Cut-Off Points for Mild, Moderate, and Severe Pain on the Numeric Rating Scale for Pain in Patients with Chronic Musculoskeletal Pain: Variability and Influence of Sex and Catastrophizing.

Anne M Boonstra,Roy E Stewart,Henrica R Schiphorst Preuper,Albère J A Köke,Jeannette L Swaan,Karlein M G Schreurs,René F A Oosterwijk

doi:10.3389/fpsyg.2016.01466

Abstract

Objectives: The 0–10 Numeric Rating Scale (NRS) is often used in pain management. The aims of our study were to determine the cut-off points for mild, moderate, and severe pain in terms of pain-related interference with functioning in patients with chronic musculoskeletal pain, to measure the variability of the optimal cut-off points, and to determine the influence of patients’ catastrophizing and their sex on these cut-off points.Methods: 2854 patients were included. Pain was assessed by the NRS, functioning by the Pain Disability Index (PDI) and catastrophizing by the Pain Catastrophizing Scale (PCS). Cut-off point schemes were tested using ANOVAs with and without using the PSC scores or sex as co-variates and with the interaction between CP scheme and PCS score and sex, respectively. The variability of the optimal cut-off point schemes was quantified using bootstrapping procedure.Results and conclusion: The study showed that NRS scores ≤ 5 correspond to mild, scores of 6–7 to moderate and scores ≥8 to severe pain in terms of pain-related interference with functioning. Bootstrapping analysis identified this optimal NRS cut-off point scheme in 90% of the bootstrapping samples. The interpretation of the NRS is independent of sex, but seems to depend on catastrophizing. In patients with high catastrophizing tendency, the optimal cut-off point scheme equals that for the total study sample, but in patients with a low catastrophizing tendency, NRS scores ≤ 3 correspond to mild, scores of 4–6 to moderate and scores ≥7 to severe pain in terms of interference with functioning. In these optimal cut-off schemes, NRS scores of 4 and 5 correspond to moderate interference with functioning for patients with low catastrophizing tendency and to mild interference for patients with high catastrophizing tendency. Theoretically one would therefore expect that among the patients with NRS scores 4 and 5 there would be a higher average PDI score for those with low catastrophizing than for those with high catastrophizing. However, we found the opposite. The fact that we did not find the same optimal CP scheme in the subgroups with lower and higher catastrophizing tendency may be due to chance variability.

Highlights

Assessment of pain intensity is considered one of the core outcome domains in clinical pain research (Dworkin et al, 2005), and is very commonly applied
The 5,7 cut-off points (CPs) scheme had the highest F-value, indicating that this scheme provided the best fit for distinguishing pain into three categories, i.e., mild, moderate, or severe pain, in terms of interference with functioning
This means that an Numeric Rating Scale (NRS) score in the 1–5 range corresponds to mild interference with functioning, while scores of 6 and 7 represent moderate interference and a score in the 8–10 range corresponds to severe interference with functioning

Summary

Introduction

Assessment of pain intensity is considered one of the core outcome domains in clinical pain research (Dworkin et al, 2005), and is very commonly applied. Serlin et al (1995) tried to solve this problem by correlating pain intensity to the level of interference of the pain with the daily functioning of patients with pain due to cancer, using a specific statistical technique, i.e., estimating how much of the variance in pain-related disability can be explained by different possible pain intensity classifications Their statistical approach has been repeated for the same patient population, i.e., cancer patients (Paul et al, 2005) as well as being applied to other patient populations (e.g., Zelman et al, 2005; Hirschfeld and Zernikow, 2013; Oldenmenger et al, 2013; Boonstra et al, 2014). Difference in diagnoses is generally accepted as one of the main causes of differences in cut-off points between studies (Zelman et al, 2003), while differences between study samples may be explained by chance variation (Hirschfeld and Zernikow, 2013)

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