Pain drawing as a screening tool for anxiety, depression and reduced health-related quality of life in back pain patients: A cohort study

Background Back pain patients are more likely to suffer from depression, anxiety and reduced quality of life. Pain drawing is a simple, frequently used anamnesis tool that facilitates communication between physicians and patients. This study analysed pain drawings to examine whether pain drawing is suitable as a screening tool for signs of anxiety, depression or reduced quality of life, as the detection of these symptoms is essential for successful treatment. Methods Pain drawings of 219 patients with lower back pain were evaluated retrospectively. Pain drawings are a schematic drawing of a human being. Six variables of the pain drawing were analysed. Subscales of the Hospital Anxiety and Depression Scale (HADS) and the Mental Component Summary (MCS) of the Short Form 12 (SF-12) were used to measure anxiety, depression and quality of life, respectively. Descriptive statistics, uni- and multivariate linear regression analyses and analysis of variance were performed. Logistic regression analyses were conducted for suitable variables. Results We revealed significant positive correlations between the variables "filled body surface" and "number of pain sites" and the anxiety (HADS-A) and depression subscales (HADS-D) of the HADS (p<0.01). The same predictors had significant negative correlations with the MCS (p<0.01). However, the sensitivity and specificity of the variable "number of pain sites" were too low compared to those for existing screening tests to consider it as a screening tool for anxiety, depression and quality of life (HADS-A: sensitivity: 45.2%, specificity: 83.3%; HADS-D: sensitivity: 61.1%, specificity: 51%; MCS: sensitivity: 21.2%, specificity: 85.7%). Conclusions There were significant correlations between the amount of filled body surface and the number of pain sites in the pain drawing and anxiety, depression and quality of life. Although useful in routine clinical practice, pain drawing cannot be used as a screening tool based on our results.

Spatiotemporal patterns of pain distribution and recall accuracy: a dose-response study

Objectives Clinical decisions rely on a patient’s ability to recall and report their pain experience. Monitoring pain in real-time (momentary pain) may reduce recall errors and optimize the clinical decision-making process. Tracking momentary pain can provide insights into detailed changes in pain intensity and distribution (area and location) over time. The primary aims of this study were (i) to measure the temporal changes of pain intensity, area, and location in a dose-response fashion and (ii) to assess recall accuracy of the peak pain intensity and distribution seven days later, using a digital pain mapping application. The secondary aims were to (i) evaluate the influence of repeated momentary pain drawings on pain recall accuracy and (ii) explore the associations among momentary and recall pain with psychological variables (pain catastrophizing and perceived stress). Methods Healthy participants (N=57) received a low (0.5 ml) or a high (1.0 ml) dose of hypertonic saline (5.8%) injection into the right gluteus medius muscle and, subsequently, were randomized into a non-drawing or a drawing group. The non-drawing groups reported momentary pain intensity every 30-s. Whereas the drawing groups reported momentary pain intensity and distribution on a digital body chart every 30-s. The pain intensity, area (pixels), and distribution metrics (compound area, location, radiating extent) were compared at peak pain and over time to explore dose-response differences and spatiotemporal patterns. All participants recalled the peak pain intensity and the peak (most extensive) distribution seven days later. The peak pain intensity and area recall error was calculated. Pain distribution similarity was determined using a Jaccard index which compares pain drawings representing peak distribution at baseline and recall. The relationships were explored among peak intensity and area at baseline and recall, catastrophizing, and perceived stress. Results The pain intensity, area, distribution metrics, and the duration of pain were lower for the 0.5 mL than the 1.0 mL dose over time (p<0.05). However, the pain intensity and area were similar between doses at peak pain (p>0.05). The pain area and distribution between momentary and recall pain drawings were similar (p>0.05), as reflected in the Jaccard index. Additionally, peak pain intensity did not correlate with the peak pain area. Further, peak pain intensity, but not area, was correlated with catastrophizing (p<0.01). Conclusions This study showed differences in spatiotemporal patterns of pain intensity and distribution in a dose-response fashion to experimental acute low back pain. Unlike pain intensity, pain distribution and area may be less susceptible in an experimental setting. Higher intensities of momentary pain do not appear to influence the ability to recall the pain intensity or distribution in healthy participants. Implications The recall of pain distribution in experimental settings does not appear to be influenced by the intensity despite differences in the pain experience. Pain distribution may add additional value to mechanism-based studies as the distribution reports do not vary with pain catastrophizing. REC# N-20150052

Assessment of neuropathic pain after spinal cord injury using quantitative pain drawings

Study design Clinimetric cross-sectional cohort study in adults with paraplegic spinal cord injury (SCI) and neuropathic pain (NP). Objective To assess the reliability of standardized quantitative pain drawings in patients with NP following SCI. Setting Hospital-based research facility at the Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland. Methods Twenty individuals with chronic thoracic spinal cord injury and neuropathic pain were recruited from a national and local SCI registry. A thorough clinical examination and pain assessments were performed. Pain drawings were acquired at subsequent timepoints, 13 days (IQR 7.8–14.8) apart, in order to assess test-retest reliability. Results The average extent [%] and intensity [NRS 0–10] of spontaneous NP were 11.3% (IQR 4.9–35.8) and 5 (IQR 3–7), respectively. Pain extent showed excellent inter-session reliability (intraclass correlation coefficient 0.96). Sensory loss quantified by light touch and pinprick sensation was associated with larger pain extent (rpinprick = −0.47, p = 0.04; rlight touch = −0.64, p < 0.01). Conclusion Assessing pain extent using quantitative pain drawings is readily feasible and reliable in human SCI. Relating information of sensory deficits to the presence of pain may provide distinct insights into the interaction of sensory deafferentation and the development of neuropathic pain after SCI.

Pain drawings as a diagnostic tool for the differentiation between two pain-associated rare diseases (Ehlers-Danlos-Syndrome, Guillain-Barré-Syndrome)

Background The diagnosis of rare diseases poses a particular challenge to clinicians. This study analyzes whether patients’ pain drawings (PDs) help in the differentiation of two pain-associated rare diseases, Ehlers-Danlos Syndrome (EDS) and Guillain-Barré Syndrome (GBS). Method The study was designed as a prospective, observational, single-center study. The sample comprised 60 patients with EDS (3 male, 52 female, 5 without gender information; 39.2 ± 11.4 years) and 32 patients with GBS (10 male, 20 female, 2 without gender information; 50.5 ± 13.7 years). Patients marked areas afflicted by pain on a sketch of a human body with anterior, posterior, and lateral views. PDs were electronically scanned and processed. Each PD was classified based on the Ružička similarity to the EDS and the GBS averaged image (pain profile) in a leave-one-out cross validation approach. A receiver operating characteristic (ROC) curve was plotted. Results 60–80% of EDS patients marked the vertebral column with the neck and the tailbone and the knee joints as pain areas, 40–50% the shoulder-region, the elbows and the thumb saddle joint. 60–70% of GBS patients marked the dorsal and plantar side of the feet as pain areas, 40–50% the palmar side of the fingertips, the dorsal side of the left palm and the tailbone. 86% of the EDS patients and 96% of the GBS patients were correctly identified by computing the Ružička similarity. The ROC curve yielded an excellent area under the curve value of 0.95. Conclusion PDs are a useful and economic tool to differentiate between GBS and EDS. Further studies should investigate its usefulness in the diagnosis of other pain-associated rare diseases. This study was registered in the German Clinical Trials Register, No. DRKS00014777 (Deutsches Register klinischer Studien, DRKS), on 01.06.2018.

Digital Pain Mapping and Tracking in Patients With Chronic Pain: Longitudinal Study

Background Digital pain mapping allows for remote and ecological momentary assessment in patients over multiple time points spanning days to months. Frequent ecological assessments may reveal tendencies and fluctuations more clearly and provide insights into the trajectory of a patient’s pain. Objective The primary aim of this study is to remotely map and track the intensity and distribution of pain and discomfort (eg, burning, aching, and tingling) in patients with nonmalignant spinal referred pain over 12 weeks using a web-based app for digital pain mapping. The secondary aim is to explore the barriers of use by determining the differences in clinical and user characteristics between patients with good (regular users) and poor (nonregular users) reporting compliance. Methods Patients (N=91; n=53 women) with spinal referred pain were recruited using web-based and traditional in-house strategies. Patients were asked to submit weekly digital pain reports for 12 weeks. Each pain report consisted of digital pain drawings on a pseudo–three-dimensional body chart and pain intensity ratings. The pain drawings captured the distribution of pain and discomfort (pain quality descriptors) expressed as the total extent and location. Differences in weekly pain reports were explored using the total extent (pixels), current and usual pain intensity ratings, frequency of quality descriptor selection, and Jaccard similarity index. Validated e-questionnaires were completed at baseline to determine the patients’ characteristics (adapted Danish National Spine Register), disability (Oswestry Disability Index and Neck Disability Index), and pain catastrophizing (Pain Catastrophizing Scale) profiles. Barriers of use were assessed at 6 weeks using a health care–related usability and acceptance e-questionnaire and a self-developed technology-specific e-questionnaire to assess the accessibility and ease of access of the pain mapping app. Associations between total extent, pain intensity, disability, and catastrophizing were explored to further understand pain. Differences between regular and nonregular users were assessed to understand the pain mapping app reporting compliance. Results Fluctuations were identified in pain reports for total extent and pain intensity ratings (P<.001). However, quality descriptor selection (P=.99) and pain drawing (P=.49), compared using the Jaccard index, were similar over time. Interestingly, current pain intensity was greater than usual pain intensity (P<.001), suggesting that the timing of pain reporting coincided with a more intense pain experience than usual. Usability and acceptance were similar between regular and nonregular users. Regular users were younger (P<.001) and reported a larger total extent of pain than nonregular users (P<.001). Conclusions This is the first study to examine digital reports of pain intensity and distribution in patients with nonmalignant spinal referred pain remotely for a sustained period and barriers of use and compliance using a digital pain mapping app. Differences in age, pain distribution, and current pain intensity may influence reporting behavior and compliance.

Clinical Significance and Diagnostic Value of Pain Extent Extracted from Pain Drawings: A Scoping Review

The current scoping review aimed to map current literature investigating the relationship between pain extent extracted from pain drawings with clinical, psychological, and psycho-physiological patient-reported outcome measures in people with pain. Electronic databases were searched for cross-sectional cohort studies that collected pain drawings using digital technology or a pen-on-paper approach and assessed for correlations between pain extent and clinical, psychological or psycho-physical outcomes. Data were extracted by two different reviewers. The methodological quality of studies was assessed using the Newcastle–Ottawa Quality Assessment Scale. Mapping of the results included: 1, description of included studies; 2, summary of results; and 3, identification of gaps in the existing literature. Eleven cross-sectional cohort studies were included. The pain disorders considered were heterogeneous, ranging from musculoskeletal to neuropathic conditions, and from localized to generalized pain conditions. All studies included pain and/or pain-related disability as clinical outcomes. Psychological outcomes included depression and anxiety, kinesiophobia and catastrophism. Psycho-physical measures included pressure or thermal pain thresholds. Ten studies were considered of high methodological quality. There was heterogeneity in the associations between pain extent and patient-reported outcome measures depending on the pain condition. This scoping review found that pain extent is associated with patient-reported outcome measures more so in patients presenting with musculoskeletal pain, e.g., neck pain or osteoarthritis, rather than for those with neuropathic pain or headache.

Digital Pain Mapping and Tracking in Patients With Chronic Pain: Longitudinal Study (Preprint)

BACKGROUND Digital pain mapping allows for remote and ecological momentary assessment in patients over multiple time points spanning days to months. Frequent ecological assessments may reveal tendencies and fluctuations more clearly and provide insights into the trajectory of a patient’s pain. OBJECTIVE The primary aim of this study is to remotely map and track the intensity and distribution of pain and discomfort (eg, burning, aching, and tingling) in patients with nonmalignant spinal referred pain over 12 weeks using a web-based app for digital pain mapping. The secondary aim is to explore the barriers of use by determining the differences in clinical and user characteristics between patients with good (regular users) and poor (nonregular users) reporting compliance. METHODS Patients (N=91; n=53 women) with spinal referred pain were recruited using web-based and traditional in-house strategies. Patients were asked to submit weekly digital pain reports for 12 weeks. Each pain report consisted of digital pain drawings on a pseudo–three-dimensional body chart and pain intensity ratings. The pain drawings captured the distribution of pain and discomfort (pain quality descriptors) expressed as the total extent and location. Differences in weekly pain reports were explored using the total extent (pixels), current and usual pain intensity ratings, frequency of quality descriptor selection, and Jaccard similarity index. Validated e-questionnaires were completed at baseline to determine the patients’ characteristics (adapted Danish National Spine Register), disability (Oswestry Disability Index and Neck Disability Index), and pain catastrophizing (Pain Catastrophizing Scale) profiles. Barriers of use were assessed at 6 weeks using a health care–related usability and acceptance e-questionnaire and a self-developed technology-specific e-questionnaire to assess the accessibility and ease of access of the pain mapping app. Associations between total extent, pain intensity, disability, and catastrophizing were explored to further understand pain. Differences between regular and nonregular users were assessed to understand the pain mapping app reporting compliance. RESULTS Fluctuations were identified in pain reports for total extent and pain intensity ratings (<i>P</i>&lt;.001). However, quality descriptor selection (<i>P</i>=.99) and pain drawing (<i>P</i>=.49), compared using the Jaccard index, were similar over time. Interestingly, current pain intensity was greater than usual pain intensity (<i>P</i>&lt;.001), suggesting that the timing of pain reporting coincided with a more intense pain experience than usual. Usability and acceptance were similar between regular and nonregular users. Regular users were younger (<i>P</i>&lt;.001) and reported a larger total extent of pain than nonregular users (<i>P</i>&lt;.001). CONCLUSIONS This is the first study to examine digital reports of pain intensity and distribution in patients with nonmalignant spinal referred pain remotely for a sustained period and barriers of use and compliance using a digital pain mapping app. Differences in age, pain distribution, and current pain intensity may influence reporting behavior and compliance.

Can People with Chronic Neck Pain Recognize Their Own Digital Pain Drawing?

Background: Although the reliability of pain drawings (PDs) has been confirmed in people with chronic pain, there is a lack of evidence about the validity of the PD, that is, does the PD accurately represent the pain experience of the patient? Objectives: We investigate whether people with chronic neck pain (CNP) can recognize their own PD to support the validity of the PD in reporting the experience of pain. Moreover, we examined the association between their ability to recognize their own PD with their levels of pain intensity and disability and extent of psychosocial and somatic features. Study Design: Experimental. Setting: University Laboratory. Methods: Individuals with CNP completed their PD on a digital body chart, which was then automatically modified with specific dimensions using a novel software, providing an objective range of distortion and eliminating errors, which could potentially occur in manually controlled visual-subjective based methods. Following a 10-minute break listening to music, a series of 20 PDs were presented to each patient in a random order, with only 2 being their original PD. For each PD, the patients rated its likeliness to their own original PD on a scale from 0 to 100, with 100 representing “this is my pain.” Results: Overall, the patients rated their original PD with a median score of 92% similarity, followed by 91.8% and 89.5% similarity when presented with a PD scaled down to 75% and scaled up by 150% of the original size, respectively; these scores were not significantly different to the ratings given for their original PD. The PD with horizontal translation by 40 pixels (8%) and vertical translation by 70 pixels (12.8%) were rated as the most dissimilar to their original PD; these scores were significantly different to their original PD scores. The Spearman correlation coefficient revealed a significant negative association between their ability to recognize their original PD and their Modified Somatic Perceptions Questionnaire scores. Limitations: The patients in the study presented with relatively mild CNP, and the results may not be generalized to those with more severe symptoms. Conclusions: People with CNP are generally able to identify their own PD but that their ability to recognize their original PD is negatively correlated with the extent of somatic awareness. Key words: Chronic pain, perception, pain drawings, somatic awareness