Pain Drawings

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Definition[edit]

These are drawings in which the patient shows where their pains are located.

They are a widely used, practical clinical tool that helps clinicians to understand their patient’s pain. It also helps patients to express their pain-related emotions and many of the fine details about their pain.

This simplest version is to just have the patient show where their pains are. Or the clinician can also ask the patient to comment on each pain.

It can be tested by giving the patient a blank piece of paper and the instruction to draw an outline of their body and show their pains. Or, they can be given outline drawings of the front and rear views of a body for their gender, and then asked to mark their pains. Specialized versions can be used such as drawing with dermatomes in place when the clinician suspects dermatomal involvement.

Pain drawings in low back pain[edit]

Back pain is one of the more common pains in fibromyalgia.

A study was done by Chan et al. using paid drawings of 651 patients with chronic low back pain. Drawings were rated in four grades depending on the degree of organic and nonorganic pain. A correlation was found between pain drawings and Waddell’s non-organic physical signs demonstrated. It was found that “a large proportion of patients with high Waddell scores had nonorganic pain drawings.” (The pain drawing and Waddell's nonorganic physical signs in chronic low-back pain. Chan CW, Goldman S, Ilstrup DM, Kunselman AR, O'Neill PI. Spine (Phila Pa 1976).. 1993 Oct 1;18(13):1717-22.)

Pain drawings in somatoform disorders in fibromyalgia patients[edit]

This has been studied by Egloff et al. They state: “Among the patients from the medical-psychosomatic department, chronic functional somatic syndromes included fibromyalgia (n = 14), chronic tension headache (n = 4), chronic temporomandibular pain (n = 1), atypical facial pain (n = 1), chronic back pain (n = 16), functional abdominal pain or chronic pelvic pain (n = 8). Other patients suffered from inexplicable pain of the trunk (n = 8), pain-related functional hemi-syndromes (n = 6), inexplicable chronic postsurgical pain (n = 1), chronic shoulder/arm pain (6), and chronic cervico/thoracic pain (n = 11).” (Pain drawings in somatoform-functional pain. Egloff N1, Cámara RJ, von Känel R, Klingler N, Marti E, Ferrari ML. BMC Musculoskelet Disord. 2012 Dec 20;13:257. doi: 10.1186/1471-2474-13-257, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579713/. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

For Egloff’s scoring system see: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579713/figure/F2/.

Somatoform pain can co-exist with fibromyalgia (Egloff, 2012). This is also confirmed by the clinical experience of the author.

Hysterical symptoms often ideogenic, which means that the follow the distribution of an idea such as the idea of a hand in glove anaesthesia or of the body being divided in two down the middle in the case of hysterical hemi-anaesthesia.

In the experience of the author wiki, hysterical pains often fool the doctor in that they do not sound like anything the doctor has ever heard of and the doctor worries that it is strange condition that he or she has never heard of. This can lead to a long complicated and expensive investigation process. Pain diagrams in such cases have in the experience of the author resulted in dramatic insight whereby the hidden ideas behind the pains are unexpectedly revealed. An example occurs when the patient draws bizarre connecting lines between areas of their body having symptoms as when they have strange pains and eye fatigue and groin pains, then they draw long meridian lines between them showing that in their minds there is a hidden connection between body parts. (This gives one pause to wonder if there is some psychological need that has driven the ancient and modern fascination with the meridian lines of acupuncture.)


Typical drawing marks.png
Typical drawing marks.
(Pain drawings in somatoform-functional pain. Egloff N1, Cámara RJ, von Känel R, Klingler N, Marti E, Ferrari ML. BMC Musculoskelet Disord. 2012 Dec 20;13:257. doi: 10.1186/1471-2474-13-257, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579713/. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3579713/figure/F2/.


Outline drawings for clinical assessment[edit]

Outlined drawing of a naked man and woman, anterior and posterior views.png
Outlined drawing of a naked man and woman, anterior and posterior views.
Image by cdang (Christophe Dang Ngoc Chan) - Own work, from File:Human_Body.jpg by Mikael Häggström. Image sourced from Wikimedia Commons. https://commons.wikimedia.org/w/index.php?title=Special:Search&search=silhouette+humain+body&fulltext=1&ns0=1&ns6=1&ns12=1&ns14=1&ns100=1&ns106=1#/media/File:Silhouette_femme_homme_anterieur_posterieur.svg This file is made available under the Creative Commons CC0 1.0 Universal Public Domain Dedication.


Pain drawing sketch.jpeg
Pain drawing sketch.
This is figure 1 from: The course of pain drawings during a 10-week treatment period in patients with acute and sub-acute low back pain. Marie Grunnesjö,1 Johan Bogefeldt,1 Stefan Blomberg,1,2 Heléne Delaney,2and Kurt Svärdsudd1,BMC Musculoskelet Disord. 2006; 7: 65, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1570135/. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)
The author’s caption reads: The pain drawing sketch with its 34 anatomical areas, and the seven pain modalities and their symbols.”


[Comments: These authors use a system of symbols. This can be useful in complex cases including fibromyalgia patients with multiple pains and multiple pain characteristics. Without symbols, one would need to put notes which makes for clutter and difficulties in interpretation.]

A set of male and female templated for clinical pain sketching[edit]

This is the set for patients not suspected of having dermatomal pains as in shingles. It can be used in many chronic pain cases such as known or suspected fibromyalgia patients.


Female body outline.png
Female body outline for pain diagrams, front.
Public domain image by “nicubunu”, February 20, 2008, sourced from: https://openclipart.org/detail/14567/female-body-silhouette-front


Female body back.png
Female body outline for pain diagrams, front and back.
Public domain image by “nicubunu”, February 20, 2008, sourced from: https://openclipart.org/detail/14565/female-body-silhouette-back


Male body front.png
Male body silhouette for use in pain diagrams, front view.
Public domain image by “nicubunu”, February 20, 2008, sourced from open clip art, sourced from: https://openclipart.org/detail/14574/male-body-silhouette-front


Male body back.png
Male body silhouette for use in pain diagrams, back view.
Public domain image by “nicubunu”, February 20, 2008, sourced from open clip art, sourced from: https://openclipart.org/detail/14572/male-body-silhouette-back.


Use of pain drawings in clinical assessment of fibromyalgia patients[edit]

These are markings by patients on outlines of their body which allow them to indicate the locations of their pain. Men and women should be given and appropriate, gender compatible outline of the body that includes both the front and the back.

The examiner may wish to combine them with a visual analogue scale or a numeric rating scale whereby the patient can indicate the severity of each area of pain. One option is to ask the patient to write a number beside each pain between 1 and 10 beside each area on the diagram that they have marked as bing painful. One is for very mild pain and 10 is the most severe possible pain.

The examiner will need to stipulate the time frame. If the goal is to assess the current status, then the time horizon should be short such as “today” or “within the last seven days”. If the goal is to get an overview over a longer time horizon the one could use a time horizon of say two years.

Diagrams can be analyzed through gross inspection for factors such pain symmetry.

If the has both fibromyalgia pains and non-fibromyalgia pains, they need to be discriminated.

This sometimes requires considerable discussion with the patient. For example, if the patient had a shoulder tear their right shoulder has hurt since that moment, then the pain is likely not from fibromyalgia.

One option is to give the patient the following instruction: “Mark the locations of any body pains that you have had in the last 3 months that cannot be easily explained by an injury or disorder other than fibromyalgia such as another disease like rheumatoid arthritis.”

If any of your pains are shooting, then draw arrows to where. Muscle pains that are worse with bad sleep or stress are more likely to be fibromyalgia pains.

Examiners can ask the patients to write notes showing if they have any specific adjectives for specific pains.

Some patients have a lot to say about individual pain areas that they mark on their pain diagrams. They sometimes relate certain areas so particular meanings and experiences. Patient’s should be encouraged to write such comments as it may shed light on their beliefs and interpretations of their pains.

A study by Steele et al. of fibromyalgia patients scored the average pain at rest as 4.39 ± 0.39, and pain with movement as 5.23 ± 0.39.(Clinical Application of Pain Diagrams In Fibromyalgia. Amanda Steele1, Dana Dailey2 and Kathleen Sluka2, 1Rheumatology, University of Iowa Hospitals and Clinics, Iowa City, IA, 2Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA ABSTRACT NUMBER: 127, From 2013 ACR/ARHP Annual Meeting the https://acrabstracts.org/abstract/clinical-application-of-pain-diagrams-in-fibromyalgia/.) The FIQ [Fibromyalgia Impact Questionnaire] was 58.17 ± 2.24 and MPQ [McGill Pain Questionnaire] was 44.93 ± 2.5. They also found the average scores on a body diagram study of 43 subjects to have averaged 16.55 ± 1.3 (95% CI 13.92 to 19.18). The most common pain areas were the neck (91%), shoulders (81%), and low back (63%). There was excellent inter-rater reliability for the body diagram scoring. They also found that higher scores on the body diagram were significantly correlated with higher scores on MPQ (R2= 0.44**), pain at rest (R2=0.324*) and pain with movement (R2=0.380*). Higher scores were not correlated with FIQ (R2=0.298). The authors concluded that pain diagram serve to provide a quick and “clinically applicable self-report measure”.

Further information[edit]

For a template with a drawing and a guide to the patient on how to add descriptors, see: http://leit-usa.com/dr/pain/images/form3.jpg

For further information on pain diagrams in fibromyalgia see: https://www.researchgate.net/figure/Percentage-distribution-of-pain-areas-in-patients-with-fibromyalgia-FM-with-and-without_fig2_51576768.

Validity of pain drawings for predicting psychological status outcome in patients with recurrent or chronic low back pain. J.H. Abbott, 1 Megan Foster, 2 Lucien Hamilton, 2 Michael Ravenwood, and Nicholas Tan .J Man Manip Ther. 2015 Feb; 23(1): 12–19, available in full online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4459138/, doi: 10.1179/2042618613Y.0000000046. Patient pain drawing is a valuable instrument in assessing the causes of exercise-induced leg pain. Kajsa Rennerfelt, Qiuxia Zhang, Jón Karlsson, Jorma Styf, BMJ Open Sport and Exercise Medicine, Volume 4, Issue 1 available in full online at: https://bmjopensem.bmj.com/content/bmjosem/4/1/e000262.full.pdf. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license.

A rating system for use with patient pain drawings. Margolis RB, Tait RC, Krause SJ. Pain. 1986 Jan;24(1):57-65.

Patient pain drawing is a valuable instrument in assessing the causes of exercise-induced leg pain. Kajsa Rennerfelt, Qiuxia Zhang, Jón Karlsson, Jorma Styf, https://bmjopensem.bmj.com/content/4/1/e000262, BMJ Open Sport and Exercise Medicine Volume 4, Issue 1, 2017. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/ licenses/by-nc/4.0/