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.     

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.     

Relationship of pain drawings to invasive tests assessing intervertebral disc pathology

It has been found that the pain patterns in pain drawings are related to the presence of herniated disc identified by myelography. The purpose of this study was to determine whether the pattern of pain in the drawings or the type of pain indicated (aching, burning, numbness, pins and needles, stabbing) was related to the presence of symptomatic disc pathology identified by CT/discography. In a subgroup of patients who underwent myelography, the relationship of the drawings to myelographic findings was also investigated. Pain drawings were completed by 187 patients with low back and/or radicular pain who were undergoing CT/discography. The drawings were scored in two ways, first by the system described by Ransford and secondly by visual inspection. They were classified as being indicative, or not, of disc pathology. The CT/discograms were classified as disrupted, or not, and the pain responses were recorded upon injection of each disc, based on the similarity of the pain provoked to clinical symptoms. Among the 133 patients with discogenic pain confirmed by discography, 110 (82.7%) had pain drawings that were classified as indicative. Among the 45 patients without discogenic pain, 29 (64.4%) had pain drawings classified as non-indicative. Patients with discogenic pain used more symbols indicating burning pain and aching pain than did non-discogenic pain patients. Our results confirmed those reported earlier by Udén, who found a relationship between the pattern of pain in the drawings and myelographic findings. Pain drawings may be helpful in the diagnosis of symptomatic disc pathology. Received: 26 February 1998 Revised: 31 August 1998 Accepted: 26 October 1998     

Pain-drawing does not predict the outcome of fusion surgery for chronic low-back pain: a report from the Swedish Lumbar Spine Study

Despite a widespread use of pain drawing in the selection of patients for surgical and non-surgical treatment, its value as a predictor of outcome is still not well documented. In a prospective multicentre randomised controlled trial of surgical and non-surgical treatment for chronic low-back pain (CLBP), two hypotheses were tested: (1). Pain drawing predicts outcome of treatment for CLBP, (2). Pain drawing is associated with psychological characteristics of patients with CLBP. Two hundred and sixty-four patients with severe CLBP of long duration completed pain drawings as part of a battery of questionnaires prior to treatment. They were followed up at 2 years post-treatment, with renewed completion of questionnaires. Outcome was measured in three ways: patient global assessment, change of disability/pain, and work status. The pain drawing was analysed by four different methods. The association between the pain drawings and outcomes was analysed. Personality traits and depressive symptoms were evaluated in the psychological assessment. None of the four methods of interpretation of the pain drawings demonstrated any significant association with outcome, in either the surgical or the non-surgical group. The pain drawing was associated with pre-treatment back pain intensity and depressive symptoms. No predictive value of the pain drawing regarding the outcome of treatment of CLPB was demonstrated. The concept of "organic/non-organic" pain in conjunction with chronic low-back pain is not supported by the results of the present study.     

Pain drawing as an investigative tool in hand surgery.

Fifty consecutive patients referred to the departments of hand surgery in Malm? and Lund were asked to chart their pain on a diagram of the body before their first visit to the clinic. Three patients never answered the questionnaire and were excluded. The drawings were evaluated separately by a senior hand surgeon without access to the case records. In 19 of 47 cases (40%) the evaluation of the pain drawings agreed with the clinical diagnosis. In another 17% (8 of 47), in which the pain drawings had indicated a condition not related to hand surgery, clinical examination failed to establish a diagnosis. The evaluation of the drawings had a false negative rate of 4% (2 of 47). In the remaining 18 cases pain drawings did not give enough information for diagnosis because of the variety of symptoms. Pain drawing seems to be valuable in the evaluation of patients with chronic pain in the upper extremity.     

Design of an artificial neural network for diagnosis of facial pain syndromes

A classification scheme for facial pain syndromes describing seven categories has previously been proposed. Based on this classification scheme and a binomial (yes/no) facial pain questionnaire, we have designed and trained an artificial neural network (ANN) and as an initial feasibility assessment of such an ANN system examined its ability to recognize and correctly diagnose patients with different facial pain syndromes. One hundred patients with facial pain were asked to respond to a facial pain questionnaire at the time of their initial visit. After interview, an independent diagnosis was assigned to each patient. The patients' responses to the questionnaire and their diagnoses were input to an ANN. The ANN was able to retrospectively predict the correct diagnosis for 95 of 100 patients (95%), and prospectively determine a correct diagnosis of trigeminal neuralgia Type 1 with 84% sensitivity and 83% specificity in 43 new patients. The ability of the ANN to accurately predict a correct diagnosis for the remaining types of facial pain was limited by our clinic sample size and hence less exposure to those categories. This is the first demonstration of the utilization of an ANN to diagnose facial pain syndromes.     

Pain drawings in chronic back pain

Pain drawings were obtained from two groups of patients and one of nonpatients, in a total of 264 subjects, all suffering from back pain. The pain drawings were rated in four grades according to the degree of nonorganic and extended pain. The reliability was excellent with an intra- and interrater agreement of 80 and 70%, respectively. Three quarters of the nonpatient group had dull aching pain in the lower back only, whereas widespread or nonanatomical pain was prevalent in patients responding poorly to treatment. A correlation was also found to ethnic background and social situation but not to alcohol abuse or psychiatric illness. Pain drawings afford an important clue to nonorganic factors in the assessment of back pain.     

The predictive value of pain drawings in lumbar spinal fusion surgery

Background contextPain drawings have been used extensively in spine surgery. It has been associated with inferior outcome after disc and stenosis surgery. Results regarding the predictive value in fusion surgery have been conflicting.PurposeTo evaluate the predictive value of pain drawings in relation to outcome after lumbar spinal fusion. To investigate if there are differences between spondylolisthesis patients and patients with degenerative disease as well as between patients with or without radicular pain.Study designProspective clinical cohort with a minimum of 1-year follow-up.Patient sampleOne hundred thirty-five patients undergoing lumbar spinal fusion. Fifty-seven men and 78 women, mean age 44 years (range 21–59 years).Outcome measuresDallas Pain Questionnaire (DPQ), Low Back Pain Rating Scale (LBPRS) pain index and patient satisfaction. Minimal clinical important difference was defined for the LBPRS score.MethodsPain drawings were classified, using the visual inspection method, as organic or nonorganic and correlated to outcomes. Multivariate adjustment for several possible confounding variables was done using logistic regression analysis.ResultsThirty-three percent of the drawings were classified as nonorganic. Nonorganic drawings were associated with significantly higher DPQ and LBPRS scores preoperatively and at follow-up. Differences between organic and nonorganic drawings were larger in spondylolisthesis patients than in patients with degenerative disorders. Nonorganic pain drawings were associated with poorer outcome in patients with low back pain and radicular symptoms, however, not in patients without radicular symptoms. A nonorganic pain drawing predicted negative patient satisfaction with odds ratio (OR) 3.01 (95% confidence interval (CI): 1.14–8.55, p=.027) but had no significant predictive value with respect to improvement in the LBPRS pain index OR 1.92 (95% CI: 0.82–4.47, p=.132).ConclusionsA nonorganic pain drawing was a significant risk factor for inferior outcome after spinal fusion surgery. The predictive value did not allow for patient selection.     

Expert performance in low-back disorder recognition using patient pain drawings.

Eight low-back-pain experts who regularly include pain drawings in their clinical workup were asked to classify 25 drawings. The experts used only the drawings to place cases into one of five broadly defined diagnostic categories: benign disorder, herniated disc, spinal stenosis, underlying disorder, or psychogenic disturbance. The physicians demonstrated adequate accuracy--51% correct--when compared with change (20% correct). Classification accuracy was greatest for psychogenic disorders (85%), followed by spinal stenosis (58%), herniated discs (52%), and benign disorders (50%). Predictions were comparatively poor for the underlying disorder category (10%). The individual physician accuracies varied from 44 to 60%. "Classic" pain patterns for each disorder group were identified by determining which drawings were correctly classified by most physicians. Physicians may wish to impart greater significance to pain drawings close to one of our "classic" patterns than to others.     

Pain 5 years after instrumented and non-instrumented posterolateral lumbar spinal fusion

Pain drawings have been used in spine surgery for diagnostic use and psychological evaluation of fusion candidates; they have rarely been used to evaluate pain status after spinal fusion. This study is a 5-year follow-up on a randomised clinical trial assigning patients to posterolateral spinal fusion with or without pedicle screw instrumentation. Patients were mailed a pain drawing and questionnaires including questions regarding work, social status, smoking status, the Dallas Pain Questionnaire (DPQ), and the Low Back Pain Rating Scale (LBPRS). Pain drawings were scored using a visual inspection method and a surface-based point scoring and evaluated for the presence of donor site pain. Pain drawings from 109 patients (87% of the initially included patients), 56 men and 53 women, mean age at follow-up 51 years, were analysed. Fifty-three patients had undergone an instrumented fusion and 56 a non-instrumented fusion. Some presence of low back pain was marked by 79% and leg pain by 69%. Sixty-two percent of the pain drawings were classified as "organic" and 38% as "non-organic". There was no difference between the instrumented and the uninstrumented group. DPQ and LBPRS scores were higher in the non-organic group ( P=0.007). Using the point scoring, no difference between the instrumented and the uninstrumented group was seen. The results of the point scoring were found to correlate with the DPQ and LBPRS scores ( P=0.001). Working patients (39%) had significantly better scores than the rest. Ten percent of the patients had donor site pain. Twenty percent of spinal fusion patients are totally pain free at 5-year follow-up. Ten percent still experience donor site pain. In general, instrumentation does not affect the amount and localisation of pain 5 years after lumbar spinal fusion surgery. The pain drawing seems to be a valuable tool when following spinal fusion patients, but its use as prognostic marker in connection with fusion surgery needs further investigation.     

The relationship of disability (Oswestry) and pain drawings to functional testing

There was much enthusiasm about the development of computerized dynamometry in providing large quantities of data to objectively assess muscle performance. However, a much more basic issue arose questioning what these machines actual measure, particularly in pain populations. The purpose of the present study was to determine whether patients’ self-reported disability and pain expression, as evaluated with simple questionnaires, were related to isokinetic performance in low back pain patients. Method: Oswestry Disability Questionnaires and pain drawings were collected from 76 patients undergoing isokinetic testing upon entering a physical rehabilitation program. Isokinetic trunk testing was performed in the standing position and results recorded for flexion and extension at speeds of 50°, 100°, and 150° per second. Results: Patients indicating minimal disability on the Oswestry questionnaire performed better than those indicating greater levels of disability (P < 0.05; ANOVA with Tukey adjustment for multiple comparisons). Patients with greater pain drawing scores, indicating unusual pain patterns, performed more poorly during isokinetic testing than those with normal drawings (P < 0.05). Regression analysis revealed that the lifting question from the Oswestry questionnaire, pain drawings scores, and sex were all significantly related to isokinetic performance and could account for 37.6–48.1% of the variance in performance (varying with speed of test). Conclusions: The results of this study indicate that isokinetic test values are significantly influenced by a patient’s self-reported disability and pain expression, which can be evaluated using simple tools such as pain drawings and the Oswestry questionnaire. This study supports the supposition that dynamometry testing is related to factors other than muscle performance. Received: 29 December 1998 Revised: 26 November 1999 Accepted: 8 December 1999     

Pain patterns in lumbar disc hernia: Drawings compared to surgical findings in 159 patients

We compared preoperative pain-drawing patterns of 159 patients with findings at lumbar disc surgery. Disc pathology was classified into 2 groups: intact anulus (negative exploration and protruding disc) and ruptured anulus (subligamentary perforation and sequestrated hernia). Patients with intact anulus drew fewer modalities, but more often marked pain in the trunk, neck and upper extremities, than those with ruptured anulus. Certain pain-drawing patterns-e.g., extra text, arrows and nonanatomical pain distribution-have previously been shown to correlate to unfavorable pathological traits in psychometric tests in populations of patients with chronic low back pain. in our study, most of these so-called nonorganic pain-pattern items occurred equally often in the 2 groups. in fact, one third of the patients with ruptured anulus produced pathological drawings according to the scoring system designed by Ransford et al. (1976). Although pain drawings help the investigator to obtain a rapid overview of the patient's pain pattern, the use of penalty points as a preoperative psychological screening instrument in patients with pain that is not chronic may be questioned.     

Automated,patient-interactive,spinal cord stimulator adjustment: a randomized controlled trial

OBJECTIVE: Programmable, multicontact, implanted stimulation devices represent an important advance in spinal cord stimulation for the management of pain. They facilitate the technical goal of covering areas of pain by stimulation-evoked paresthesiae. Adjustment after implantation requires major investments of time and effort, however, if the capabilities of these devices are to be used to full advantage. The objective of maximizing coverage should be met while using practitioners' time efficiently. METHODS: We have developed a patient-interactive, computerized system designed for greater ease and safety of operation, compared with the standard external devices used to control and adjust implanted pulse generators. The system automatically and rapidly presents to the patient the contact combinations and pulse parameters specified by the practitioner. The patient adjusts the amplitude of stimulation and then records drawings of stimulation paresthesiae (for comparison with pain drawings), followed by visual analog scale ratings for each setting. Test results are analyzed and sorted to determine the optimal settings. We compared the automated, patient-interactive system with traditional, practitioner-operated, manual programming methods in a randomized controlled trial at two study centers, with 44 patients. RESULTS: The automated, patient-interactive system yielded significantly (P < 0.0001) better technical results than did traditional manual methods, in achieving coverage of pain by stimulation paresthesiae (mean 100-point visual analog scale ratings of 70 and 46, respectively). The visual analog scale ratings were higher for automated testing for 38 patients, higher for manual testing for 0 patients, and equal (tied) for 6 patients. Multivariate analysis demonstrated that the advantage of automated testing occurred independently of practitioner experience; the advantage was significantly greater, however, for experienced patients. The rate of testing (number of settings tested per unit time) was significantly (P < 0.0001) greater for the automated system, in comparison with the rate with a human operator using traditional, manual, programming methods (mean of 0.73 settings/min versus 0.49 settings/min). The automated system also identified settings with improved estimated battery life (and corresponding anticipated cost savings). No complications were observed with automated testing; one complication (transient discomfort attributable to excessive stimulation) occurred with manual testing. CONCLUSION: Automated, patient-interactive adjustment of implanted spinal cord stimulators is significantly more effective and more efficient than traditional manual methods of adjustment. It offers not only improved clinical efficacy but also potential cost savings in extending implanted battery life. It has the additional potential advantages of standardization, quality control, and record keeping, to facilitate clinical research and patient care. It should enhance the clinical application of spinal cord stimulation for the treatment of chronic intractable pain.     

Pain drawing evaluation-the problem with the clinically biased surgeon: Intra- and interobserver agreement in 50 cases related to clinical bias

To assess whether the clinical knowledge of the treating surgeon had any effect on the reliability of the pain-drawing evaluation, drawings from 50 low-back pain patients were evaluated by the treating surgeon and by three colleagues who had no clinical knowledge of the patient. The evaluation was repeated after 10 days. The treating surgeons were also blinded to clinical data. The kappa value in the evaluation when the surgeon had clinical knowledge of the patient was lower (0.29 (95% CI 0.13-0.45)) than the kappa value in the evaluations made without clinical knowledge (0.60 (CI 0.45-0.75)). The differences observed in interobserver reliability between open and blind evaluations suggest that clinical knowledge of a patient influences the evaluation of the pain drawings.     

Dolor agudo en fosa ilíaca derecha. Un nuevo algoritmo de diagnóstico basado en árboles de clasificación y red neuronal artificial

IntroductionPain in the right iliac fossa (RIF) continues to pose diagnostic challenges. The objective of this study is the development of a RIF pain diagnosis model based on classification trees of type CHAID (Chi-Square Automatic Interaction Detection) and on an artificial neural network (ANN).MethodsProspective study of 252 patients who visited the hospital due to RIF pain. Demographic, clinical, physical examination and analytical data were registered. Patients were classified into 4 groups: NsP (nonspecific RIFP group), AA (acute appendicitis), NIRIF (RIF pain with no inflammation) and IRIF (RIF pain with inflammation). A CHAID-type classification tree model and an ANN were constructed. The classic models (Alvarado [ALS], Appendicitis Inflammatory Response [AIR] and Fenyö-Linberg [FLS]) were also evaluated. Discrimination was assessed using ROC curves (AUC [95% CI]) and the correct classification rate (CCR).Results53% were men. Mean age 33.3±16 years. The largest group was the NsP (45%), AA (37%), NRIF (12%) and IRIF (6%). The analytical model results were: ALS (0.82 [0.76-0.87]), AIR (0.83 [0.77-0.88]) and FLS (0.88 [0.84-0.92]). CHAID determined 10 decision groups: 3 with high probability for NsP, 3 high for AA and 4 special groups with no predominant diagnosis. CCR of ANN and CHAID were 75% and 74.2%, respectively.ConclusionsThe methodology based on CHAID-type classification trees establishes a diagnostic model based on four pain groups in RIF and generates decision rules that can help us in the diagnosis of processes with RIF pain.     

A comparison of outcomes of anterior cervical discectomy and fusion in patients with and without radicular symptoms

Anterior cervical discectomy and fusion (ACDF) is commonly performed for degenerative conditions of the cervical spine with good to excellent results. There is controversy over the use of ACDF for patients with axial neck pain alone. A retrospective review of 202 patients from two private practice orthopaedic spine surgeons following ACDF with 39-month mean follow-up was performed. Patients completed pain drawings, pre- and postoperative visual analog pain scales (VAS), Oswestry functional capacity evaluations (OSW), and a postoperative neck disability index. Forty-one patients had axial neck pain alone, and 161 had radicular pain with or without neck pain. There were significant improvements in VAS and OSW scores following surgery for the combined study population as well as the neck pain only and radicular pain groups (p < .01). ACDF can be effectively used for treatment of patients with axial neck pain without radicular symptoms.     

Usefulness of artificial neural networks to predict follow-up dietary protein intake in hemodialysis patients

BACKGROUND: Artificial neural networks (ANN) represent a promising alternative to classical statistical and mathematic methods to solve multidimensional nonlinear problems. The aim of the study was to verify, by comparing the performance of ANN with that of experienced nephrologists, whether ANN are useful tools in hemodialysis to predict the follow-up (=1 month after the observation used for the prediction) dietary protein intake (PCR), and whether their performance is influenced by the size of the population and by the data pool used to built the model. METHODS: A combined retrospective and prospective observational study was performed in two Swiss dialysis units (84 chronic hemodialysis patients, 500 monthly clinical observations and biochemical test results). Using mathematical models based on linear regressions to evaluate the variables, ANN were built and then prospectively and interinstitutionally compared with the ability of six experienced nephrologists to predict the follow-up PCR. RESULTS: ANN compared with nephrologists gave a more accurate correlation between estimated and calculated follow-up PCR (P < 0.001). The same superiority of ANN was also seen in the ability to detect a follow-up PCR <1.00 g/kg/day expressed as a percentage of correct predictions, sensitivity, specificity, and predictivity. The interinstitutional performance of the ANN is positively influenced by the size and the variability of the population used to build the mathematical model. CONCLUSION: The use of ANN significantly improves the ability of the experienced nephrologist to estimate and to detect an unsatisfactory (<1.00 g/kg/day) follow-up PCR. The size of the population selected to build the ANN is critical for his performance.     

The use of oral colchicine for low-back pain. A double-blind study

The use of colchicine for the treatment of low-back pain has been controversial; however, recent studies have shown its effectiveness when used intravenously. Studies using oral colchicine alone are lacking. The purpose of this study is to evaluate in a prospective, double-blind fashion the use of oral colchicine in the treatment of low back pain. Group I patients (15) were treated with a placebo capsule, and Group II (12) patients were treated with a colchicine capsule prescribed in a "burst dose" regimen. Patients were evaluated at 1, 2, 4, 6, and 12 weeks with a mean followup of 12 weeks. Parameters studied included patient characteristics, compliance, the McCoy pain drawings, pain analogue scales, the Million scale and objective tests. In terms of therapeutic response, the study shows no statistically significant difference between oral colchicine and placebo. The colchicine group did have an increased number of side effects.