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Pain drawings in somatoform-functional pain

Niklaus Egloff*, Rafael JA Cámara, Roland von Känel, Nicole Klingler, Elizabeth Marti and Marie-Louise Gander Ferrari

BMC Musculoskeletal Disorders 2012, 13:257  doi:10.1186/1471-2474-13-257

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Pain drawings; similar observations but different interpretations.

Brian Sweetman   (2013-01-24 17:13)  NHS email

Egloff and colleagues (1) provide one of the most detailed assessments of pain drawings in terms of the number of criteria they inspected. They compared a group of 62 patients selected as seemingly having somatoform-functional pain with a control group of 49 patients from the orthopaedic department with what the authors described as somatoform- nociceptive type pain. They identified 13 drawing criteria out of 24 that distinguish the ��psychological�� functional pain element. The number of criteria could be reduced to three, which identified the functional cases almost as effectively as did all thirteen criteria. These three best drawings criteria included the total number of marks, the length of the longest mark, and the presence of symmetric patterns.
Their study of a variety of conditions affecting various parts of the body thus brings together similar findings to those made in a number of other disparate low back pain studies over the years, and as such is most helpful. It happens that the number of marks was also identified as important by Uden et al (2) and Sivik et al (3) amongst others.
But the other two best criteria have generally not been included in such studies, though we have looked at them in terms of what we concluded were actually criteria of severity of low back pain. The extent of pain down the leg (4) was seemingly a good indicator of severity of referred pain even if radicular pain can also reach far down the leg. In both situations the line mark drawn can be longer because of the length of the leg compared with the more limited lumbar area.
With regard the symmetric patterns for low back pain, we suggested (5) that symmetric low back pain of bilaterally equal severity on both sides was the more severe end of a pain spectrum, with the milder end represented by midline back pain. The more severe the symmetric type pain was, the further the spread was sideways from the midline.
Pain is induced somatically at the periphery but is perceived and enters consciousness centrally in the central nervous system. With regard to the interpretation of such findings we suggested (6) that there had been a general drift in opinion over the last half century. Since Harold Palmers original article (7) implied afunctional causative mechanisms for prolific pain drawings, there has been a drift towards implicating severity of pain as the factor responsible for these expansive criteria repeatedly being identified as distinctive. In retrospect it is easy to accept that the continuous variables of number of markings and the length of the longest marks could be severity measures. But it is not quite so intuitive that bilateral symmetry is the severity antithesis of midline pain. Perhaps the confounding factor for so many such studies suggesting primary psychological causes has been that the more severe the pain, the more likely it is that there are going to be more overtly psychological responses. But the latter are probably mostly the effects of pain, not causes.
Thus the findings of the various studies are similar, but the interpretations differ with what are probably going to be considerably different consequences for the patients involved in terms of the style of management of their problems.
Sweetman BJ, Sweetman SJ. NHS

Swansea, UK.


1. Egloff N, C��mara RJA, von K��nel R, Klingler N, Marti E, Gander Ferrari M-L. Pain drawings in somatoform-functional pain. BMC Musculoskeletal Disorders 2012, 13: 257.
Published: 20 December 2012

2. Uden A, Astrom M, Bergenudd H. Pain drawings in chronic back pain. Spine 1988; 13 (4): 389-92.

3. Sivik TM, Gustafsson E, Klingberg Olsson K. Differential diagnosis of low-back pain patients: A simple quantification of the pain drawing. Nord J Psychiatry 1993; 46: 55��62.

4. Sweetman BJ. Remote manifestations of Low Back Pain; Sciatica and extent of leg involvement; A statistical clinical study. International Musculoskeletal Medicine 2010; 32 (2): 72-7.

5. Sweetman BJ, Sweetman SJ. Midline back pain; a clinical database analysis. International Musculoskeletal Medicine 2013; in press.

6. Sweetman BJ, Sweetman SJ. Midline low back pain, a literature review. International Musculoskeletal Medicine 2013; in press.

7. Palmer H. Pain charts: a description of a technique whereby functional pain may be diagnosed from organic pain. N Z Med J 1949:187-213.

Competing interests



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