Extent measurement in localised low-back pain: a comparison of four methods

Data-driven identification of distinct pain drawing patterns and their association with clinical and psychological factors: a study of 21,123 patients with spinal pain

ABSTRACT

The variability in pain drawing styles and analysis methods has raised concerns about the reliability of pain drawings as a screening tool for nonpain symptoms. In this study, a data-driven approach to pain drawing analysis has been used to enhance the reliability. The aim was to identify distinct clusters of pain patterns by using latent class analysis (LCA) on 46 predefined anatomical areas of a freehand digital pain drawing. Clusters were described in the clinical domains of activity limitation, pain intensity, and psychological factors. A total of 21,123 individuals were included from 2 subgroups by primary pain complaint (low back pain (LBP) [n = 15,465]) or midback/neck pain (MBPNP) [n = 5658]). Five clusters were identified for the LBP subgroup: LBP and radiating pain (19.9%), radiating pain (25.8%), local LBP (24.8%), LBP and whole leg pain (18.7%), and widespread pain (10.8%). Four clusters were identified for the MBPNP subgroup: MBPNP bilateral posterior (19.9%), MBPNP unilateral posterior + anterior (23.6%), MBPNP unilateral posterior (45.4%), and widespread pain (11.1%). The clusters derived by LCA corresponded to common, specific, and recognizable clinical presentations. Statistically significant differences were found between these clusters in every self-reported health domain. Similarly, for both LBP and MBPNP, pain drawings involving more extensive pain areas were associated with higher activity limitation, more intense pain, and more psychological distress. This study presents a versatile data-driven approach for analyzing pain drawings to assist in managing spinal pain.

Digital mapping of shoulder pain in patients with shoulder disorders: a reliability study

INTRODUCTION

Digital body mapping can be used to document and quantify the area and location (distribution) of pain and discomfort and support assessment, monitoring, and treatment in clinical populations. This study determines the test-retest reliability of drawings detailing pain and pins and needles using digital body charts and their relationship to pain intensity and patient-reported shoulder function.

METHODS

Sixty-two participants with shoulder disorder completed pain and pins and needles drawings with test-retest interval of 30 minutes. Pain intensity in the last week and the patient-reported shoulder function questionnaires were completed. Area and radiating extent were determined using customized software. To assess relative and absolute test-retest reliability, the intraclass correlation coefficient (ICC3,1), standard error of measurement (SEM) and minimal detectable change (MDC95) were calculated. Regression analysis evaluated relation between area and radiating extent of pain and pins and needles with patient-reported function questionnaires.

RESULTS

Relative reliability for pain area and radiating extent was excellent (>0.90). Absolute reliability (SEM and MDC95) values for the pain area and radiating extent were 0.20%/34 pixels and 0.57%/94 pixels. Absolute reliability improves for smaller pain areas. Regression analysis revealed the area and radiation extent for both pain and pins and needles are independent constructs to the patient-reported function outcome when adjusted for pain intensity.

CONCLUSIONS

Digital body mapping assessing pain area and radiation extent in patients with shoulder disorders are reliable. The magnitude of absolute reliability suggests other sources of variability on repeat testing in this population. Pain area and radiation extent appear to be independent constructs.

Larger pain extent is associated with greater pain intensity and disability but not with general health status or psychosocial features in patients with cervical radiculopathy

Pain as a result of cervical radiculopathy (CR) can be widespread, nondermatomal and individually specific, but the association between pain extent and other clinical features has never been explored. The objective of this study is to investigate whether pain extent relates to clinical variables including pain intensity in addition to health indicators including disability, general health, depression, somatic anxiety, coping strategies or self-efficacy.An observational cohort study was conducted. Participants were recruited from 4 hospital spinal centres in Sweden. Pain extent was quantified from the pain drawings of 190 individuals with cervical disc disease, verified with magnetic resonance imaging (MRI) and compatible with clinical findings (examined by a neurosurgeon), that show cervical nerve root compression. Pain extent was evaluated in relation to neck pain, arm pain, and headache intensity. Multiple linear regression analysis were then used to verify whether pain extent was associated with other health indicators including disability, health-related quality of life, depression, somatic anxiety, coping strategies and self-efficacy.Pain extent was directly related to neck, arm and headache pain intensity (all P < .01). Multiple linear regression revealed that pain extent was significantly associated only to the level of perceived disability (P < .01).Increased pain extent in people with CR is associated with higher headache, neck and arm pain intensity, and disability but not measures of general health, depression, somatic anxiety, coping strategies or self-efficacy.

Digital manikins to self-report pain on a smartphone: A systematic review of mobile apps

BACKGROUND

Chronic pain is the leading cause of disability. Improving our understanding of pain occurrence and treatment effectiveness requires robust methods to measure pain at scale. Smartphone-based pain manikins are human-shaped figures to self-report location-specific aspects of pain on people's personal mobile devices.

METHODS

We searched the main app stores to explore the current state of smartphone-based pain manikins and to formulate recommendations to guide their development in the future.

RESULTS

The search yielded 3,938 apps. Twenty-eight incorporated a pain manikin and were included in the analysis. For all apps, it was unclear whether they had been tested and had end-user involvement in the development. Pain intensity and quality could be recorded in 28 and 13 apps, respectively, but this was location specific in only 11 and 4. Most manikins had two or more views (n = 21) and enabled users to shade or select body areas to record pain location (n = 17). Seven apps allowed personalising the manikin appearance. Twelve apps calculated at least one metric to summarise manikin reports quantitatively. Twenty-two apps had an archive of historical manikin reports; only eight offered feedback summarising manikin reports over time.

CONCLUSIONS

Several publically available apps incorporated a manikin for pain reporting, but only few enabled recording of location-specific pain aspects, calculating manikin-derived quantitative scores, or generating summary feedback. For smartphone-based manikins to become adopted more widely, future developments should harness manikins' digital nature and include robust validation studies. Involving end users in the development may increase manikins' acceptability as a tool to self-report pain.

SIGNIFICANCE

This review identified and characterised 28 smartphone apps that included a pain manikin (i.e. pain drawings) as a novel approach to measure pain in large populations. Only few enabled recording of location-specific pain aspects, calculating quantitative scores based on manikin reports, or generating manikin feedback. For smartphone-based manikins to become adopted more widely, future studies should harness the digital nature of manikins, and establish the measurement properties of manikins. Furthermore, we believe that involving end users in the development process will increase acceptability of manikins as a tool for self-reporting pain.

Predicting Opioid Use, Increased Health Care Utilization and High Costs for Musculoskeletal Pain: What Factors Mediate Pain Intensity and Disability?

This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident, and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (ie, body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale, and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received. PERSPECTIVE: This article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.

From Paper to Digital Applications of the Pain Drawing: Systematic Review of Methodological Milestones

Background

In a pain drawing (PD), the patient shades or marks painful areas on an illustration of the human body. This simple yet powerful tool captures essential aspects of the subjective pain experience, such as localization, intensity, and distribution of pain, and enables the extraction of meaningful information, such as pain area, widespreadness, and segmental pattern. Starting as a simple pen-on-paper tool, PDs are now sophisticated digital health applications paving the way for many new and exciting basic translational and clinical applications.

Objective

Grasping the full potential of digital PDs and laying the groundwork for future medical PD apps requires an understanding of the methodological developments that have shaped our current understanding of uses and design. This review presents methodological milestones in the development of both pen-on-paper and digital PDs, thereby offering insight into future possibilities created by the transition from paper to digital.

Methods

We conducted a systematic literature search covering PD acquisition, conception of PDs, PD analysis, and PD visualization.

Results

The literature search yielded 435 potentially relevant papers, from which 53 methodological milestones were identified. These milestones include, for example, the grid method to quantify pain area, the pain-frequency maps, and the use of artificial neural networks to facilitate diagnosis.

Conclusions

Digital technologies have had a significant influence on the evolution of PDs, whereas their versatility is leading to ever new applications in the field of medical apps and beyond. In this process, however, there is a clear need for better standardization and a re-evaluation of methodological and technical limitations that no longer apply today.

Profiling the Location and Extent of Musicians' Pain Using Digital Pain Drawings

Background and Aims

According to existing literature, musicians are at risk of experiencing a range of painful musculoskeletal conditions. Recently, a novel digital technology was developed to investigate pain location and pain extent. The aim of this study was to describe pain location and pain extent in musicians using a digital method for pain drawing (PD) analysis. Additionally, the association between PD variables and clinical features were explored in musicians with pain.

Methods

One hundred and fifty‐eight musicians (90 women and 68 men; aged 22.4 ± 3.6 years) were recruited from Swiss and U.K. conservatories. Participants were asked to complete a survey including both background musical information and clinical features, the QuickDASH (QD) questionnaire, and the digital PDs.

Results

Of the 158 participants, 126 musicians (79.7%) reported having pain, with higher prevalence in the areas of the neck and shoulders, the lower back, and the right arm. The mean percentage of pain extent was 3.1% ± 6.5%. The mean QD score was higher for musicians with pain than for those without pain. Additionally, the results indicated a positive correlation between the QD score and pain extent, and there were significant correlations between age and pain intensity, as well as between pain extent and pain intensity.

Conclusions

The high prevalence of pain among musicians has been confirmed using a digital technique for PD acquisition and analysis. In addition, positive correlations between pain extent and upper limb disability have been demonstrated. Our findings highlight the need for effective prevention and treatment strategies for musicians.

Psychometric Study of the Pain Drawing

Purpose

The objectives of the study were to (1) assess the extent to which interrater reliability of pain drawing location and dispersion scoring methods are similar across pain disciplines in a sample of patients with cancer treatment-induced neuropathic pain (N = 56) and (2) investigate indicators of validity of the pain drawing in this unique sample.

Methods

Patients undergoing cancer therapy completed the Brief Pain Inventory Body Map, the MD Anderson Symptom Inventory, and the McGill Pain Questionnaire.

Results

Intraclass correlation coefficients among medical and psychology professionals ranged from .93-.99. Correlations between pain drawing score and symptom burden severity ranged from .29-.39; correlations between pain drawing score and symptom burden interference ranged from .28-.34. Patients who endorsed pain in the hands and feet more often described their pain as electric, numb, and shooting than patients without pain in the hands and feet. They also endorsed significantly more descriptors of neuropathic pain.

Conclusions

Results suggest a similar understanding among members of a multidisciplinary pain team as to the location and dispersion of pain as represented by patients' pain drawings. In addition, pain drawing scores were related to symptom burden severity and interference and descriptors of neuropathic pain in expected ways.

Unique Contributions of Body Diagram Scores and Psychosocial Factors to Pain Intensity and Disability in Patients With Musculoskeletal Pain

Study Design Retrospective cross-sectional cohort of military patients with musculoskeletal pain. Background Body diagrams are used to document symptoms and can also serve as a proxy to assess psychological influence. However, literature to support this is conflicting. Objectives To (1) examine the unique contribution of pain and nonpain symptom distribution to magnitude of self-reported pain intensity and disability, and (2) assess the moderating influence of psychological factors and body diagram score on concurrent pain intensity and disability. Methods Pain, numbness, and tingling were denoted on a body diagram at initial evaluation. Fear-avoidance beliefs, pain catastrophizing, and region-specific self-reported disability measures were collected. The contributions of pain and nonpain symptom distribution to pain intensity and disability were assessed to determine which body diagram symptom scoring method (pain only, nonpain, or composite) was appropriate for subsequent analyses. Hierarchical linear regression analyses were then used to determine the moderating effects of the Pain Catastrophizing Scale and Fear-Avoidance Beliefs Questionnaire and the body diagram score on concurrent pain and disability. Results The Pain Catastrophizing Scale and Fear-Avoidance Beliefs Questionnaire explained between 16% and 17% of the variance in pain intensity, and 8% of variance in disability (all, P<.001). The composite symptom score explained an additional 4% to 5% variance in concurrent disability and pain intensity (all, P<.001). The Pain Catastrophizing Scale moderated the relationship between body diagram score and pain intensity. The positive relationship between composite symptom score and concurrent pain intensity is stronger for patients with low catastrophizing. Conclusion The clinical utility of body diagrams with low symptom distribution may be improved by concomitant assessment of pain catastrophizing and warrants further longitudinal investigation. Level of Evidence Symptom prevalence, level 2b. J Orthop Sports Phys Ther 2017;47(2):88-96. Epub 5 Nov 2016. doi:10.2519/jospt.2017.6778.

Test-retest Reliability in Reporting the Pain Induced by a Pain Provocation Test: Further Validation of a Novel Approach for Pain Drawing Acquisition and Analysis

BACKGROUND

Pain drawings (PD) are frequently used in research to illustrate the pain response to pain provocation tests. However, there is a lack of data on the reliability in defining the extent and location of pain. We investigated the test-retest reliability in reporting an acute painful sensation induced by a pain provocation test using a novel approach for PD acquisition and analysis in healthy volunteers.

METHODS

Forty healthy volunteers participated. Each participant underwent 2 upper limb neurodynamic tests 1 (ULNT1), once to the point of pain onset (PO) and once until the point of submaximal pain (SP). After each ULNT1, participants completed 2 consecutive PD with an interval of 1 minute. Custom software was used to quantify the pain extent and analyze the pain overlap. The test-retest reliability of pain extent was examined using Intraclass Correlation Coefficient (ICC _2,1 ) and Bland-Altman plots. Pain location reliability was examined using the Jaccard similarity coefficient (JSC).

RESULTS

The ICC values for PO and SP were 0.98 (95% CI: 0.96-0.99) and 0.97 (95% CI: 0.95-0.98), respectively. The mean difference and 95% limits of agreement (± 1.96 SD) in the Bland-Altman plots were 14 pixels (-1080;1110) for PO, and 145 (-1610;1900) for SP. The median JSCs (Q1;Q3) were 0.73 (0.64;0.80) for PO and 0.76 (0.65;0.79) for SP.

CONCLUSIONS

Pain drawings is a reliable instrument to investigate pain extent and pain location in healthy individuals experiencing an acute painful sensation induced by a pain provocation test.

Reproducibility of pain manikins: a comparison of paper versus online questionnaires

BACKGROUND

In epidemiological studies, pain location is often collected by paper questionnaire using blank body manikins, onto which participants shade the location of their pain(s). However, it is unknown how reliable these will transfer to online questionnaires. The aim of the current study was to determine agreement between online- and paper-based completion of pain manikins.

METHODS

A total of 264 children, aged 15-18 years, completed both an online and a paper questionnaire. Participants were asked to identify the location of their pain by highlighting predefined body areas on a manikin (online) or by shading a blank version of the manikin (paper). The difference in the prevalence of 12 regional/widespread pain conditions was determined, and agreement between online and paper questionnaires was assessed using prevalence- and bias-adjusted kappa (PABAK).

RESULTS

For the majority of pain conditions, prevalence was higher when ascertained by paper questionnaire. However, for the most part, the difference in prevalence was modest (range: -1.1 to 5.7%) the exceptions being hip/thigh pain (difference: 10.6%) and upper back pain (difference: 14.8%). For most pain locations, there was good or very good agreement between paper and online manikins (PABAK range: 0.61 to 0.88). However, identification of pain in the hip/thigh and in the upper back had poorer agreement (PABAK: 0.49 and 0.29, respectively).

CONCLUSIONS

This is the first study to examine the reproducibility of body manikins on different media, in a population-based survey. We have shown that online manikins can be used to capture data on pain location in a manner satisfactorily comparable to paper questionnaires.

Measuring the Pain Area: An Intra- and Inter-Rater Reliability Study Using Image Analysis Software

Pain drawings have frequently been used for clinical information and research. The aim of this study was to investigate intra- and inter-rater reliability of area measurements performed on pain drawings. Our secondary objective was to verify the reliability when using computers with different screen sizes, both with and without mouse hardware. Pain drawings were completed by patients with chronic neck pain or neck-shoulder-arm pain. Four independent examiners participated in the study. Examiners A and B used the same computer with a 16-inch screen and wired mouse hardware. Examiner C used a notebook with a 16-inch screen and no mouse hardware, and Examiner D used a computer with an 11.6-inch screen and a wireless mouse. Image measurements were obtained using GIMP and NIH ImageJ computer programs. The length of all the images was measured using GIMP software to a set scale in ImageJ. Thus, each marked area was encircled and the total surface area (cm(2) ) was calculated for each pain drawing measurement. A total of 117 areas were identified and 52 pain drawings were analyzed. The intrarater reliability between all examiners was high (ICC = 0.989). The inter-rater reliability was also high. No significant differences were observed when using different screen sizes or when using or not using the mouse hardware. This suggests that the precision of these measurements is acceptable for the use of this method as a measurement tool in clinical practice and research.

How fast pain, numbness, and paresthesia resolves after lumbar nerve root decompression: a retrospective study of patient's self-reported computerized pain drawing

STUDY DESIGN

A single-center retrospective study.

OBJECTIVE

To compare the speed of recovery of different sensory symptoms, pain, numbness, and paresthesia, after lumbar nerve root decompression.

SUMMARY OF BACKGROUND DATA

Lumbar radiculopathy is characterized by different sensory symptoms like pain, numbness, and paresthesia, which may resolve at different rates after surgical decompression.

METHODS

Eighty-five cases with predominant lumbar radiculopathy treated surgically were reviewed. Oswestry Disability Index score, 36-Item Short Form Health Survey scores (Physical Component Summary and Mental Component Summary), and pain drawing at preoperative and at 6 weeks, 3 months, 6 months, and 1-year follow-up were reviewed. Recovery rate between different sensory symptoms were compared in all patients, and between the short-term compression (<6 mo) and long-term compression groups.

RESULTS

At baseline, 73 (85.8%) patients had pain, 63 (74.1%) had numbness, and 38 (44.7%) had paresthesia; 28 (32.9%) had all these 3 component of sensory symptoms. Mean pain score improved fastest (55.3% at 6 wk); further resolution until 1 year was slow and not significant compared with each previous visit. Both numbness and paresthesia scores showed a trend of faster recovery during the initial 6-week period (20.5% and 24%, respectively); paresthesia recovery reached a plateau at 3 months postoperatively, but numbness continued a slow recovery until 1-year follow-up. Both Oswestry Disability Index score and Physical Component Summary scores (54.02 ± 1.87 and 26.29 ± 0.93, respectively, at baseline) improved significantly compared with each previous visits at 6 weeks and 3 months postoperatively, but further improvement was insignificant. Mental Component Summary showed a similar trend but smaller improvement. The short-term compression group had faster recovery of pain than the long-term compression group.

CONCLUSION

In lumbar radiculopathy patients after surgical decompression, pain recovers fastest, in the first 6 weeks postoperatively, followed by paresthesia recovery that plateaus at 3 months postoperatively. Numbness recovers at a slower pace but continues until 1 year.

LEVEL OF EVIDENCE

4.

Computer-aided surface estimation of pain drawings - intra- and inter-rater reliability

Pain drawings are often utilized in the documentation of pain conditions. The aim here was to investigate intra- and inter-rater reliability of area measurements performed on pain drawings consecutively, using the computer program Quantify One. Forty-eight patients with chronic nonmalignant pain had shaded in their experienced pain on the front and back views of a pain drawing. The templates were scanned and displayed on a 17-inch computer screen. Two independent examiners systematically encircled the shaded-in areas of the pain drawings with help of a computer mouse, twice each on two separate days, respectively. With this method it is possible to encircle each marked area and to obtain immediate details of its size. The total surface area (mm²) was calculated for each pain drawing measurement. Each examiner measured about 2400 areas, and as a whole, the number of areas measured varied only by 3%. The intra-rater reliability was high with intraclass correlation coefficients 0.992 in Examiner A and 0.998 in Examiner B. The intra-individual absolute differences were small within patients within one examiner as well as between the two examiners. The inter-rater reliability was also high. Still, significant differences in the absolute mean areas (13%) were seen between the two examiners in the second to fourth measurement sessions, indicating that one of the examiners measured systematically less. The measurement error was ≤10%, indicating that use of the program would be advantageous both in clinical practice and in research, but if repeated, preferably with the same examiner. Since pain drawings with this method are digitized, high quality data without loss of information is possible to store in electronic medical records for later analysis, both regarding precise location and size of pain area. We conclude that the computer program Quantify One is a reliable method to calculate the areas of pain drawings.

Effectiveness of an ergonomic intervention on work-related posture and low back pain in video display terminal operators: a 3 year cross-over trial

This study investigated the effectiveness of a workstation ergonomic intervention for work-related posture and low back pain (LBP) in Video Display Terminal (VDT) workers. 100 VDT workers were selected to receive the ergonomic intervention, whereas 100 were assigned to a control group. The two groups were then crossed-over after 30 months from baseline. Follow-ups were repeated at 5, 12, and 30 months from baseline and then at 6 months following crossover.

OUTCOMES

Work-related posture and LBP point-prevalence using the Rapid Entire Body Assessment method and a Pain Drawing, respectively. The ergonomic intervention at the workstation improved work-related posture and was effective in reducing LBP point-prevalence both in the first study period and after crossover, and these effects persisted for at least 30 months. In conclusion, our findings contribute to the evidence that individualized ergonomic interventions may be able to improve work-related posture and reduce LBP for VDT workers.

Comparison of low back pain sites identified by patient's finger versus hand: prospective randomized controlled clinical trial

BACKGROUND

Accurate diagnosis and appropriate therapy for low back pain are based on knowledge of the site of the patient's pain. In clinical settings, patients generally indicate the site of low back pain using the hand, but Chapman and Syrjala as well as Macnab recommended that the patient should indicate the site with the finger. Whether any differences emerge from these methods is an important fundamental question. The purpose of this study was to compare low back pain sites identified by the patient's finger versus the hand. Specifically, we conducted a prospective randomized controlled comparison and investigated the surface area and the accuracy of the sites indicated by the two identifications.

METHODS

Subjects were 137 low back pain patients meeting the following criteria: (1) age 18-65 years; (2) low back pain induced by lumbar flexion, extension, or lateral bending while standing; (3) absence of leg pain; and (4) pain at only one site. Subjects indicated the site of pain by hand and by index finger immediately after provocation of pain. A demonstrably reproducible site was outlined on the skin. The outlines of the sites were recorded and verified by digital images. The body surface area of the sites was determined using NIH Image Version 1.61. Sites identified by hand versus index finger were compared on the surface area. Additionally, to compare the accuracy of the two identifications, patients were asked which of two sites more accurately represented the pain site in outline form after the two identification procedures.

RESULTS

The surface area of sites identified by the finger was significantly smaller than that of sites identified by the hand (P < 0.05). Furthermore, a considerably higher proportion, approximately 80%, of patients answered that the site of the pain was identified more accurately by finger than by hand.

CONCLUSIONS

The indication by a finger resulted in more accurate, localized identification of the site of low back pain than the indication by a hand. The identification of the pain site with a patients' finger indication does not directly clarify the etiology of low back pain, but it has the potential to provide important information useful for making an accurate diagnosis and for determining the appropriate therapy.

Evaluation of two preventive interventions for reducing musculoskeletal complaints in operators of video display terminals

BACKGROUND AND PURPOSE

The purpose of this study was to evaluate the efficacy of a preventive ergonomic intervention, which was provided by physical therapists, on spinal and upper-extremity work-related posture and symptom complaints of workers who use video display terminals (VDT).

SUBJECTS

Two hundred employees who spent at least 20 hours per week at a VDT were randomly divided into 2 groups. Group E received the ergonomic intervention and an informative brochure, and group I received only the brochure.

METHODS

Both groups were evaluated at the beginning of the study and at a follow-up 5 months later. The following tools were used: a pain drawing and the Rapid Entire Body Assessment (REBA) method to assess spinal and upper-extremity work-related posture.

RESULTS

Group E had a lower REBA score and reduced lower back, neck, and shoulder symptoms compared with group I.

DISCUSSION AND CONCLUSION

The results suggest that a personalized preventive ergonomic intervention can improve spinal and upper-extremity work-related posture and musculoskeletal symptoms for workers who use VDTs.

Sex differences in pain drawing area for individuals with chronic musculoskeletal pain

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To (1) determine the association between pain severity and pain drawing area for men and women; (2) determine if sex differences exist in pain severity or pain drawing area; (3) determine the relative influence of pain severity, anatomical location of pain, personality, and psychological coping factors on pain drawing area for men and women.

BACKGROUND

Pain drawings have been postulated to assist in clinical decision making regarding classification and treatment of musculoskeletal pain. Prior studies have been ambiguous on this topic, possibly because they have not considered if sex differences exist for pain drawing area.

METHODS AND MEASURES

One hundred twenty-six subjects referred to a multidisciplinary chronic pain clinic with chronic musculoskeletal pain were included in this study. Subjects completed a pain drawing, the Multidimensional Pain Inventory (MPI), the Coping Strategies Questionnaire (CSQ), and the Minnesota Multiphasic Personality Inventory (MMPI-2). Pearson correlations investigated the associations of pain severity and pain drawing area, independent t tests investigated sex differences in pain severity and pain drawing area, and multiple regression investigated factors that influenced pain drawing area.

RESULTS

P a in severity w as positively correlated with pain drawing area for men (r = 0.38, P = .003) and women (r = 0.23, P = .052), accounting for approximately 14% and 5% of the total variance, respectively. There was no significant sex difference in pain severity ratings, but women reported a significantly larger area of symptoms on the pain drawings (effect size, 0.61; P = .002). The sex difference in pain drawing area was consistent across different anatomical locations of pain. In women, the final regression model accounted for 39% (P < .001) of the variance in pain drawing area, with anatomical location of pain (beta = .42, P < .001) and hypochondriasis (beta = .31, P = .005) as the only unique predictors in the final model. In men, the regression model accounted for 27% (P = .003) of the variance in pain drawing area, with pain severity (beta = .32, P = .021) and a coping style of ignoring pain (beta = -.32, P = .018) as the only unique predictors in the final model.

CONCLUSIONS

Women had larger pain drawing area and this area was significantly associated with anatomical location of pain and hypochondriasis. Men had smaller pain drawing area and this area was associated with pain severity and a coping style of ignoring pain. These findings suggest that clinicians interpreting pain diagram area should consider the sex of the individual.

Pain drawing scoring is not improved by inclusion of patient-reported pain sensation

STUDY DESIGN

This is a retrospective study of 250 patients who describe low back pain with pain drawings. A computer application using artificial neural networks was designed to analyze pain drawings and evaluate the contribution of pain sensation to drawing classification.

OBJECTIVE

The primary goal of this study was to assess the contribution of patient recorded pain sensation marks in classifying pain drawings into one of five broadly defined categories. The hypothesis was that including pain sensation would improve classification.

SUMMARY OF BACKGROUND DATA

With no perfect diagnostic test for patients with low back pain, many approaches have been proposed and are used. One common diagnostic tool is the pain drawing. Several quantitative methods have been proposed to score the drawings. Some methods use pain sensation in the scoring; however, the contribution of pain sensation has not been defined.

METHODS

A custom computer application classified the pain drawing. Data consisted of 250 pain drawings from patients with low back pain.

RESULTS

Patient recorded pain sensation is not necessary in computer-based scoring of pain drawings.

CONCLUSION

Patient-reported pain sensation does not improve classification when quantitatively scoring pain drawings.

The course of pain drawings during a 10-week treatment period in patients with acute and sub-acute low back pain

Background

Pain drawings are widely used as an assessment of patients' subjective pain in low back pain patients being considered for surgery. Less work has been done on primary health care patients. Moreover, the possible correlation between pain drawing modalities and other pain assessment methods, such as pain score and functional variables needs to be described. Thus, the objectives were to describe the course of pain drawings during treatment in primary health care for low back pain patients.

Methods

160 primary health care outpatients with acute or sub-acute low back pain were studied during 10 weeks of a stay active concept versus manual therapy in addition to the stay active concept. The patients filled out 3 pain drawings each, at baseline and after 5 and 10 weeks of treatment. In addition the patients also reported pain and functional variables during the 3 measurement periods.

Results

The proportion of areas marked, the mean number of areas marked (pain drawing score), mean number of modalities used (area score), and the proportion of patients with pain radiation all decreased during the 10-week treatment period. Most of the improvement occurred during the first half of the period. The seven different pain modalities in the pain drawing were correlated to pain and functional variables. In case of no radiation some modalities were associated with more pain and disability than others, a finding that grew stronger over time. For patients with pain radiation, the modality differences were smaller and inconsistent.

Conclusion

Pain modalities are significantly correlated with pain and functional variables. There is a shift from painful modalities to less painful ones over time.

Defining worthwhile and desired responses to treatment of chronic low back pain

OBJECTIVE

To describe patients' perceptions of minimum worthwhile and desired reductions in pain and disability upon commencing treatment for chronic low back pain.

DESIGN AND SETTING

Descriptive study nested within a community-based randomized controlled trial on prolotherapy injections and exercises.

PATIENTS

A total of 110 participants with chronic low back pain. Interventions. Prior to treatment, participants were asked what minimum percentage reductions in pain and disability would make treatment worthwhile and what percentage reductions in pain and disability they desired with treatment.

OUTCOME MEASURES

Minimum worthwhile reductions and desired reductions in pain and disability.

RESULTS

Median (inter-quartile range) minimum worthwhile reductions were 25% (20%, 50%) for pain and 35% (20%, 50%) for disability. This compared with desired reductions of 80% (60%, 100%) for pain and 80% (50%, 100%) for disability. The internal consistency between pain and disability responses was high (Spearman's coefficient of association of 0.81 and 0.87, respectively). A significant association existed between minimum worthwhile reductions and desired reductions, but no association was found between these two factors and patient age, gender, pain severity or duration, disability, anxiety, depression, response to treatment, or treatment satisfaction.

CONCLUSIONS

Inquiring directly about patients' expectations of reductions in pain and in disability is important in establishing realistic treatment goals and setting benchmarks for success. There is a wide disparity between the reductions that they regard as minimum worthwhile and reductions that they hope to achieve. However, there is a high internal consistency between reductions in pain and disability that they expect.

Usefulness of pain drawings in identifying real or imagined pain: Accuracy of pain professionals, nonprofessionals, and a decision model

The aim of this study was to determine the accuracy of pain specialists, nonprofessionals, and a decision model in judging whether a pain diagram was marked by a patient with chronic pain or by a healthy volunteer. Two hundred twenty-eight pain drawings were shown in random order to 10 pain medicine physicians, 10 pain medicine fellows, 10 nonphysician specialists, and 10 nonprofessionals. One half of the drawings (n = 114) had been produced by patients treated at a pain center and the other half (n = 114) by healthy individuals who were instructed to mark the diagrams as if they had a pain problem. The nonprofessionals were found to be 51.5% accurate, pain medicine fellows 52.7%, nonphysician specialists 54.3%, and pain medicine physicians 55.2 % accurate at distinguishing drawings by actual pain patients from drawings from volunteers without pain. A decision model was able to achieve 68.9% accuracy in determining which drawings were made by pain patients and which drawings were made by healthy individuals. The results suggest that subjective assessment of pain drawings alone is not useful in determining whether someone has real or imagined pain. A decision model that makes decisions on the basis of the number of highlighted squares on the pain diagram can identify real pain drawings with greater accuracy than humans.

PERSPECTIVE

Pain drawings are clinically useful but have limitations. This study illustrates some of the benefits of computerized pain assessment and highlights the importance of not judging patients on the basis of one source of information.

Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial

OBJECTIVES

To assess the efficacy of a prolotherapy injection and exercise protocol in the treatment of chronic nonspecific low back pain.

DESIGN

Randomized controlled trial with two-by-two factorial design, triple-blinded for injection status, and single-blinded for exercise status.

SETTING

General practice.

PARTICIPANTS

One hundred ten participants with nonspecific low-back pain of average 14 years duration were randomized to have repeated prolotherapy (20% glucose/0.2% lignocaine) or normal saline injections into tender lumbo-pelvic ligaments and randomized to perform either flexion/extension exercises or normal activity over 6 months.

MAIN OUTCOME MEASURES

Pain intensity (VAS) and disability scores (Roland-Morris) at 2.5, 4, 6, 12, and 24 months.

RESULTS

Follow-up was achieved in 96% at 12 months and 80% at 2 years. Ligament injections, with exercises and with normal activity, resulted in significant and sustained reductions in pain and disability throughout the trial, but no attributable effect was found for prolotherapy injections over saline injections or for exercises over normal activity. At 12 months, the proportions achieving more than 50% reduction in pain from baseline by injection group were glucose-lignocaine: 0.46 versus saline: 0.36. By activity group these proportions were exercise: 0.41 versus normal activity: 0.39. Corresponding proportions for >50% reduction in disability were glucose-lignocaine: 0.42 versus saline 0.36 and exercise: 0.36 versus normal activity: 0.38. There were no between group differences in any of the above measures.

CONCLUSIONS

In chronic nonspecific low-back pain, significant and sustained reductions in pain and disability occur with ligament injections, irrespective of the solution injected or the concurrent use of exercises.

Perceived pain and self-estimated activity limitations in women with back pain post-partum

BACKGROUND AND PURPOSE

In the general population many daily activities have an impact on low back pain. The aim of the present study was to describe pain intensity, localization, type of sensation and perceived activity limitation in women with different back pain patterns post-partum.

METHOD

In this cross-sectional survey 119 women with back pain persisting for two months after having given birth were interviewed and examined on average 7.2 months (range 6-10 months) post-partum. Based on pain provocation tests, four different back pain pattern groups were identified. Pain could be provoked in the area of the posterior pelvic/sacroiliac joints, in the lumbar spine, both in the posterior pelvic/sacroiliac joints and in the lumbar spine, and in none of the above areas. All women rated pain intensity on a visual analogue scale (VAS, 0-100 mm), and the pain localization and type of sensation were indicated on a pain drawing. They scored their activity limitations by use of the Disability Rating Index (DRI), which covers 12 daily activity items (VAS, 0-100 mm).

RESULTS

There was no significant difference (p = 0.12) in pain intensity (range of medians 19.5-10 mm) between the four groups. However, on average, most areas in the lower back (median 5 mm (range 2-14 mm)), were marked in the group with pain in both the posterior pelvic/sacroiliac joints and in the lumbar spine. The women in the three groups where pain was provoked in the lower area of the back had significantly (p < 0.01) more difficulties with movement-related daily activities than the group where no pain could be provoked.

CONCLUSIONS

The findings of this descriptive study suggest that back pain post-partum provoked by clinical tests considerably hampers movement-related activities. It seems important to pay special attention to the women where pain could be provoked in the lower back areas. The women should be identified early in the post-partum period to initiate adequate treatment.

Repeatability of pain drawings in a low back pain population

STUDY DESIGN

This is a prospective test-retest repeatability study.

OBJECTIVE

The primary purpose of this study was to determine the test-retest repeatability, using a variety of scoring methods, of pain drawings in a group of chronic low back pain patients. The intraevaluator repeatability for the methods requiring subjective interpretation was also evaluated.

SUMMARY OF BACKGROUND DATA

Pain drawings have been used in a variety of applications, including documentation of symptom location, as a tool for diagnosis and as a psychological screening tool. Accordingly, there have been several methods described for interpreting the drawings and several groups have investigated evaluators' abilities to replicate their interpretation. However, there has been less investigation of patients' consistency in completing the drawings.

METHODS

The intraevaluator repeatability was determined for the two scoring methods requiring subjective interpretation by the evaluator rescoring the drawings 2 weeks after the initial scoring. To determine repeatability, drawings were completed on two occasions by 75 patients. Patients who indicated on a questionnaire that there had been no change in their pain location since their first clinic visit (the day the first drawing was completed) were included in the study. This subgroup consisted of 45 patients who completed pain drawings on two occasions separated by a mean of 244.2 days (range, 26-1197 days). Repeatability was assessed for several scoring methods described in the literature: penalty point system, overall visual inspection, body regions, and a grid method.

RESULTS

Patients were consistent in completing the drawings, assessed by the various scoring methods. The worst repeatability values were for some of the sensation types.

DISCUSSION

As reported by others, the intraevaluator repeatability was high. The results of this study, finding acceptable repeatability for most scoring methods for pain drawing completed on occasions separated by a relatively long period of time, support that the pain drawing is a stable instrument for use in chronic back pain patients.

Pain maps from facial pain patients indicate a broad pain geography

Two hundred consecutive female patients, who were referred to a university-based facial pain clinic, were asked to mark all painful sites on sketches showing the contours of a human body in the frontal and rear views. The drawings were analyzed with transparent templates containing 1875 (frontal view) and 1929 (rear view) square cells of equal size. The average patient scored 71.8 cells in the frontal and 99.7 cells in the rear view (corresponding to 3.8% and 5.2% of the maximum possible scores). In individual patient drawings, however, up to 42.7% and 44.9% of all cells were marked. Only 37 cases (18.5%) exhibited pain that was limited to the trigeminal system. An analysis of the pain distribution according to the arrangements of dermatomes revealed three distinct clusters of patients: (1) pain restricted to the region innervated by the trigeminal nerves (n = 37); (2) pain in the trigeminal dermatomes and any combination involving the spinal dermatomes C2, C3, and C4, but no other dermatomes (n = 32); and (3) pain sites involving dermatomes in addition to the ones listed above (n = 131). Mean ages in the three clusters were 38.7, 35.5, and 37.5 years, respectively (p = 0.62, n.s.). Widespread pain existed for longer durations (median, 48 months) than conditions involving local and regional pain (median, 24 months) (p = 0.02, s.). Our findings showed that among a great percentage of persistent facial pain patients the pain distribution is more widespread than commonly assumed, and that the persistence of pain in the regional and widespread pain presentations is significantly greater than in cases with pain limited to the trigeminal system.

Quantified pain drawing in subacute low back pain. Validation in a nonselected outpatient industrial sample

STUDY DESIGN

The criterion and construct validities of pain drawing, quantified by a simple total body area score of pain extent (area raw extent assessment score), were analyzed prospectively on consecutive patients (n = 103), drawn from a predefined blue collar worker population, all sick listed for 6 weeks as a result of low back pain.

OBJECTIVES

To evaluate the validity of pain drawing as a screening tool in the secondary prevention of subacute low back pain.

SUMMARY OF BACKGROUND DATA

Pain drawings have been used clinically for more than 40 years as a complement to a patient's verbal pain descriptions. The main objectives have been to differentiate functional pain from organic pain and to identify meaningful features in spatial-anatomic pain distribution. The ability of the pain drawing to delineate concurrent psychopathology correctly has been questioned. There is no consensus on which scoring method should be used.

METHODS

The area raw extent assessment score was analyzed concurrently against the penalty point system and predictively against return to work and absenteeism over a period of 2 years. Content and construct validity assessed the relative influence of medical, psychologic, and subjective disability as well as psychosocial factors.

RESULTS

Criterion validation of the area raw extent assessment score showed significant correlations, both concurrently against the penalty point score (r = 0.86, P < 0.001, with explained variance R2 = 0.75, P < 0.001) and predictively against occupational handicap (r = 0.48, P < 0.001). In construct validation, the highest explained variance was shown for medical (R2 = 0.46, P < 0.001) and psychologic factors (R2 = 0.46, P < 0.001) and psychologic factors (R2 = 0.34, P < 0.001) and for subjective disability (R2 = 0.32, P < 0.001). Variance in the area raw extent assessment score also was explained by psychosocial factors (R2 = 0.19, P < 0.01).

CONCLUSIONS

Pain drawing quantification of the extent of pain shows high criterion and construct validity for the area raw extent assessment score. Content validity could be shown for significant clinical aspects of the disability experience--assets preferred for a screening tool in secondary prevention.