title: A method for overcoming the ceiling effect of bounded pain scales.
abstract: OBJECTIVE
  The Verbal Numerical Scale (VNS) for rating pain is bounded between 0 (= no pain) and 10 (= worst pain imaginable). We hypothesized that the limitations inherent to this boundary when rating extremely painful stimuli may be identified by integrating the VNS with an unbounded score such as magnitude estimation of relative change.
  
  
  METHODS
  Volunteers received stimuli of increasing current via cutaneous electrodes until they rated >5 on the VNS scale. This stimulus, termed S, was arbitrarily assigned a magnitude estimate of 100%. Then, stimuli of varying currents were delivered; two were 10 mA and 20 mA higher than S (S(+10) and S(+20)), two were 1/2 of the current for the S stimulus (S(1/2)), and one was at the original current (Srepeat). The pain elicited by each stimulus was scored in proportion to the S stimulus. The extrapolated VNS score (VNSext) was determined by multiplying this magnitude estimate (%) by the VNS score for S.
  
  
  RESULTS
  Seventy percent of the stimuli with higher intensity than S generated a VNSext score above 10. The mean magnitude estimations for S(+10) and S(+20) were 186% and 242%: they generated mean (median) VNSext values of 12.4 and 16.2, respectively (p = 0.019 for the difference between them by Wilcoxon signed rank test).
  
  
  CONCLUSIONS
  The combined use of VNS and magnitude estimation confirmed that the ceiling of the bounded pain scale may significantly limit a patient's ability to describe a new pain stimulus. VNSext may provide a means of overcoming this limitation.
authors.affiliation: Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520-8051, USA.
authors.forename: M W
authors.initials: MW
authors.lastname: Hartmannsgruber
authors.forename: C P
authors.initials: CP
authors.lastname: Swamidoss
authors.forename: A
authors.initials: A
authors.lastname: Budde
authors.forename: S
authors.initials: S
authors.lastname: Qadir
authors.forename: S J
authors.initials: SJ
authors.lastname: Brull
authors.forename: D G
authors.initials: DG
authors.lastname: Silverman
mesh_terms: D000328:Adult; D004558:Electric Stimulation; D005260:Female; D006801:Humans; D007802:Language; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement / Q000379:methods* / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D012720:Severity of Illness Index