Background: Pain is complex and multifaceted. We can convey information about pain by communicating verbally, textually and non-verbally. We investigated the use of pain drawings as an aide to communication and compared it with verbal and other pain measurement tools.

Method: We conducted a qualitative study using in-depth interviews with a purposive sample of pain patients. Data were analysed using the ‘Framework Approach’.

Results: Aches and pains are seen as an increasing continuum, aches distract people, pain stops them doing things. As pain progresses along the continuum patients pain reports progress from verbal through textual to visual representation. Verbal and textual communication about pain was inconsistent, especially for those with multi site pain. Visual communication was more about significant pain, verbal covered the range. As pain worsened so did the complexity, the need for help, life change and communication all increased. Current measuring tools do not seem adequate to assess multi site pain, transient pain and pain with movement.

Conclusions: Two methods of describing pain exist, clinical (physical symptoms) and behavioural (effect on life). Patients felt confident communicating about the latter but perceived a need for active help by the clinician for the former.

The effect of pain on lifestyle is paramount to the patient, physical symptoms for the clinician. Acknowledging this disparity may reduce frustration experienced in consultations as both have different communication and management needs. Indicating treatment success by focusing on lifestyle improvement in patients rather than reductions in physical symptoms may be more appropriate.

We conducted a community survey of the prevalence, health impact and location of chronic pain. We explored the relationship and patterns of chronic pain that commonly occur, with a view to understanding why some treatment approaches may be more appropriate than others for particular patterns of pain.

In 2002, 2504 randomly sampled patients from 16 General Practices in the South East of England responded to a postal questionnaire about chronic pain. Those with chronic pain completed a pain drawing. We calculated descriptive statistics, relative risk and correlations to identify the associations and risks of having linked pain.

The highest prevalences were low back (23%), shoulder (20%) and knee (18%) pain. The number of pain sites experienced was age related in men but less so in women. Lower body pain was more age related than upper body and non musculoskeletal pain. Multi site pain was more common than single site pain. Of those with low back, knee and shoulder pain, 14%, 4.5 % and 1.9% had only low back, knee and shoulder pain respectively. Correlations and minimum spanning trees showed that chronic upper and lower body pain are distinct and axial pain link the two.

Chronic pain is more likely to be multi site, especially at middle age. Research, physical treatments and approaches to managing chronic pain are often site specific, therefore specialising treatment to one area eg low back pain often negates the bigger issue. This may help explain the self perpetuating problem of persistent chronic pain.

Background and Significance: Pain drawings could be a means of easily identifying sub-groups of patients who might benefit from different treatment approaches. In particular it has been suggested that they can be used to identify the psychological ‘state’ of patients in terms of distress, depression, somatisation and anxiety.

Purpose/Hypothesis: To systematically appraise data from the literature about the validity and reliability of using pain drawings to evaluate psychological ‘state’.

Method: We searched 12 medical and social science databases, using key words and their derivatives; pain; drawings; diagrams; vis(z)ualisation; body mapping; mannequins and homunculi. We appraised studies directly evaluating the utility of pain drawings and psychological state.

Results: We selected 19 for final inclusion. The majority of studies reviewed focused on low back pain (79%) and secondary and tertiary care (90%). Pain drawings were evaluated against psychological tools testing personality (MMPI), somatisation (MSPQ, IBQ) and psychological states such as depression (Zung) anxiety (SF36) and distress (GHQ).

11/19 studies reported inconclusive results, 8/19 showed a statistical association between drawings and the psychological assessment tool. However the more clinically relevant, sensitivity data ranged from 24–93%, specificity 44–91%, positive predictive values 28–93%, and negative predictive values 35–92%. The range of this data is too wide to be acceptable clinically as predictive of psychological state.

Conclusions: There is insufficient evidence to support the assumption that unusual pain drawings indicate a disturbed psychological state, therefore pain-drawing use as a psychological assessment tool is not recommended.