Case Report
Volume 11 Issue 10 - 2020
Pain Assessed Using the Visual Analog Scale Differs between Initial Clinic Visit and the Day of Surgery in Orthopedic Patients and is Associated with Several Demographic Variables
Bradley S Lambert*, David Dong, Thomas C Sullivan, Patrick C McCulloch and Joshua D Harris
Orthopedic Biomechanics Research Laboratory, Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, Texas, USA
*Corresponding Author: Bradley S Lambert, Director of Human Subjects Research, Orthopedic Biomechanics Research Laboratory, Department of Orthopedics and Sports Medicine, Houston Methodist Hospital Outpatient Center, Houston, TX, USA.
Received: August 26, 2020; Published: September 30, 2020


Background: Pain assessment using the visual analog scale (VAS) is common during patient evaluation in orthopedic settings. However, several factors contribute to variability in patient pain scoring when only assessed in clinic. As a subjective psychological measure, we hypothesized that patient VAS scores would differ between the time of initial clinic visit (CV) and the day of surgery (DOS) and that the change in VAS scores (ΔVAS) would be associated with patient demographics, time of day and time between VAS recordings.

Methods: One-hundred-fourteen [m = 54, 42 ± 17yr | f = 60, 45 ± 16yr] orthopedic patients were recruited during their initial CV prior to surgery. Pain VAS was recorded using a handwritten mark on a 100-millimeter (mm) line representing a spectrum of no pain to worst pain at two time-points: CV and DOS. A ΔVAS of 14 mm was considered as a minimum clinically important difference (MCID) between measures. Demographics, time of day, time between CV and DOS measures and injury diagnoses were recorded. Student’s t-test and analysis of covariance were used to detect differences in VAS between CV and DOS. Pearson correlation analysis was used to detect relationships between independent variables and ΔVAS. Type-I error set at α = 0.05 for all analyses.

Results: VAS scores decreased on average when examining all patients (-4.86 ± 2.42 mm, p < 0.05) with 46% having a ΔVAS (increase or decrease) that exceeded the MCID (> 14 mm) and 24% with ΔVAS exceeding twice the MCID (> 28 mm). Patients with a body mass index ≥ 30 kg/m2 were found to have elevated VAS scores at DOS compared to < 30 kg/m2 (p < 0.05). Decreases in VAS were observed in patients < 35 years of age (-8.8 ± 3.7 mm), patients with knee (-15.5 ± 3.7 mm) rather than hip or upper body injuries, and patients who had morning CV appointments (-7.4 ± 3.2 mm) (p < 0.05). Age (R = 0.19) and initial VAS score during CV (R = -0.39) were found to be correlated with ΔVAS (p < 0.05).

Conclusion: Visual Analogue Scale scores vary considerably between CV and DOS in this patient population with the variance being partially attributable to several independent factors.

Level of Evidence: Level III, Retrospective.

Keywords: Pain; Pain Management; Visual Analog Scale; Orthopedic Surgery


  1. Bijur PE., et al. "Reliability of the visual analog scale for measurement of acute pain”. Academic Emergency Medicine12 (2001): 1153-1157.
  2. Williamson A., et al. "Pain: a review of three commonly used pain rating scales”. Journal of Clinical Nursing7 (2005): 798-804.
  3. Hjermstad MJ., et al. "Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review”. Journal of Pain and Symptom Management6 (2011): 1073-1093.
  4. Sommer M., et al. "The prevalence of postoperative pain in a sample of 1490 surgical inpatients”. European Journal of Anaesthesiology4 (2008): 267-274.
  5. Price DD., et al. "The validation of visual analogue scales as ratio scale measures for chronic and experimental pain”. Pain1 (1983): 45-56.
  6. Abend R., et al. "Reliability, validity and sensitivity of a computerized visual analog scale measuring state anxiety”. Journal of Behavior Therapy and Experimental Psychiatry4 (2014): 447-453.
  7. Bird M-L., et al. "Accuracy, validity, and reliability of an electronic visual analog scale for pain on a touch screen tablet in healthy older adults: a clinical trial”. Interactive Journal of Medical Research1 (2016).
  8. Delgado DA., et al. "Validation of Digital Visual Analog Scale Pain Scoring With a Traditional Paper-based Visual Analog Scale in Adults”. JAAOS Global Research and Reviews3 (2018): e088.
  9. Jamison RN., et al. "Comparative study of electronic vs. paper VAS ratings: a randomized, crossover trial using healthy volunteers”. Pain1-2 (2002): 341-347.
  10. Wolfe F., et al. "Assessment of pain in rheumatoid arthritis: minimal clinically significant difference, predictors, and the effect of anti-tumor necrosis factor therapy”. The Journal of Rheumatology8 (2007): 1674-1683.
  11. McCarberg BH., et al. "The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey”. American Journal of Therapeutics4 (2008): 312-320.
  12. Conaghan PG., et al. "Guidelines: care and management of osteoarthritis in adults: summary of NICE guidance”. BMJ: British Medical Journal7642 (2008): 502.
  13. Ogden CL., et al. "Prevalence of obesity among adults and youth: United States, 2011-2014”. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics Washington, DC (2015).
  14. Adamson J., et al. "Prevalence and risk factors for joint pain among men and women in the West of Scotland Twenty-07 study”. Annals of the Rheumatic Diseases4 (2006): 520-524.
  15. Dieppe PA., et al. "Pathogenesis and management of pain in osteoarthritis”. The Lancet 9463 (2005): 965-973.
  16. Heo M., et al. "Obesity and functional impairment: influence of comorbidity, joint pain, and mental health”. Obesity10 (2010): 2030-2038.
  17. Hartz AJ., et al. "The association of obesity with joint pain and osteoarthritis in the HANES data”. Journal of Chronic Diseases4 (1986): 311-319.
  18. Okifuji A., et al. "The association between chronic pain and obesity”. Journal of Pain Research 8 (2015): 399.
  19. Courties A., et al. "Metabolic stress-induced joint inflammation and osteoarthritis”. Osteoarthritis and Cartilage11 (2015): 1955-1965.
  20. Guilak F. "Biomechanical factors in osteoarthritis”. Best Practice and Research Clinical Rheumatology6 (2011): 815-823.
  21. Dalle S., et al. "The role of inflammation in age-related sarcopenia”. Frontiers in Physiology 8 (2017): 1045.
  22. Greene MA., et al. "Aging-related inflammation in osteoarthritis”. Osteoarthritis and Cartilage11 (2015): 1966-1971.
  23. Franceschi C., et al. "Chronic inflammation (inflammaging) and its potential contribution to age-associated diseases”. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences1 (2014): S4-S9.
  24. Bicket MC., et al. "Chronic pain in older adults”. Anesthesiology Clinics3 (2015): 577-590.
  25. Riley Iii JL., et al. "Age and race effects on pain sensitivity and modulation among middle-aged and older adults”. The Journal of Pain3 (2014): 272-282.
  26. Koutsaki M., et al. "Influence Of Stress And Anxiety On Blood Pressure Levels In Patients Undergoing Orthopedic Surgery”. Journal of Hypertension 35 (2017): e223.
  27. Tighe PJ., et al. "Clinically derived early postoperative pain trajectories differ by age, sex, and type of surgery”. Pain4 (2015): 609.
  28. Nakano N., et al. "Age-dependent healing potential of anterior cruciate ligament remnant-derived cells”. The American Journal of Sports Medicine3 (2015): 700-708.
  29. Defrin R., et al. "Quantitative somatosensory testing of warm and heat-pain thresholds: the effect of body region and testing method”. The Clinical Journal of Pain2 (2006): 130-136.
  30. Defrin R., et al. "Spatial summation of pressure pain: effect of body region”. Pain3 (2003): 471-480.
  31. Shum GLK., et al. "Effect of low back pain on the kinematics and joint coordination of the lumbar spine and hip during sit-to-stand and stand-to-sit”. Spine17 (2005): 1998-2004.
  32. Collins NJ., et al. "Pain during prolonged sitting is a common problem in persons with patellofemoral pain”. Journal of Orthopaedic and Sports Physical Therapy8 (2016): 658-663.
  33. Onambele-Pearson NLG., et al. "Time-of-day effect on patella tendon stiffness alters vastus lateralis fascicle length but not the quadriceps force–angle relationship”. Journal of Biomechanics5 (2007): 1031-1037.
  34. Carter SJ., et al. "A matter of time: study of circadian clocks and their role in inflammation”. Journal of Leukocyte Biology4 (2016): 549-560.
  35. Singh JA., et al. "The impact of gender, age, and preoperative pain severity on pain after TKA”. Clinical Orthopaedics and Related Research11 (2008): 2717-2723.
  36. Holtzman J., et al. "Gender differences in functional status and pain in a Medicare population undergoing elective total hip arthroplasty”. Medical Care (2002): 461-470.
  37. Katz JN., et al. "Differences between men and women undergoing major orthopedic surgery for degenerative arthritis”. Arthritis and Rheumatism: Official Journal of the American College of Rheumatology5 (1994): 687-694.
  38. Sundblad GMB., et al. "Prevalence and co‐occurrence of self‐rated pain and perceived health in school‐children: Age and gender differences”. European Journal of Pain2 (2007): 171-180.
  39. Dao TTT., et al. "Gender differences in pain”. Journal of Orofacial Pain3 (2000): 169-184.
  40. Bartley EJ., et al. "Sex differences in pain: a brief review of clinical and experimental findings”. British Journal of Anaesthesia1 (2013): 52-58.
  41. Satku K., et al. "Anterior cruciate ligament injuries. To counsel or to operate?" The Journal of Bone and Joint Surgery British3 (1986): 458-461.
  42. Löfvendahl S., et al. "Waiting for orthopaedic surgery: factors associated with waiting times and patients’ opinion”. International Journal for Quality in Health Care2 (2005): 133-140.
  43. Sri-Ram K., et al. "The incidence of secondary pathology after anterior cruciate ligament rupture in 5086 patients requiring ligament reconstruction”. The Bone and Joint Journal1 (2013): 59-64.
  44. Turk DC., et al. "Assessment of patients' reporting of pain: an integrated perspective”. The Lancet9166 (1999): 1784-1788.
  45. Steingrımsdóttir OA., et al. "Variation in reporting of pain and other subjective health complaints in a working population and limitations of single sample measurements”. Pain1-2 (2004): 130-139.
  46. Williams ACdC., et al. "Simple pain rating scales hide complex idiosyncratic meanings”. Pain3 (2000): 457-463.
  47. Kersten P., et al. "Is the pain visual analogue scale linear and responsive to change? An exploration using Rasch analysis”. PloS One6 (2014): e99485.
  48. Lambert BS., et al. "DEXA or BMI: clinical considerations for evaluating obesity in collegiate division IA American football athletes”. Clinical Journal of Sport Medicine5 (2012): 436-438.
  49. Baldassari AR., et al. "Socioeconomic factors and self-reported health outcomes in African Americans with rheumatoid arthritis from the Southeastern United States: the contribution of childhood socioeconomic status”. BMC Musculoskeletal Disorders1 (2016): 10.
  50. Hirsh AT., et al. "The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions”. The Journal of Pain6 (2015): 558-568.
Citation: Bradley S Lambert., et al.. “Pain Assessed Using the Visual Analog Scale Differs between Initial Clinic Visit and the Day of Surgery in Orthopedic Patients and is Associated with Several Demographic Variables”. EC Orthopaedics 11.10 (2020): 83-93.

PubMed Indexed Article

EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005

EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777

EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347

EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478

EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253

EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033

EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992

EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505

EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793

EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211

EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047

EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560

EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318

EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819

EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840

EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344

EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476

EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658

EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489

EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278

EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108

EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571

EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333

EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883

EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001

EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937

EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723

EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726

EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603

EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646

EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616

EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290

EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226

EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812

EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268

News and Events

December Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the November issue of respective journals and the latest articles can be viewed on the current issue pages.

Submission Deadline for Upcoming Issue

ECronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the upcoming issue of respective journals. Submissions are accepted on/before December 21, 2022.

Certificate of Publication

ECronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

ECronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.