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Borgs Rating of Perceived Exertion Scales: Do the VerbalAnchors 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: dothe 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 an-chors 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 anchorsfrom the Borg RPE 620 and the newer 10-point category ratioscale.

Results: All groups placed the verbal anchors in the orderthat they occur on the scales. There were significant within-group differences (P.05) between VAS scores for 4 verbalanchors in the control group, 8 in the CLBP group, and 2 in thebrain injury group. There was no significant difference in ratingof each verbal anchor between the groups (P.05).

Conclusions: All subjects rated the verbal anchors in theorder they occur on the scales, but there was less agreement inrating of each verbal anchor among subjects in the brain injurygroup. Clinicians should consider the possibility of small dis-crepancies 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 andRehabilitation

EXERCISE IS INCREASINGLY USED during rehabilita-tion with clinical populations.1,2 For exercise to be effec-tive, it needs to be carefully prescribed and monitored. Itsintensity must be high enough to induce a training effect butnot so high as to detrimentally affect compliance or provoke

symptoms.3 People do modify exercise intensity in accordancewith symptoms of exertion.4-6 Every person has a point atwhich they can just perceive any sensation and a point at whichthat sensation becomes maximal. Therefore, everyone is as-sumed to have an equal range of sensations, although theperceptual experience itself may differ.7 Rating of perceivedexertion (RPE) has been used extensively to monitor intensityduring exercise in healthy populations8 and in clinical popula-tions that have symptoms that require monitoring during activ-ities.1,2

The 2 most widely used scales of perceived exertion inexercise were developed by Borg; they are Borgs 620 RPEand category ratio scale (CR-10).9,10 The scales use both verbal

anchors and numbers that have been reported to have categor-ical and interval properties.11,12 There has been extensive re-search into the relation between physiologic response andexertional symptoms such as breathlessness and musclepain8,13; however, the validity of interindividual comparisonsof symptoms during exercise, using either scale, depends onsubjects interpreting the verbal anchors with the same mean-ing.12 The method of evaluating the quantitative meaning of thewords used as verbal anchors in the RPE 620 scale and theCR-10 scale11 was based on earlier work of rating adjectivesand adverbs in general.14,15 Borg and Lindblad11 examined thequantitative meaning of a range of words used to describeexertion in a group of psychologists, psychology students, andpeople receiving support for psychologic illness. Verbal an-chors were rated for their quantitative meaning by both a visual

analog scale (VAS) and as a percentage. Verbal anchors thatspanned the full range of quantitative interpretation, did notoverlap each other, and were normally distributed in quantita-tive rating were used as verbal anchors for the RPE scales.11

These anchors were then arranged in relation to numbers, usingevidence of the physiologic response to exercise,10 to give theappropriate growth function for each scale. In agreement withearlier findings about the meaning of words in general,14,15

Borg and Lindblad found good agreement in the rating of eachverbal anchor. It is thus assumed that when subjects rate withthe RPE scales by choosing the appropriate verbal anchor fortheir feelings of exertion and by using the numeric value thatcorresponds to that anchor, interindividual comparisons can bemade.9

The verbal anchors were tested originally in healthy subjects

and in a small group of people with somatic or psychologicproblems that affected their ability to work.9 However, thescale has been used extensively with both healthy1,2 and clin-ical populations,16-18 and it is possible that people with differ-ent clinical conditions have altered meanings of the verbalanchors. Thus the interpretation of the anchors by clinicalgroups may differ from that of the subjects who were used toconstruct the scale. Rating of the anchors by clinical groups hasnot been examined. We explored the use of RPE at the per-ceptual levelthat is, interpretation of the terms used as verbalanchorsrather than at the experiential level of physiologicsymptoms associated with different degrees of actual energyexpenditure. We examined a cohort of moderately impaired

From the Movement Science Group, School of Biological and Molecular Sciences,Oxford Brookes University, Headington, Oxford (Dawes); Oxford Centre for Enable-ment (Dawes, Wade) and Physiotherapy Research Unit, Nuffield Orthopaedic Centre(Barker), Nuffield Orthopaedic Centre, Oxford; School of Psychology, University ofReading, 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 financial interest in the results of the research

supporting this article has or will confer a benefit on the author(s) or on anyorganization with which the author(s) is/are associated.

Reprint requests to Helen Dawes, PhD, MCSP, Movement Science Group, Sch ofBiological and Molecular Sciences, Oxford Brookes University, Gipsy Ln, Heading-ton, Oxford OX3 0BP, UK, e-mail: [email protected].

0003-9993/05/8605-9384$30.00/0doi:10.1016/j.apmr.2004.10.043

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patient groups in rehabilitation who were representative ofsubjects likely to have exercise prescribed as part of theirrehabilitation. Thus, we selected the acquired brain injury andchronic low back pain (CLBP) groups, for which exercise isbeing increasingly prescribed as part of rehabilitation. Ourprimary purpose in this study was to examine the interpretationof the terms used as verbal anchors by people with CLPB andpeople recovering from acquired brain injury. Then, in view ofthe changing nature of language over time, our secondarypurpose was to examine the current interpretation of the verbalanchors in a group of healthy controls.

METHODS

Participants

A convenience sample of patients consecutively referred tothe Nuffield Orthopaedic Centre were invited to participate.Nineteen subjects with acquired brain injury (traumatic braininjury, n5; stroke, n14; 12 men, 7 women; age, 3060y)and 16 subjects with CLBP (8 men, 8 women; age, 2355y)agreed to participate. Twenty healthy students (10 men, 10women; age, 1925y) were included as a control group.

Inclusion CriteriaSubjects were included in the brain injury group if they had

a history and clinical presentation of acquired brain injury, ifthey could cycle or walk with or without assistance, if theycould communicate with staff, if they could carry out simplecommands, and if they had no experience with the RPE orCR-10 scales. People were included in the CLBP group if theycould cycle or walk with or without assistance, if they had adiagnosis of nonspecific low back pain for more than 12months, if they had been screened for serious pathology andnerve root involvement using the red flag system,19 if theycould communicate with staff, and if they had no experiencewith the RPE 620 or CR-10 scale. Students were included inthe control group if they had a sedentary lifestyle, as depictedby a score of 3 or less on the activity Allied Dunbar National

Fitness Survey scale,20 and if they had with experience of theRPE or CR-10 scale.

The subjects we included had the following characteristics.Subjects with acquired brain injury were a mean standarddeviation (SD) of 14.212.03 months after injury, were rea-sonably oriented (Short Orientation-Memory-ConcentrationTest21,22 score range, 028; mean, 23.24.01), were able tocommunicate (Frenchay Aphasia Screening Test for verbalexpression23 score range, 010; mean, 9.80.284), had com-prehension (range, 010; mean, 9.70.48), were able to func-tion in most activities of daily living (Barthel Index24 scorerange, 020; mean, 17.33.1), and were able to walk with orwithout aid but not run (Rivermead Mobility Index25 scorerange, 015; mean, 12.21.8). Subjects with CLBP were insome discomfort and were disabled in some tasks because ofthe pain (Oswestry Disability Index26 score range, 0 100;mean, 41.422.02).

Procedure

Participants gave informed consent in accordance with the1976 Declaration of Helsinki. The study was approved by thelocal research ethics committee.

Quantitative Semantics

We replicated the method used by Borg and Lindblad,11 withthe imagined activity modified to cycling. Subjects were in-structed to imagine themselves cycling during progressive ex-

ercise up a hill that gets steeper, to a point where they reachtheir maximal exertion and are unable to continue. During thiscycle ride they were told that they would feel symptoms ofexertion (ie, tiredness) that would gradually increase. Imaginedexercise was chosen for ease of administration and so thatphysical impairments did not influence the subjects ability torate verbal anchors.

To prevent cognitive fatigue with the testing procedure, weincluded 10 verbal anchors from the original Borg and Lind-blad research. The following verbal anchors were selected fromthe RPE 620 scale9: nothing at all, extremely light, verylight, light, somewhat hard, hard, very hard, ex-tremely hard, and maximum; we also included moderatefrom the CR-10 scale.12 We evaluated these anchors becausethey were used in a version of the CR-10 RPE scale that wasmodified from the RPE 620 scale for use with people whomay present with weak limbs.27 When cycling during physio-logic pilot testing, such subjects had refused to use the verbalanchor strong if they felt weak, so the verbal anchors weakand strong were replaced by light and hard from the RPE620 scale. We then explored the relation of this modifiedversion of the scale to physiologic and performance markers ofexertion in clinical groups, as described elsewhere.27 In that

study, we found that the relation between physiologic markersand exertional symptoms did not differ between subjects withbrain injury and sedentary controls, although the former groupterminated exercise earlier.27 The verbal anchors were rated inrelation to symptoms of breathlessness and leg fatigue. Bothexertion symptoms were documented, because in the clinicalsetting, information about specific symptoms is frequently re-quired. We presented symptoms and verbal anchors in a ran-dom order.

Subjects were asked to rate each verbal anchor on a 20-cmVAS,11 with the limits being nothing at all and maximum.Subjects were also asked to mark a point on the VAS wherethey thought the verbal anchor should be placed. Immediatelyafter rating each anchor, they were asked to rate it as a per-centage by writing its value on a piece of paper or by commu-

nicating it verbally. Because there can be no objective criterionfor measuring peoples quantitative meaning of words, we usedthe VAS and percentage rating method11 as the criteria againstwhich to compare the verbal anchors. The order of presentationof the verbal anchors for both breathlessness and leg fatiguewere randomly allocated for each participant in blocks of 4. Afresh VAS and blank card were presented for each verbalanchor, and the previous one was hidden. Before the test,subjects were assured that the researcher was interested only intheir opinions and that there were no right or wrong answers.

Data Analyses

All analyses were performed with SPSS, version 10.a Dataobtained from VAS and percentage rating methods were ex-amined for normal distribution and uniform variance.

Agreement of rating using VAS and percentage methods. Weexamined the agreement between the VAS and percentageratings of the verbal anchors and the agreement in rating theverbal anchors for symptoms of breathlessness and leg fatigueby dependent t tests; (equal variance) intraclass correlationcoefficient (ICC) model 3,1; and Bland and Altmans limits ofagreement28 (bias [mean difference] random error [1.96 SDdifference]).

Interpretation of verbal anchors within groups. Using theVAS rating method for symptoms of breathlessness to establishinterpretation of the verbal anchors, we calculated means and95% confidence intervals (CIs) for each of the verbal anchorsrated with the VAS. To find differences in ratings of verbal

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anchors, we did 1-way repeated-measure analysis of variance(ANOVA) in each group. We did a post hoc Tukey test todetermine differences between verbal anchors. To reduce thelikelihood of a type I error, was set at P less than .01.

Between-group differences. To examine between-groupdifferences, we performed a mixed 2-way ANOVA (within-subject factor of verbal anchors; between-subject factor ofgroup). A P value of .05 or less was considered statisticallysignificant. Using a 2-tailed test with power of 0.8 and set at.05, sample size was calculated.

RESULTS

There were no significant differences between ratings withthe VAS and percentage methods (dependent t test, P.58;ICC3,1.98; bias random error,

28 1.513.7). Rating wassimilar for both the sensations of breathlessness and leg fa-tigue, with no significant differences between ratings for eachsensation (dependent t tests, P.85; ICC3,1.96; bias ran-dom error, 0.3719.1). To simplify data presentation, fromthis point all analyses will be of the VAS method rating thesensation of breathlessness.

Interpretation of Verbal Anchors Within Groups

Figure 1 shows boxplots of mean values with 95% CI for theVAS rating of the semantic verbal anchors describing the

symptom of breathlessness for all groups. Rating was similar inall 3 groups, with mean rating of each verbal anchor falling intothe expected sequence of placement as represented on the RPEscale. The mean values formed a sigmoid-shaped curve in allgroups, and the intervals between mean values of rating of theverbal anchors nothing, extremely light, very light, andlight were small. There was a bigger interval from light tomoderate and moderate to somewhat hard. The intervalbetween the mean rating of the verbal anchors very hard,extremely hard, and maximum were small. The 95% CIswere larger in all groups in the middle of the scale.

Table 1 shows results of a 1-way within-subjects ANOVA ofthe quantitative semantics of the verbal anchors used in theRPE scale using the VAS method of rating of the breathless-ness symptom. Significant overall differences in verbal anchorrating are shown in all groups.

A Tukey test post hoc analysis for consecutive verbal an-chors in the control group showed significant differences be-tween the verbal anchors very light and light (P.02),light and moderate (P.00), moderate and somewhathard (P.00), and hard and very hard (P.00). In theCLBP group, there were significant differences between not atall and extremely light (P.01), extremely light and

very light (P

.00), very light and light (P

.04), lightand moderate (P.00), moderate and somewhat hard(P.00), somewhat hard and hard (P.02), hard andvery hard (P.02), and extremely hard and maximum(P.00). In the brain injury group, there were significantdifferences between light and moderate (P.00) andmoderate and somewhat hard (P.00).

Between-Group Differences and Power

To examine between-group differences, we did a mixed2-way ANOVA (within-subject factor of verbal anchors; be-tween-subject factor of group). The main effect of group wasnot significant (F1,502.6111, P.083). A sample size of 975would be required to detect significant between-group differ-ences.

DISCUSSION

Subjects in both clinical and healthy groups could interpretthe conceived intensities of the verbal anchors in the RPEscales in an ordinal manner. The interpretation of the verbalanchors, represented by mean rating, was sigmoid in shape inall groups, with greater distances between mean values of theverbal anchors light, moderate, and somewhat hard inthe middle of the scale. There was good agreement in rating ofeach verbal anchor by the control and CLBP groups but not bythe brain injury group. Although the 3 groups rated verbalanchors with different degrees of agreement between subjects,there was some variation in ratings in general and no overalldifferences in ratings between the groups.

When examining different conceived exertional symptoms

(leg fatigue, breathlessness), we found a high level of agree-ment for ratings of the verbal anchors (ICC3,1.98). Borg and

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

Table 1: One-Way Within-Subjects Repeated-Measures ANOVA ofthe Word Rating Using the VAS Method of the Symptom

Breathlessness for Each Group

Test Group F P

Type of word Brain injury F9,153214.31 .001

CLBP F9,135411.03 .001

Control F9,162755.23 .001

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Lindblad11 rated verbal anchors when considering overall ex-ertion; rating the anchors when considering differentiated typesof exertional symptoms has not previously been examined. Ourresults suggest that the verbal anchors are suitable for ratingboth exercise symptoms and support the use of the scale fordifferent sensory descriptors, which is in agreement with phys-iologic studies.8,13

Analysis of the interpretation of the verbal anchors showedthat all groups demonstrated a similar sigmoid pattern of rating.However, agreement of rating of verbal anchors varied be-tween the groups. In subjects with CLBP, there was goodagreement in the value given to each of the verbal anchors,with significant differences (P.01) between all consecutiveverbal anchors used in the scale except between very hardand extremely hard. This supports the use of the scale indetermining with some accuracy exercise intensity in thisgroup of subjects. In the control group there were significantdifferences (P.01) between consecutive verbal anchors verylight and light, light and moderate, moderate andsomewhat hard, and hard and very hard. This suggeststhat, in this group, there is good agreement in the meaning ofthe verbal anchors between subjects but that they did notclearly differentiate between the intensifiers very and ex-

tremely at either end of the scale. It would appear that 30years after the original study, subjects rate the verbal anchors ina similar pattern, although there was less cohesion in rating inour group when the intensifiers very and extremely wereused. In subjects with brain injury, there was a significantdifference (P.01) only between consecutive verbal anchorslight and moderate and moderate and somewhat hard,with no significant differences between other consecutive an-chors. This suggests that there is less cohesion in the meaningof the verbal anchors in this group but that subjects were ableto discriminate between light, moderate, and hard intensities.Our findings in the brain injury group differ somewhat fromthose of Borg and Lindblad who found that the verbal anchorswere placed in a sigmoid curve and that all the verbal anchorswere placed significant distances apart in healthy controls and

subjects with somatic or psychologic illness.11

It is not surpris-ing that subjects in the brain injury group were more variablein their understanding of the meaning of some of the verbalanchors. Some in this group may have had cognitive impair-ments that affected their responses. The high level of agree-ment in the CLBP group may be a result of the pain andsensation that affect their lives, making them more sophisti-cated in their interpretation of the verbal anchors that may beused to quantify sensations.

In this study, we examined a typical cohort of moderatelyimpaired patient groups in rehabilitation that were representa-tive of subjects likely to be prescribed exercise; thus the braininjury and CLBP groups were selected because exercise isbeing increasingly prescribed as part of their rehabilitation. Ourresults, when compared with those of the Swedish study,11 may

have been affected by patient demographics. The level ofimpairment of subjects in rehabilitation was not reported in theSwedish study; the effect of both the level and type of impair-ment on ratings should be examined in future studies. Thegreater variation in interpretation of verbal anchors in the braininjury group suggests that it should not be assumed that allclinical groups attach the same meaning to the anchors. Thepossibility of small discrepancies in the meaning for individualsubjects should be considered when the scales are used toevaluate a persons exercise perceptions.

The lower agreement in ratings of verbal anchors at thelower limit of the scale, where the intensifiers extremely andvery are used, has clinical implications because it is within

these lower intensities that clinical groups are often asked toexercise. The large difference in mean ratings in all groupsfrom light to somewhat hard is again interesting because inthe RPE 620 scale the word moderate is not used; thismight suggest that the scale is less sensitive to changes inintensity in this middle region. Further investigations of areduced scale for people with brain injury is warranted becauseour findings suggest this would be valid and could simplify themonitoring of exercise intensity in this group.

Our findings should be considered in the context of thestudys limitations. The groups had relatively small samplesizes, and with the moderate variation in rating of verbalanchors between subjects, our analysis suggests that a muchlarger sample would be required to detect between-group dif-ferences. However, the interindividual variation in rating is animportant finding. The clinical groups were selected becausethey provided a range of physical, cognitive, and behavioralimpairments that might influence the interpretation of words.There is a need now to investigate the factors that may alterinterpretation of the verbal anchors by individual subjects. Thecontrol subjects were selected to match by age and character-istics 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 thedifferent responses in the clinical groups. The imagined exer-cise was performed in line with the original study, and theimagining prevented the exercise experience from influencingthe rating of the verbal anchors.

CONCLUSIONS

Subjects in all groups rated the verbal anchors in the order inwhich they occur on the scales, but there was some variation inratings of each verbal anchor between subjects, particularlywithin the brain injury group. The passage of time does notappear to have altered the interpretation of the verbal anchors;the interpretation was similar in our control group to that in theoriginal study. The possibility of small discrepancies in the

meaning of the verbal anchors to people, particularly in thoserecovering from brain injury, should be considered when ex-ercise perceptions are evaluated. A reduced version of the scalecould be considered for use with people with brain injury.

Acknowledgments: We thank Nicki Burley of Oxford BrookesUniversity for her part in collecting the student and acquired braininjury data and Hooshang Izadi, PhD, for his support with statistics.

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