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Is a line the same as a box?Speech assessment by VAS is not superior to Likert scales in laryngeal cancer patients
Abstract
The primary purpose was to assess if VAS or Likert was relatively more suitable when assessing self-ratings of voice and speech in patients treated for laryngeal cancer. An additional purpose was to investigate whether the scales differed in measuring change after treatment.
Using both VAS and Likert, 71 patients answered three questions at baseline and 12 months after treatment began. For test-retest analyses, additional data were used from 21 subjects. Non-parametric statistical methods suitable for comparing scales with different numbers of response alternatives were applied.
Test-retest reliability was strongest for the Likert scale. From baseline to follow-up, both scales detected significant improvements. However, for some Likert scores the associated VAS values varied across a wide range, and this was true for assessments at baseline, at follow-up, and for score changes. At baseline the inter-scale concordance showed a greater number of disordered pairs than at follow-up and on both occasions the older group produced a greater number of disordered pairs.
No support for the superiority of VAS over Likert was found. However, VAS may produce instability in response patterns. When using self-ratings of voice and speech to identify a need of further rehabilitation, Likert scales seem better suited.
... The primary outcome measures were patient self-assessment of heel pain (at rest, in the morning, and during activities) using the categorical Likert pain scale (LPS) with an incremental range of values. The participants were instructed to mark a designated interval, from 0 to 100, in 10-point intervals, with 0 indicating no pain and 100 indicating the worst pain (14)(15)(16). ...
We compared the effectiveness of ultrasound (US)-guided corticosteroid, injected superficial or deep to the fascia, in patients with plantar fasciitis. Thirty patients (24 females [75%] and 6 males [25%]) with unilateral chronic plantar fasciitis were divided into 2 groups according to the corticosteroid injection site: superficial (n = 15) or deep (n = 15) to the plantar fascia. Patient heel pain was measured using a Likert pain scale and the Foot Ankle Outcome Scale (FAOS) for foot disability, evaluated at baseline and repeated in the first and sixth weeks. The plantar fascia and heel pad thicknesses were assessed on US scans at baseline and the sixth week. The groups were similar in age, gender, and body mass index (p > .05 for all). Compared with the baseline values, the Likert pain scale (p < .001 for all) and FAOS subscale (p < .01 for all) scores had improved at the first and sixth week follow-up visits in both groups. Although the plantar fascia thickness had decreased significantly in both groups at the sixth week (p < .001 for both), the heel pad thickness remained unchanged (p > .05 for both). The difference in the FAOS subscales (pain, p = .002; activities of daily living, p = .003; sports/recreational activities, p = .008; quality of life, p = .009) and plantar fascia thickness (p = .049) showed better improvement in the deep than in the superficial injection group. US-guided corticosteroid injections are safe and effective in the short-term therapeutic outcome of chronic plantar fasciitis. Additionally, injection of corticosteroid deep to the fascia might result in greater reduction in plantar fascia thickness, pain, and disability and improved foot-related quality of life.
... Furthermore, Likert pain scales are often used and have been validated. [17][18][19][20][21] Quality of life was quantified using the validated Digestive Disease Questionnaire-15 (DDQ-15) quality-of-life instrument (Appendix Table A2, online only). 22 Diagnostic and staging EUS was then performed as an outpatient procedure under conscious sedation, using therapeutic, linear array echoendoscope (Pentax, 3830UT, Pentax America, Montvale, NJ), by one of two experienced endosonographers (Ͼ 5,000 procedures each). ...
Celiac plexus neurolysis (CPN) is currently used as salvage therapy for morphine-resistant pancreatic cancer pain. Endoscopic ultrasound-guided CPN (EUS-CPN) can be performed early, at the time of EUS. We hypothesized that early EUS-CPN would reduce pain and morphine consumption, increase quality of life (QOL), and prolong survival.
Patients were eligible if referred for EUS for suspected pancreatic cancer with related pain. If EUS and EUS-guided fine-needle aspiration cytology confirmed inoperable adenocarcinoma, patients were randomly assigned to early EUS-CPN or conventional pain management. Pain scores (7-point Likert scale), morphine equivalent consumption, and QOL scores (Digestive Disease Questionnaire-15) were assessed at 1 and 3 months.
Five hundred eighty eligible patients were seen between April 2006 and December 2008. Ninety-six patients were randomly assigned (48 patients per study arm). Pain relief was greater in the EUS-CPN group at 1 month and significantly greater at 3 months (difference in mean percent change in pain score = -28.9 [95% CI, -67.0 to 2.8], P = .09, and -60.7 [95% CI, -86.6 to -25.5], P = .01, respectively). Morphine consumption was similar in both groups at 1 month (difference in mean change in morphine consumption = -1.0 [95% CI, -47.7 to 49.2], P = .99), but tended toward lower consumption at 3 months in the neurolysis group (difference in mean change in morphine consumption = -49.5 [95% CI, -127.5 to 7.0], P = .10). There was no effect on QOL or survival.
Early EUS-CPN reduces pain and may moderate morphine consumption in patients with painful, inoperable pancreatic adenocarcinoma. EUS-CPN can be considered in all such patients at the time of diagnostic and staging EUS.
... Socio-demographic data were also recorded. Two articles based on this material have previously been published [3,30]. ...
Using a longitudinal design, aim of this study was to investigate the relation between mental adjustment to cancer and anxiety, depression, health-related quality of life (HRQL) and survival in patients treated for laryngeal cancer.
95 patients with Tis-T4 laryngeal cancer were assessed at one and 12 months after start of treatment, respectively, using the Mini-Mental Adjustment to Cancer Scale (Mini-MAC), the European Organisation for Research and Treatment of Cancer (EORTC) Study Group on Quality of Life core questionnaire (EORTC QLQ-C30) supplemented with the Head and Neck cancer module (QLQ-H&N35) and the Hospital Anxiety and Depression (HAD) Scale. For survival analyses patients were followed up for a median time of 4.22 years from inclusion.
The most commonly used adjustment response at both occasions was Fighting Spirit. The use of adjustment responses was relatively stable over time. Correlation analyses showed that patients using Helpless-Hopeless and Anxious Preoccupation responses reported more anxiety and depression, as well as decreased HRQL. Tumour site and stage showed no effect on adjustment response. Survival analysis indicated that use of a Helpless-Hopeless response was related to poorer survival (HR 1.17, p 0.001).
The relation between adjustment responses Helpless-Hopeless and Anxious Preoccupation and anxiety, depression, HRQL and possibly poorer survival indicate that assessment of mental adjustment should be considered when planning treatment and rehabilitation in laryngeal cancer patients.
... Guyatt et al. [31] consider filling Likert scales more intuitive than selecting a position on a continuous line. Children and elderly people have been reported to prefer a Likert scale to a VAS, or to have problems understanding the VAS itself [32][33][34][35]. Gift reviews some difficulties reported for VAS [17]. ...
in Occidental languages, no widely accepted questionnaire is available which deals with health related quality of life from the specific point of view of Traditional Chinese Medicine (TCM). Some psychometric tools of this kind are available in Chinese. One of them is the Chinese Quality of Life questionnaire (ChQoL). It comprises 50 items, subdivided in 3 Domains and 13 Facets. The ChQoL was built from scratch on the basis of TCM theory. It is therefore specifically valuable for the TCM practitioner. This paper describes our translation into Italian of the ChQoL, its first application to Occidental oncological patients, and some of its psychometric properties.
a translation scheme, originally inspired by the TRAPD procedure, is developed. This scheme focuses on comprehensibility and clinical usefulness more than on linguistic issues alone. The translated questionnaire is tested on a sample of 203 consecutive female patients with breast cancer. Shapiro-Wilk normality tests, Fligner-Killeen median tests, exploratory Two-step Cluster Analysis, and Tukey's test for non-additivity are applied to study the outcomes.
an Italian translation is proposed. It retains the TCM characteristics of the original ChQoL, it is intelligible to Occidental patients who have no previous knowledge of TCM, and it is useful for daily clinical practice. The score distribution is not Normal, and there are floor and ceiling effects. A Visual Analogue Scale is identified as a suitable choice. A 3-point Likert scale can also efficiently describe the data pattern. The original scales show non-additivity, but an Anscombe-Tukey transformation with γ = 1.5 recovers additivity at the Domain level. Additivity is enhanced if different γ are adopted for different Facets, except in one case.
the translated questionnaire can be adopted both as a filing system based on TCM and as a source of outcomes for clinical trials. A Visual Analogue Scale is recommended, but a simpler 3-point Likert scale also suitably fits data. When estimating missing data, and when grouping items within Domain in order to build a summary Domain index, an Anscombe-Tukey transformation should be applied to the raw scores.
Purpose:
Successful communication is influenced by communication partners, the community and communication environment. This study examines community members' perceptions of voice function following laryngeal cancer management compared to ratings by clinicians and patients.
Method:
Sixty-six (Tis-T3) laryngeal cancer patients post-radiotherapy, 10 community members and three speech-language pathologists (clinicians) were recruited. Patients completed voice recordings and self-rated voice quality and acceptability, six months post-radiotherapy. Community members and clinicians rated patient voice recordings using (a) Voice Quality/Acceptability questionnaire, (b) Communicative Suitability Scale (voice function in different vocally demanding environments) and (c) a gender perception question.
Result:
Ratings for voice quality differed significantly (p < 0.001) between community members and clinicians and approached significance (p= 0.08) between community members and patients. No significant difference for voice acceptability was noted between community members and clinicians/patients. Community members rated the irradiated voice significantly different (p ≤ 0.02) across communication environments with more vocally demanding environments being rated as "Barely Sufficient". Incorrect sex identification (gender perception) occurred with 25% of females.
Conclusion:
Community communication partners identify functional voice impairments post-radiotherapy, particularly across more vocally demanding environments and for female speakers. Implications for voice rehabilitation including appropriate patient selection is highlighted.
Background
The purpose of this study was to establish minimum clinically important difference (MCID) scores for the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer (S-SECEL) in order to facilitate clinical interpretation and identify cutoff values for voice rehabilitation.Method
One hundred nineteen patients with laryngeal cancer completed the S-SECEL instrument and an anchor question regarding acceptability of speech in a social context pretreatment and 12-month postoncologic treatment. Receiver operating characteristic (ROC) curves analysis was used for calculation of cutoff values.ResultsVoice rehabilitation cutoff values were identified for all domains (Total = 20; General = 4; Environmental = 16, and Attitudinal = 5), presenting acceptable sensitivity and specificity. Initial MCID estimates were obtained for all domains; improvement of −13 points (p < .0001) or a deterioration of +8 points (p = .035) for the Total domain.ConclusionMCID and cutoff scores for the S-SECEL have been identified and may be used in clinical practice to help identify patients with laryngeal cancer in need of voice rehabilitation. © 2015 Wiley Periodicals, Inc. Head Neck, 2015
The goals of this study were to evaluate the validity of the visual analogue scale (VAS) for young children and to compare a newly developed method of teaching children to use a VAS with one used in our previous studies. It was hypothesized that the new method would increase the number of children who understand the VAS and correctly mark their responses on the VAS line. The association between child's age and ability to understand the VAS was also evaluated. One hundred-six children with a laceration requiring sutures and receiving a lidocaine injection for local anesthesia participated in the study. They ranged in age from 5 to 14 years. Two outcome measures were used to assess the baseline and lidocaine injection pain: a 5-point Likert scale and a VAS. A calibration study was used to determine whether the subjects were able to use the VAS to make proportional judgments about their perceptions. Teaching method had no effect on the number of subjects who could correctly mark their responses on the VAS line, nor did it significantly increase the number of subjects who could understand the concept of the VAS. Subjects who were able to understand the VAS were significantly older (mean = 9.8 years, SD = 2.8) than those who did not (mean = 8.2 years, SD = 2.5). Overall, only about one third of the subjects were able to correctly mark the VAS and understand the concept of the VAS. Other measures of pain that are better understood by young children may be more valid indicators of pain than the VAS.
Rating scales like the visual analogue scale, VAS, and the verbal rating scale, VRS, are often used for pain assessments both in clinical work and in research, despite the lack of a gold standard. Interchangeability of recorded pain intensity captured in the two scales has been discussed earlier, but not in conjunction with taking the influence of pain etiology into consideration.
In this cross-sectional study, patients with their pain classified according to its etiology (chronic/idiopathic, nociceptive and neuropathic pain) were consecutively recruited for self-assessment of their actual pain intensity using a continuous VAS, 0-100, and a discrete five-category VRS. The data were analyzed with a non-parametric statistical method, suitable for comparison of scales with different numbers of response alternatives.
An overlapping of the VAS records relative the VRS categories was seen in all pain groups. Cut-off positions for the VAS records related to the VRS categories were found lower in patients with nociceptive pain relative patients suffering from chronic/idiopathic and neuropathic pain. When comparing the VAS records transformed into an equidistant five-category scale with the VRS records, systematic disagreements between the scales was shown in all groups. Furthermore, in the test-retest a low percentage of the patients agreed to the same pain level on the VAS while the opposite hold for the VRS.
The pain intensity assessments on VAS and VRS are in this study, not interchangeable due to overlap of pain records between the two scales, systematic disagreements when comparing the two scales and a low percentage intra-scale agreement. Furthermore, the lower VAS cut-off positions relative the VRS labels indicate different meaning of the rated pain intensity depending on pain etiology. It is also indicated that the scales have non-linear properties and that the two scales probably have different interpretation. Our findings are in favor of using the VRS in pain intensity assessments but if still the VAS is preferred, the VAS data should be analyzed as continuous using statistical methods suitable for ordinal data. Furthermore, our findings indicate a risk to over or under estimate the patient's perceived pain when interpreting condensed VAS data.
Complex health-related concepts are commonly measured by means of multi-item scales or questionnaires. As the item scales of an instrument cover different aspects of the same variable, a single global response value is required of the concept to be measured. In this paper, different approaches that take into account the non-metric properties of ordered categorical data when aggregating multi-item scales into global scaling were suggested. A single score of equally important items is easily defined by the median. When the multi-items are constructed to identify the most serious sign of a particular state, the maximum categorical level of the items could be an appropriate single score of the variable. By means of the joint response scheme over two aspects of the same variable, a global scale with an optional number of ordered categories could be defined. Some of the multi-item scales of the Short-Form Health Survey (SF-36) and Euro-QoL were used for illustrations to the proposed approaches. Copyright © 2001 John Wiley & Sons, Ltd.
There are various types of rating scales in which the possible responses are either continuous or discrete. A large number of studies have compared the visual analogue scale (VAS) with various types of discrete scales, such as verbal descriptor scales and numerical rating scales. These studies have reported conflicting results, with no firm evidence of superiority of either type of scale. However, the conclusions have often been based on parametric statistical methods. In the present study, a rank-invariant approach for inter-scale comparisons is used to evaluate the order consistency between the VAS, the graphic rating scale and a five-point verbal descriptor scale. The comparative evaluation showed that both the verbal descriptor scale and the graphic rating scale assessments were superior to the visual analogue scale assessments, and that assessments on the discrete scale had the highest level of stability.
The effect of analgesics on pathological pain in a double-blind, complete cross-over design was assessed by means of two rating scales, a verbal rating scale (VRS) and visual analogue scale (VAS). The VRS is widely used, but has several disadvantages as compared to the VAS. The results obtained by means of the VRS showed higher F-ratios (analysis of variance and Kruskall-Wallis H-test) than those obtained by means of the VAS. The VRS, which transfers a continuous feeling into a digital system, seems to augment artificially the measurement of effects produced by analgesics, and the VAS seems to assess more closely what a patient actually experiences with respect to change in pain intensities. The correlation between the two scales was highly significant (r = 0.81, P less than 0.001). The calculated regression line (y=-29.6 + 0.55-x) was not similar to the line of identity and showed much lower values for the VAS, supporting our interpretation. The distribution of the variances of the values obtained by means of both scales was not homogenous. This indicates that the homogeneity of the distribution of variances should always be checked and a Kruskall-Wallis H-test used, if they are inhomogenously distributed.
Many controlled trials rely on subjective measures of symptoms or quality of life as primary outcomes. The relative merits of different response options for these measures is an important, but largely unexplored, issue. Therefore, we compared the responsiveness of seven-point Likert vs visual analogue scales (VAS) in a questionnaire measuring quality of life in chronic lung disease. The VAS and seven-point scale versions of the questionnaire were administered to 28 patients before and after completing an inpatient respiratory rehabilitation program of known benefit. For all four dimensions of the questionnaire (dyspnea, fatigue, emotional function, and mastery) the VAS showed a larger improvement than the seven-point scale when both were standardized on a scale of 0-10. However, in each case the variability of the improvement was greater using the VAS. The difference in improvement between the two scales was not statistically significant. We conclude that the two methods of presenting response options show comparable responsiveness. The ease of administration and interpretation of the seven-point scale recommend its use in clinical trials.
After brief consideration of the definition of the term ‘quality of life’, methods previously adopted and problems encountered in assessing and evaluating quality of life in clinical studies of cancer are reviewed. Desirable properties of any such assessment methods and approaches to the analysis of quality of life data are discussed.
Illustrations are provided by reference to the methods of assessment of quality of life incorporated in two recently-initiated studies of cancer treatment.
The study compared level of fatigue measured by two self-report instruments in 43 patients on chronic haemodialysis. The two fatigue measures were the multi-item fatigue subscale of the Profile of Mood States (POMS) and a single-item visual analogue scale (VAS). There was a significant relationship between the two measures (r = 0.80); however, the shared variance was only 64%. Males and females, as well as subjects of different ages, responded to the two scales in different ways. Nurses need to know that different tools may give different results, even when the same concept, that is fatigue, is being measured in the same subjects at the same time.
One way to ensure adequate sensitivity for analgesic trials is to test the intervention on patients who have established pain of moderate to severe intensity. The usual criterion is at least moderate pain on a categorical pain intensity scale. When visual analogue scales (VAS) are the only pain measure in trials we need to know what point on a VAS represents moderate pain, so that these trials can be included in meta-analysis when baseline pain of at least moderate intensity is an inclusion criterion. To investigate this we used individual patient data from 1080 patients from randomised controlled trials of various analgesics. Baseline pain was measured using a 4-point categorical pain intensity scale and a pain intensity VAS under identical conditions. The distribution of the VAS scores was examined for 736 patients reporting moderate pain and for 344 reporting severe pain. The VAS scores corresponding to moderate or severe pain were also examined by gender. Baseline VAS scores recorded by patients reporting moderate pain were significantly different from those of patients reporting severe pain. Of the patients reporting moderate pain 85% scored over 30 mm on the corresponding VAS, with a mean score of 49 mm. For those reporting severe pain 85% scored over 54 mm with a mean score of 75 mm. There was no difference between the corresponding VAS scores of men and women. Our results indicate that if a patient records a baseline VAS score in excess of 30 mm they would probably have recorded at least moderate pain on a 4-point categorical scale.
Efficacy in osteoarthritis (OA) is principally measured using subjective visual analogue (VAS) and/or Likert scale responses. The relationship between these two scales and their relative precision in discriminating active from placebo treatment in OA patients was determined.
Patient overall pain assessment, and patient and investigator global assessments were each measured on a 100mm VAS and on a 0 to 4 point Likert scale in a 6-week OA study of rofecoxib vs placebo. The relationship between the VAS and Likert responses was examined graphically and via summary statistics. Analysis of variance was used to assess consistency of the VAS/Likert relationship over time and across the different endpoints. Precision was compared using effect size, and normality of VAS scale of measurement was assessed using the Shapiro-Wilk test.
Mean VAS scores and changes from baseline at individual time points were generally highly correlated with corresponding Likert responses (r-values generally approximately 0.7-0.8). The magnitude of VAS values and changes varied depending on endpoint, on the associated magnitude of increment of Likert score, and on the Likert baseline value (i.e., where on the Likert scale the change was occurring). Precision of VAS and Likert responses to detect difference between treatments was generally similar with effect sizes approximately 1. Normality and homogeneity of variance of VAS scores was most closely approximated by actual changes in comparison to percent change or log-transformed measures.
VAS and Likert responses are highly correlated and yield similar precision for discriminating treatments in OA patients. Since Likert responses are easier to administer and interpret, they may be preferable to measure OA response.
To examine which response options children prefer and which they find easiest to use, and to study the relative reliability of the different response options.
A consecutive group of unselected children (n = 120) filled out three questionnaires in a paediatric outpatient clinic. Each questionnaire included seven similar questions, but had different response options: the Likert scale, the Visual Analogue Scale (VAS) and the numeric VAS. In general, the questions were not related to the children's particular diseases, but dealt with the frequency of simple activities, their feelings and opinions. The pages with the three different response options were offered in random order. Afterwards, the children rated their preference and ease of use of the different response options on a scale from one to 10.
Children preferred the Likert scale (median mark 9.0) over the numeric VAS (median mark 8.0) and the simple VAS (median 6.0). They considered the Likert scale easiest to fill out (median mark 10 vs 9 and 7.5 for the numeric and simple VAS, respectively). Results of the different response options correlated strongly with each other (rho = 0.67-0.90, p < 0.05).
Children prefer the Likert scale over the numeric and simple VAS and find it easiest to complete. The Likert scale, the simple VAS and the numeric VAS are of comparable reliability. The Likert scale is recommended for use in questionnaires for children, although research into larger and more diverse samples is needed.
The purpose of this study was to assess the validity of Visual Analog Scales in urogynecologic research.
In phase I, 35 women completed short forms of the urogenital distress inventory, incontinence impact questionnaire, and Beck depression inventory fast screen using the Likert-type scale and Visual Analog Scale formats. Reliability was estimated with Spearman's correlations and Cronbach's alpha; construct validity was assessed with the use of factor analyses. In phase II, 101 women were recruited for the test-retest reliability assessment of the Visual Analog Scale formats of the urogenital distress inventory and incontinence impact questionnaire short forms. Reproducibility was analyzed with intraclass correlations.
In phase I, correlations between the Likert-type scale and the Visual Analog Scale were good: urogenital distress inventory (0.748), incontinence impact questionnaire (0.787), and Beck depression inventory fast screen (0.852; P <.05). In phase II, intraclass correlations were 0.898 and 0.938 for the urogenital distress inventory and incontinence impact questionnaire scores, respectively ( P <.001).
The Visual Analog Scale is a simple, reliable, and reproducible method for the assessment of quality of life in urogynecologic research.
This review aims to explore the research available relating to three commonly used pain rating scales, the Visual Analogue Scale, the Verbal Rating Scale and the Numerical Rating Scale. The review provides information needed to understand the main properties of the scales.
Data generated from pain-rating scales can be easily misunderstood. This review can help clinicians to understand the main features of these tools and thus use them effectively.
A MedLine review via PubMed was carried out with no restriction of age of papers retrieved. Papers were examined for methodological soundness before being included. The search terms initially included pain rating scales, pain measurement, Visual Analogue Scale, VAS, Verbal Rating Scale, VRS, Numerical/numeric Rating Scale, NRS. The reference lists of retrieved articles were used to generate more papers and search terms. Only English Language papers were examined.
All three pain-rating scales are valid, reliable and appropriate for use in clinical practice, although the Visual Analogue Scale has more practical difficulties than the Verbal Rating Scale or the Numerical Rating Scale. For general purposes the Numerical Rating Scale has good sensitivity and generates data that can be statistically analysed for audit purposes. Patients who seek a sensitive pain-rating scale would probably choose this one. For simplicity patients prefer the Verbal Rating Scale, but it lacks sensitivity and the data it produces can be misunderstood.
In order to use pain-rating scales well clinicians need to appreciate the potential for error within the tools, and the potential they have to provide the required information. Interpretation of the data from a pain-rating scale is not as straightforward as it might first appear.