By Donelda Gowan-Moody

Introduction

 Current events are changing the way we practice Massage Therapy.  The driving force in health care toward evidence-based practice is consumer, practitioner, and politically-driven as the search for access to interventions that are safe, effective, and affordable continues.  An evidence-based approach to practice isn’t solely about using the best research evidence to choose and apply our therapeutic actions, it also means using our clinical expertise, and it never shuts out the importance of what our client’s value from us[1]. 

As health care professionals we need up to date information and tools to use to guide our clinical decision-making.  Learning to use simple, valid, and reliable assessment approaches allows MTs to proceed with confidence in managing low back pain and in communicating our results to stakeholders.  Changing and updating the way we practice helps us in providing the best possible care for our clients.

Massage Therapy has an ample evidence base with regard to its effectiveness as an intervention for reducing low back pain.[2][3][4][5][6][7][8]  In successful practice, individual massage therapists must continually ask if their care is safely and effectively aiding in the resolution of the client’s back pain.  As clinicians we need to have valid, reliable, and responsive tools to establish a baseline, and monitor change as a result of our treatment.  Use of outcome measures is also invaluable for the therapist wishing to write and publish case reports and case series and also for those wishing to engage in clinical audit.  Using these simple tools may also aid in addressing the identified need to know more about appropriate dose related variables in massage therapy such as the frequency, duration, and number of treatments required to achieve clinically significant outcomes.[9] 

Outcome Measurement

Outcome measurement is “the systematic collection and analysis of information that is used to evaluate the efficacy of a treatment intervention”.[10]  In a published systematic review on massage and low-back pain the authors categorize primary outcome measures as pain, return-to-work or work status, subjective change of symptoms, and functional status as expressed by validated instruments.  Physical examination measures like range of motion, spinal flexibility, degrees of straight leg raising, and muscle strength are categorized as secondary outcome measures as they do not show good correlation with the patient’s clinical status.[11]

An important idea in health sciences research on efficacy is that the outcomes measured should be patient-important such as pain, function, quality of life, and satisfaction with care.[12]  This article will focus on the use of pain intensity rating scales.  Pain intensity scales are used by clinicians and researchers in a variety of disciplines from nursing care and occupational therapy in hospitals to physiotherapy and chiropractic practices. 

Three common types of pain intensity scales are the Verbal Rating Scale, Visual Analogue Scale and the Numeric Rating Scale. The reader is reminded that as outcome measures, all pain intensity scales are in effect instruments used by care providers to create a record of the client's pain experience and any changes in pain over time.

Verbal Rating Scale (VRS)

The VRS, or verbal rating scale, allows for the recording of the client's current experience of pain by having the client or the therapist mark the appropriate response on a graph with adjectives ranging from no pain to severe pain. A typical scale of this kind simply uses words to represent the client's current experience of pain and the instrument allows for a review of changes over time.

A verbal rating scale is shown below. Click on the image for a closer look or to download it for your practice.

Since the purpose of the scale is to measure pain at the present moment, when there are multiple scales on the same page, the paper needs to be folded so the client cannot view their previous pain report as they are reporting their current pain level. Hence the "Therapist Fold Here" note and the dotted line to fold along in the VRS above. 

A limitation of the VRS is a lack of sensitivity to small changes in pain due to the restricted adjectives from which to choose. Also, non-English speaking patients and those with cognitive difficulties may have difficulty with the VRS.

Visual Analog Scale (VAS)  

The VAS, or visual analogue scale, is a horizontal 10 cm line anchored at either end by descriptors of no pain at one end and worst pain possible at the other end. The patient is asked to mark along the line to indicate the intensity of the pain that they are experiencing. The VAS is scored by measuring with a ruler the distance from the zero anchor to the mark made by the patient.

A VAS is presented below. Click on the image for a closer look or to download it for your practice.

The obvious limitation of the VAS is that careful measurement is required to score the results, and the patient must be physically present and visually and cognitively capable of using the scale.

Numeric Rating Scale (NRS)

The NRS, or numeric rating scale, simply uses numbers to represent and record the client's current experience of pain and the instrument allows for assessment of changes over time. Either the client or the therapist marks the appropriate score on the graph with a choice of numbers from "0" meaning no pain to "10" denoting pain as bad as it could be.  

A NRS is presented below. Click on the image for a closer look or to download it for your practice.

A practical limitation of the NRS is the variance in instruction and subsequent differences in interpretation about the meaning of the descriptive anchors.  Various sources cite the often used prompts to help the patient to understand what 10 or worst pain might mean.  It has been variously described as emergency room pain, suicide pain, or labour pain[13], the worst possible pain you can imagine (like being eaten alive by a shark), or that there is nothing anyone can do to you to inflict more pain,[14] or the worst pain you have ever experienced.[15] 

Measuring the Usefulness of Scales

An investigation comparing these three commonly used scales reveals that all three scales are valid and reliable for clinical use.[16]  The authors conclude from their study that while patients tended to prefer the Verbal Rating scale it can be easily misunderstood, the Visual Analogue Scale has more practical difficulties in clinical use and thus the Numeric Rating Scale may be the preferred choice.  

The reliability of a measure refers to the tool's ability to consistent measure the same thing regardless of who administers it or where and validity refers to the extent to which an instrument measures what it claims to measure and not something else.  Responsiveness of any measurement tool is defined as “the ability of an instrument to detect clinically relevant change over time” or “clinically meaningful change”.[18]  A 2-3 point difference on the NRS scale is cited as the smallest clinically relevant value to demonstrate change over time in both acute low back pain and chronic low back pain populations[19][20]. 

For example, Lou Lumbago came in for massage therapy assessment and treatment on June 12. Before the treatment his pain level was at a 9. After the treatment his pain level was at a 7. Research on the use of pain intensity scales suggests that this may be a clinically significant change.

Click on the image below for a full size copy of Lou Lumbago's NRS ratings before and after his first massage treatment.

An additional common strategy is to calculate changes in pain intensity scores as percentage changes in pain.  A percentage pain reduction can be calculated simply as:

100X(Difference between pre-treatment and post-treatment scores)/Pre-treatment intensity.  For example on the 11 point NRS a change from 5 to 4 represents a change of 20%.  Williamson & Hoggart (2005) cite studies indicating that 30-50% reduction in pain is a clinically important change in pain that would signify that the patient is much improved or very much improved.[17]

To calculate Lou’s percentage pain reduction over the course of his four treatment series you take the difference between his initial pain (9) and his pain after the last treatment (1) to get 8. Then you divide 8 by his initial pain level (9) and multiply by 100. This gives a percentage improvement of 89%.

Click on the image below for a work-up of Lou Lumbago's data from his first treatment and the last treatment of a 4 week treatment series.

Conclusion

Massage Therapists can easily adopt the use of pain intensity scales into their daily practice.  Any of the three common scales can be used with confidence as a method of monitoring change in the client’s pain and therefore evaluating and communicating the effectiveness of our treatment. The NRS in particular is simple to use in both clinical and research settings.  Practitioners can be confident that a 2 point change represents clinically meaningful results and therefore can gather and use this information to evaluate the effectiveness of their care for the treatment of low back pain.

It is always a good time to increase our knowledge, polish up any skills that may be rusty, and patch any holes where clinical tools may be missing.  Using pain intensity scales should aid us in making better clinical decisions in order to be more effective and more confident in our ability to help those with low back pain.

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Biography

Donelda Gowan-Moody is the President of Education Initiatives Canada (EIC). Donelda graduated from the Canadian College of Massage and Hydrotherapy in Sutton Ontario in 1987 and the University of Saskatchewan with a Bachelor of Arts (Hons) degree in 1997. Her thesis titled The Effects of Therapeutic Massage on Mood garnered significant results. She has maintained a thriving private practice over the last 19 years and taught massage theory and practical classes at the Professional Institute of Massage Therapy in Saskatoon from 1995 to 2003.

Donelda has recently been appointed Co-chair of the Canadian Massage Therapy Research Network (CMTRN) and contributed to the National Taskforce on Outcome-based Massage.  Donelda also belongs to the IN CAM research network, and CAMera (Complimentary and Alternative Medicine Education and Research Network of Alberta).

You can reach Donelda through her website link below.  

Evidence Based and Best Practices Oriented Massage Therapy Education