1073-93.
 
Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain 1986;27:117-26.
 
Jensen MP, Karoly P, Huger R. The development and preliminary validation of an instrument to assess patients' attitudes toward pain. J Psychosom Res. 1987;31(3):393-400.
 
Jensen MP, Karoly P, O'Riordan EF, Bland F Jr, Burns RS. The subjective experience of acute pain. An assessment of the utility of 10 indices. Clin J Pain. 1989 Jun;5(2):153-9.
 
Jensen M, Karoly P. Self-report scales and procedures for assessing pain in adults. In: DC Turk, R Melzack, editors. Handbook of pain assessment. Vol. 2. New York: Guilford Press, 1992: p. 135-151.
 
Jensen MP, McFarland CA. Increasing the reliability and validity of pain intensity measurement in chronic pain patients. Pain. 1993 Nov;55(2):195-203.
 
Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain 1994;58:387e392.
 
Langley GB, Sheppeard H. The visual analogue scale: its use in pain measurement. Rheumatol Int. 1985;5(4):145-8.
 
Miró J, Castarlenas E, Huguet A. Evidence for the use of a numerical rating scale to assess the intensity of pediatric pain. Eur J Pain. 2009;13:1089-1095.
 
Paice JA, Cohen FL. Validity of a verbally administered numeric rating scale to measure cancer pain intensity. Cancer Nurs 1997;20:88e93.
 
Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010 Nov;126(5):e1168-98.
von Baeyer CL, Spagrud LJ, McCormick JC, et al. Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children's self-reports of pain intensity. Pain. 2009;143:223-227.
 
Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005 Aug;14(7):798-804.
World health Organization (2001). International Classification of Functioning, Disability and Health (ICF) Retrieved 19August2021 https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health
 
CP-specific:
Miró J, Castarlenas E, de la Vega R, et al. Validity of three rating scales for measuring pain intensity in youths with physical disabilities. Eur J Pain. 2016;20:130-137.
 
Document last updated August 2022