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Borgs Rating of Perceived Exertion Scales: Do the Verbal Anchors Mean the Same for Different Clinical Groups?
Helen N. Dawes, PhD, MCSP, Karen L. Barker, PhD, MCSP, Janet Cockburn, PhD, Neil Roach, MSc, Oona Scott, PhD, Derick Wade, MD
ABSTRACT. Dawes HN, Barker KL, Cockburn J, Roach N, Scott O, Wade D. Borgs rating of perceived exertion scales: do the verbal anchors mean the same for different clinical groups? Arch Phys Med Rehabil 2005;86:912-6. Objective: To examine the interpretation of the verbal anchors used in the Borg rating of perceived exertion (RPE) scales in different clinical groups and a healthy control group. Design: Prospective experimental study. Setting: Rehabilitation center. Participants: Nineteen subjects with brain injury, 16 with chronic low back pain (CLBP), and 20 healthy controls. Interventions: Not applicable. Main Outcome Measures: Subjects used a visual analog scale (VAS) to rate their interpretation of the verbal anchors from the Borg RPE 6 20 and the newer 10-point category ratio scale. Results: All groups placed the verbal anchors in the order that they occur on the scales. There were signicant withingroup differences (P .05) between VAS scores for 4 verbal anchors in the control group, 8 in the CLBP group, and 2 in the brain injury group. There was no signicant difference in rating of each verbal anchor between the groups (P .05). Conclusions: All subjects rated the verbal anchors in the order they occur on the scales, but there was less agreement in rating of each verbal anchor among subjects in the brain injury group. Clinicians should consider the possibility of small discrepancies in the meaning of the verbal anchors to subjects, particularly those recovering from brain injury, when they evaluate exercise perceptions. Key Words: Exercise; Exertion; Perception; Rehabilitation; Semantics. 2005 by American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation XERCISE IS INCREASINGLY USED during with populations. For E tionneeds clinicalcarefully prescribedexercise torehabilitabe effective, it to be and monitored. Its
1,2

intensity must be high enough to induce a training effect but not so high as to detrimentally affect compliance or provoke

From the Movement Science Group, School of Biological and Molecular Sciences, Oxford Brookes University, Headington, Oxford (Dawes); Oxford Centre for Enablement (Dawes, Wade) and Physiotherapy Research Unit, Nufeld Orthopaedic Centre (Barker), Nufeld Orthopaedic Centre, Oxford; School of Psychology, University of Reading, Reading (Cockburn); Manchester Metropolitan University, Manchester (Roach); and University of East London, London (Scott), UK. Supported by the University of East London. No commercial party having a direct nancial interest in the results of the research supporting this article has or will confer a benet on the author(s) or on any organization with which the author(s) is/are associated. Reprint requests to Helen Dawes, PhD, MCSP, Movement Science Group, Sch of Biological and Molecular Sciences, Oxford Brookes University, Gipsy Ln, Headington, Oxford OX3 0BP, UK, e-mail: hdawes@brookes.ac.uk. 0003-9993/05/8605-9384$30.00/0 doi:10.1016/j.apmr.2004.10.043

symptoms.3 People do modify exercise intensity in accordance with symptoms of exertion.4-6 Every person has a point at which they can just perceive any sensation and a point at which that sensation becomes maximal. Therefore, everyone is assumed to have an equal range of sensations, although the perceptual experience itself may differ.7 Rating of perceived exertion (RPE) has been used extensively to monitor intensity during exercise in healthy populations8 and in clinical populations that have symptoms that require monitoring during activities.1,2 The 2 most widely used scales of perceived exertion in exercise were developed by Borg; they are Borgs 6 20 RPE and category ratio scale (CR-10).9,10 The scales use both verbal anchors and numbers that have been reported to have categorical and interval properties.11,12 There has been extensive research into the relation between physiologic response and exertional symptoms such as breathlessness and muscle pain8,13; however, the validity of interindividual comparisons of symptoms during exercise, using either scale, depends on subjects interpreting the verbal anchors with the same meaning.12 The method of evaluating the quantitative meaning of the words used as verbal anchors in the RPE 6 20 scale and the CR-10 scale11 was based on earlier work of rating adjectives and adverbs in general.14,15 Borg and Lindblad11 examined the quantitative meaning of a range of words used to describe exertion in a group of psychologists, psychology students, and people receiving support for psychologic illness. Verbal anchors were rated for their quantitative meaning by both a visual analog scale (VAS) and as a percentage. Verbal anchors that spanned the full range of quantitative interpretation, did not overlap each other, and were normally distributed in quantitative rating were used as verbal anchors for the RPE scales.11 These anchors were then arranged in relation to numbers, using evidence of the physiologic response to exercise,10 to give the appropriate growth function for each scale. In agreement with earlier ndings about the meaning of words in general,14,15 Borg and Lindblad found good agreement in the rating of each verbal anchor. It is thus assumed that when subjects rate with the RPE scales by choosing the appropriate verbal anchor for their feelings of exertion and by using the numeric value that corresponds to that anchor, interindividual comparisons can be made.9 The verbal anchors were tested originally in healthy subjects and in a small group of people with somatic or psychologic problems that affected their ability to work.9 However, the scale has been used extensively with both healthy1,2 and clinical populations,16-18 and it is possible that people with different clinical conditions have altered meanings of the verbal anchors. Thus the interpretation of the anchors by clinical groups may differ from that of the subjects who were used to construct the scale. Rating of the anchors by clinical groups has not been examined. We explored the use of RPE at the perceptual levelthat is, interpretation of the terms used as verbal anchorsrather than at the experiential level of physiologic symptoms associated with different degrees of actual energy expenditure. We examined a cohort of moderately impaired

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patient groups in rehabilitation who were representative of subjects likely to have exercise prescribed as part of their rehabilitation. Thus, we selected the acquired brain injury and chronic low back pain (CLBP) groups, for which exercise is being increasingly prescribed as part of rehabilitation. Our primary purpose in this study was to examine the interpretation of the terms used as verbal anchors by people with CLPB and people recovering from acquired brain injury. Then, in view of the changing nature of language over time, our secondary purpose was to examine the current interpretation of the verbal anchors in a group of healthy controls. METHODS Participants A convenience sample of patients consecutively referred to the Nufeld Orthopaedic Centre were invited to participate. Nineteen subjects with acquired brain injury (traumatic brain injury, n 5; stroke, n 14; 12 men, 7 women; age, 30 60y) and 16 subjects with CLBP (8 men, 8 women; age, 2355y) agreed to participate. Twenty healthy students (10 men, 10 women; age, 19 25y) were included as a control group. Inclusion Criteria Subjects were included in the brain injury group if they had a history and clinical presentation of acquired brain injury, if they could cycle or walk with or without assistance, if they could communicate with staff, if they could carry out simple commands, and if they had no experience with the RPE or CR-10 scales. People were included in the CLBP group if they could cycle or walk with or without assistance, if they had a diagnosis of nonspecic low back pain for more than 12 months, if they had been screened for serious pathology and nerve root involvement using the red ag system,19 if they could communicate with staff, and if they had no experience with the RPE 6 20 or CR-10 scale. Students were included in the control group if they had a sedentary lifestyle, as depicted by a score of 3 or less on the activity Allied Dunbar National Fitness Survey scale,20 and if they had with experience of the RPE or CR-10 scale. The subjects we included had the following characteristics. Subjects with acquired brain injury were a mean standard deviation (SD) of 14.2 12.03 months after injury, were reasonably oriented (Short Orientation-Memory-Concentration Test21,22 score range, 0 28; mean, 23.2 4.01), were able to communicate (Frenchay Aphasia Screening Test for verbal expression23 score range, 0 10; mean, 9.8 0.284), had comprehension (range, 0 10; mean, 9.7 0.48), were able to function in most activities of daily living (Barthel Index24 score range, 0 20; mean, 17.3 3.1), and were able to walk with or without aid but not run (Rivermead Mobility Index25 score range, 0 15; mean, 12.2 1.8). Subjects with CLBP were in some discomfort and were disabled in some tasks because of the pain (Oswestry Disability Index26 score range, 0 100; mean, 41.4 22.02). Procedure Participants gave informed consent in accordance with the 1976 Declaration of Helsinki. The study was approved by the local research ethics committee. Quantitative Semantics We replicated the method used by Borg and Lindblad,11 with the imagined activity modied to cycling. Subjects were instructed to imagine themselves cycling during progressive ex-

ercise up a hill that gets steeper, to a point where they reach their maximal exertion and are unable to continue. During this cycle ride they were told that they would feel symptoms of exertion (ie, tiredness) that would gradually increase. Imagined exercise was chosen for ease of administration and so that physical impairments did not inuence the subjects ability to rate verbal anchors. To prevent cognitive fatigue with the testing procedure, we included 10 verbal anchors from the original Borg and Lindblad research. The following verbal anchors were selected from the RPE 6 20 scale9: nothing at all, extremely light, very light, light, somewhat hard, hard, very hard, extremely hard, and maximum; we also included moderate from the CR-10 scale.12 We evaluated these anchors because they were used in a version of the CR-10 RPE scale that was modied from the RPE 6 20 scale for use with people who may present with weak limbs.27 When cycling during physiologic pilot testing, such subjects had refused to use the verbal anchor strong if they felt weak, so the verbal anchors weak and strong were replaced by light and hard from the RPE 6 20 scale. We then explored the relation of this modied version of the scale to physiologic and performance markers of exertion in clinical groups, as described elsewhere.27 In that study, we found that the relation between physiologic markers and exertional symptoms did not differ between subjects with brain injury and sedentary controls, although the former group terminated exercise earlier.27 The verbal anchors were rated in relation to symptoms of breathlessness and leg fatigue. Both exertion symptoms were documented, because in the clinical setting, information about specic symptoms is frequently required. We presented symptoms and verbal anchors in a random order. Subjects were asked to rate each verbal anchor on a 20-cm VAS,11 with the limits being nothing at all and maximum. Subjects were also asked to mark a point on the VAS where they thought the verbal anchor should be placed. Immediately after rating each anchor, they were asked to rate it as a percentage by writing its value on a piece of paper or by communicating it verbally. Because there can be no objective criterion for measuring peoples quantitative meaning of words, we used the VAS and percentage rating method11 as the criteria against which to compare the verbal anchors. The order of presentation of the verbal anchors for both breathlessness and leg fatigue were randomly allocated for each participant in blocks of 4. A fresh VAS and blank card were presented for each verbal anchor, and the previous one was hidden. Before the test, subjects were assured that the researcher was interested only in their opinions and that there were no right or wrong answers. Data Analyses All analyses were performed with SPSS, version 10.a Data obtained from VAS and percentage rating methods were examined for normal distribution and uniform variance. Agreement of rating using VAS and percentage methods. We examined the agreement between the VAS and percentage ratings of the verbal anchors and the agreement in rating the verbal anchors for symptoms of breathlessness and leg fatigue by dependent t tests; (equal variance) intraclass correlation coefcient (ICC) model 3,1; and Bland and Altmans limits of agreement28 (bias [mean difference] random error [1.96 SD difference]). Interpretation of verbal anchors within groups. Using the VAS rating method for symptoms of breathlessness to establish interpretation of the verbal anchors, we calculated means and 95% condence intervals (CIs) for each of the verbal anchors rated with the VAS. To nd differences in ratings of verbal
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symptom of breathlessness for all groups. Rating was similar in all 3 groups, with mean rating of each verbal anchor falling into the expected sequence of placement as represented on the RPE scale. The mean values formed a sigmoid-shaped curve in all groups, and the intervals between mean values of rating of the verbal anchors nothing, extremely light, very light, and light were small. There was a bigger interval from light to moderate and moderate to somewhat hard. The interval between the mean rating of the verbal anchors very hard, extremely hard, and maximum were small. The 95% CIs were larger in all groups in the middle of the scale. Table 1 shows results of a 1-way within-subjects ANOVA of the quantitative semantics of the verbal anchors used in the RPE scale using the VAS method of rating of the breathlessness symptom. Signicant overall differences in verbal anchor rating are shown in all groups. A Tukey test post hoc analysis for consecutive verbal anchors in the control group showed signicant differences between the verbal anchors very light and light (P .02), light and moderate (P .00), moderate and somewhat hard (P .00), and hard and very hard (P .00). In the CLBP group, there were signicant differences between not at all and extremely light (P .01), extremely light and very light (P .00), very light and light (P .04), light and moderate (P .00), moderate and somewhat hard (P .00), somewhat hard and hard (P .02), hard and very hard (P .02), and extremely hard and maximum (P .00). In the brain injury group, there were signicant differences between light and moderate (P .00) and moderate and somewhat hard (P .00). Between-Group Differences and Power To examine between-group differences, we did a mixed 2-way ANOVA (within-subject factor of verbal anchors; between-subject factor of group). The main effect of group was not signicant (F1,50 2.6111, P .083). A sample size of 975 would be required to detect signicant between-group differences. DISCUSSION Subjects in both clinical and healthy groups could interpret the conceived intensities of the verbal anchors in the RPE scales in an ordinal manner. The interpretation of the verbal anchors, represented by mean rating, was sigmoid in shape in all groups, with greater distances between mean values of the verbal anchors light, moderate, and somewhat hard in the middle of the scale. There was good agreement in rating of each verbal anchor by the control and CLBP groups but not by the brain injury group. Although the 3 groups rated verbal anchors with different degrees of agreement between subjects, there was some variation in ratings in general and no overall differences in ratings between the groups. When examining different conceived exertional symptoms (leg fatigue, breathlessness), we found a high level of agreement for ratings of the verbal anchors (ICC3,1 .98). Borg and

Fig 1. Boxplot of mean and 95% CI for VAS method of rating breathlessness for (A) the brain injury, (B) CLBP, and (C) control groups. Abbreviations: max, maximum; mod, moderate; sw, somewhat; v, very; x, extremely.

anchors, we did 1-way repeated-measure analysis of variance (ANOVA) in each group. We did a post hoc Tukey test to determine differences between verbal anchors. To reduce the likelihood of a type I error, was set at P less than .01. Between-group differences. To examine between-group differences, we performed a mixed 2-way ANOVA (withinsubject factor of verbal anchors; between-subject factor of group). A P value of .05 or less was considered statistically signicant. Using a 2-tailed test with power of 0.8 and set at .05, sample size was calculated. RESULTS There were no signicant differences between ratings with the VAS and percentage methods (dependent t test, P .58; ICC3,1 .98; bias random error,28 1.5 13.7). Rating was similar for both the sensations of breathlessness and leg fatigue, with no signicant differences between ratings for each sensation (dependent t tests, P .85; ICC3,1 .96; bias random error, 0.37 19.1). To simplify data presentation, from this point all analyses will be of the VAS method rating the sensation of breathlessness. Interpretation of Verbal Anchors Within Groups Figure 1 shows boxplots of mean values with 95% CI for the VAS rating of the semantic verbal anchors describing the
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Table 1: One-Way Within-Subjects Repeated-Measures ANOVA of the Word Rating Using the VAS Method of the Symptom Breathlessness for Each Group
Test Group F P

Type of word

Brain injury CLBP Control

F9,153 214.31 F9,135 411.03 F9,162 755.23

.001 .001 .001

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Lindblad11 rated verbal anchors when considering overall exertion; rating the anchors when considering differentiated types of exertional symptoms has not previously been examined. Our results suggest that the verbal anchors are suitable for rating both exercise symptoms and support the use of the scale for different sensory descriptors, which is in agreement with physiologic studies.8,13 Analysis of the interpretation of the verbal anchors showed that all groups demonstrated a similar sigmoid pattern of rating. However, agreement of rating of verbal anchors varied between the groups. In subjects with CLBP, there was good agreement in the value given to each of the verbal anchors, with signicant differences (P .01) between all consecutive verbal anchors used in the scale except between very hard and extremely hard. This supports the use of the scale in determining with some accuracy exercise intensity in this group of subjects. In the control group there were signicant differences (P .01) between consecutive verbal anchors very light and light, light and moderate, moderate and somewhat hard, and hard and very hard. This suggests that, in this group, there is good agreement in the meaning of the verbal anchors between subjects but that they did not clearly differentiate between the intensiers very and extremely at either end of the scale. It would appear that 30 years after the original study, subjects rate the verbal anchors in a similar pattern, although there was less cohesion in rating in our group when the intensiers very and extremely were used. In subjects with brain injury, there was a signicant difference (P .01) only between consecutive verbal anchors light and moderate and moderate and somewhat hard, with no signicant differences between other consecutive anchors. This suggests that there is less cohesion in the meaning of the verbal anchors in this group but that subjects were able to discriminate between light, moderate, and hard intensities. Our ndings in the brain injury group differ somewhat from those of Borg and Lindblad who found that the verbal anchors were placed in a sigmoid curve and that all the verbal anchors were placed signicant distances apart in healthy controls and subjects with somatic or psychologic illness.11 It is not surprising that subjects in the brain injury group were more variable in their understanding of the meaning of some of the verbal anchors. Some in this group may have had cognitive impairments that affected their responses. The high level of agreement in the CLBP group may be a result of the pain and sensation that affect their lives, making them more sophisticated in their interpretation of the verbal anchors that may be used to quantify sensations. In this study, we examined a typical cohort of moderately impaired patient groups in rehabilitation that were representative of subjects likely to be prescribed exercise; thus the brain injury and CLBP groups were selected because exercise is being increasingly prescribed as part of their rehabilitation. Our results, when compared with those of the Swedish study,11 may have been affected by patient demographics. The level of impairment of subjects in rehabilitation was not reported in the Swedish study; the effect of both the level and type of impairment on ratings should be examined in future studies. The greater variation in interpretation of verbal anchors in the brain injury group suggests that it should not be assumed that all clinical groups attach the same meaning to the anchors. The possibility of small discrepancies in the meaning for individual subjects should be considered when the scales are used to evaluate a persons exercise perceptions. The lower agreement in ratings of verbal anchors at the lower limit of the scale, where the intensiers extremely and very are used, has clinical implications because it is within

these lower intensities that clinical groups are often asked to exercise. The large difference in mean ratings in all groups from light to somewhat hard is again interesting because in the RPE 6 20 scale the word moderate is not used; this might suggest that the scale is less sensitive to changes in intensity in this middle region. Further investigations of a reduced scale for people with brain injury is warranted because our ndings suggest this would be valid and could simplify the monitoring of exercise intensity in this group. Our ndings should be considered in the context of the studys limitations. The groups had relatively small sample sizes, and with the moderate variation in rating of verbal anchors between subjects, our analysis suggests that a much larger sample would be required to detect between-group differences. However, the interindividual variation in rating is an important nding. The clinical groups were selected because they provided a range of physical, cognitive, and behavioral impairments that might inuence the interpretation of words. There is a need now to investigate the factors that may alter interpretation of the verbal anchors by individual subjects. The control subjects were selected to match by age and characteristics the original student group used by Borg and Lindblad. We found no evidence suggesting that people of different ages would quantitatively interpret the verbal anchors differently, and so it is unlikely that age would be a factor affecting the different responses in the clinical groups. The imagined exercise was performed in line with the original study, and the imagining prevented the exercise experience from inuencing the rating of the verbal anchors. CONCLUSIONS Subjects in all groups rated the verbal anchors in the order in which they occur on the scales, but there was some variation in ratings of each verbal anchor between subjects, particularly within the brain injury group. The passage of time does not appear to have altered the interpretation of the verbal anchors; the interpretation was similar in our control group to that in the original study. The possibility of small discrepancies in the meaning of the verbal anchors to people, particularly in those recovering from brain injury, should be considered when exercise perceptions are evaluated. A reduced version of the scale could be considered for use with people with brain injury.
Acknowledgments: We thank Nicki Burley of Oxford Brookes University for her part in collecting the student and acquired brain injury data and Hooshang Izadi, PhD, for his support with statistics. References 1. Barker KL, Dawes H, Hansford P, Shamley D. Perceived and measured levels of exertion of patients with chronic back pain exercising in a hydrotherapy pool. Arch Phys Med Rehabil 2003; 84:1319-23. 2. Bateman A, Culpan FJ, Pickering AD, Powell JH, Scott OM, Greenwood RJ. The effect of aerobic training on rehabilitation outcomes after recent severe brain injury: a randomized controlled evaluation. Arch Phys Med Rehabil 2001;82:174-82. 3. American College of Sports Medicine. Guidelines for graded exercise testing and training. 5th ed. Philadelphia: Lea & Febiger; 1995. 4. Hamilton AL, Killian KJ, Summers E, Jones N. Quantication of intensity of sensations during muscular work by normal subjects. J Appl Physiol 1996;81:1156-61. 5. Kinsman RA, Weiser PC. Subjective symptomatology during work and fatigue. In: Simonson E, Weiser P, editors. Psychological aspects and physiological correlates of work and fatigue. Springeld: CC Thomas; 1975. p 336-405.
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