The researchers flipped all right leg pain charts to the left for easier analysis. When measured independently, many psychological factors show a correlation between the size of the pain drawing. However, when other factors are considered, the correlation is significantly weaker. (Image courtesy of European Journal of Pain, CC BY 4.0)
Researchers in a 2024 study of more than 15,300 patients with chronic low back pain found that patients’ pain drawings on a body chart “do not signify psychological distress.” Instead, they find that these drawings are more closely associated with physical symptoms, such as disability, pain duration, and pain intensity. The study was published in the European Journal of Pain.
Lead researcher Steen Harsted from the University of Southern Denmark said that research in the last few decades has shown that the psychological and social factors often play a “big role in prognosis—sometimes even more than physical findings.”
“That’s why many current treatments for disabling low back pain specifically target unhelpful pain-related thoughts, emotions, and behaviors,” he told Massage & Fitness Magazine in an email. “Importantly, this approach tends to work better than purely manual or exercise-based treatments. So psychosocial factors are clearly relevant and influence [musculoskeletal] health.”
“When it comes to how patients present their pain, however, we kept encountering a persistent idea: That patients who draw widespread pain, or present “a lot of pain,” are really communicating psychological distress,” Harsted continued.
The patients in the study used a digital drawing of a human body on a computer touch screen where they can indicate where they hurt. Later, 1,000 of the participants’ data were randomly selected, and the body map was superimposed or “stacked” on top of each other.
“In low back pain, it’s important diagnostically whether pain extends into the legs — and whether it’s on one side or both,” Harsted said. “In our figures, we’re overlaying thousands of individual pain drawings. For a single patient, of course it matters whether one-sided pain is on the left or the right. But when you want to show patterns across a large group, left vs. right becomes less important than unilateral vs. bilateral.
“That’s why we flipped all drawings of right-sided pain onto the left side. So in the overlays, the left leg shows how many patients drew pain on one or both sides, while the right leg specifically represents patients who drew pain on both sides. This standardization makes the group patterns much easier to interpret.”
The pain body map
Harsted and his team analyzed the drawings with each physical and psychological factor in isolation and then analyzed them altogether. Harsted pointed out that if you only compare depression scores with the pain area, you would see a correlation.
“Patients with higher depression scores actually do draw larger pain areas, about [a] 5% average increase for every extra point on the depression scale,” he said.
But when you put all the other variables together, the link between depression (and other psychological distress factors) and the drawing size “disappears.”
When psychological factors are analyzed individually, the correlation is stronger than what these factors are included together with physical symptoms. (Image courtesy of European Journal of Pain, CC BY 4.0)
“The main drivers of larger pain drawings are physical symptoms: Leg pain intensity, disability, and pain duration,” Harsted said. “Since our group also works in data science and visualization, we realized we had a rare opportunity. We could rigorously test—and visually demonstrate—how pain distribution in these drawings relates to psychosocial factors, using one of the largest patient samples available worldwide.”
According to the paper, the study does not differentiate among different types of pain (e.g. stabbing, numb, burning) and does not capture “all psychological dimensions pertinent to the pain experience.” The researcher also wrote that they had some challenges in depicting the “outside areas” that some patients had marked on the diagram. These areas indicate that their pain is felt beyond the boundaries of the body diagram.
Early research in psychosocial distress
Harsted said that the idea that pain drawings reflect psychosocial distress dates back to at least the 1970s, citing a 1976 study by Dr. Andrew Ransford and two colleagues that was published in Spine. Hardsted said that the study suggested enlarged or “bizarre” drawings might signal psychological disturbance.
“The idea seems to have grown out of clinical observation. Soon after, studies began to report correlations between pain drawings and scores on measures like hypochondriasis and hysteria,” Harstead said. “This was followed by Udén et al. (1988), who proposed distinguishing ‘organic’ from ‘non-organic’ drawings—the latter being diffuse, anatomically implausible, and interpreted as signs of distress.”
In 1998, orthopedic surgeon Gordon Waddell published “The Back Pain Revolution” that popularized those ideas and “cemented them” in clinical practice,” according to Harsted.
“[Waddell] devoted a section to pain drawings,” Harsted said. “One striking figure shows two patients with the same diagnosis but very different drawings—the larger, more diffuse one is interpreted as ‘communicating distress.’ So the idea that there is a link between pain drawings and distress is older than The Back Pain Revolution, but the book definitely did a lot to popularize it.”
(Image courtesy of Steen Harsted.)
“Our study revisits that assumption with much larger data—and finds that pain drawing size is better explained by physical symptom burden (pain intensity, disability, duration) rather than psychological distress.”
Harsted defined psychological distress as “a set of self-reported measures that capture different aspects of how people think and feel about their pain.”
Using a series of questionnaires, he and his team examined depression, anxiety, catastrophization, fear of movement, loneliness, and perceived risk of persistent pain. The patients scored each category on a 0 to 10 scale where higher scores mean more distress.
“In this context, psychological distress doesn’t mean a psychiatric diagnosis—it’s about capturing key psychological and social factors that can influence pain and disability,” Harsted said. “Our findings suggest that when patients mark very large areas on a pain drawing, this shouldn’t automatically be taken as a sign of psychological distress. Instead, it usually reflects the burden of physical symptoms—things like higher pain intensity, longer duration, and more disability.”
Clinical applications
Physical and massage therapists often used a similar body diagram that their patients use in their intake form. Harstead said that such drawings are still a useful communication tool and monitoring symptoms.
“Just don’t use them to infer anything about a patient’s psychological state,” he said.
“But the key point is the size of the drawing is best understood as reflecting symptom severity, not the patient’s psychological state,” Harsted continued. “So in practice, if a patient fills in a very extensive pain area, the next step is not to assume they are ‘exaggerating’ or ‘distressed,’ but to ask more about their pain intensity, their function, and how long they’ve been experiencing symptoms.”
While Harsted said that the study was not designed with patients in mind, he thought that patients in pain should understand that having a large pain drawing “does not mean you are exaggerating or that your pain is ‘all in your head.’”
“[Your pain] reflects your symptoms, and clinicians should respect that,” he said. “Hopefully this helps reduce stigma for people who present with widespread pain because we know some patients don’t always feel believed or respected when they try to communicate the extent of their pain.”
Further reading
Perceived discrimination on chronic pain
Nick Ng is the editor of Massage & Fitness Magazine and the managing editor for My Neighborhood News Network.
An alumni from San Diego State University with a bachelor’s degree in graphic communications, Nick had completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. In 2021, he earned an associate’s degree in journalism at Palomar College.
When he gets a chance, he enjoys weightlifting at the gym, salsa dancing, and exploring new areas in the Puget Sound area in Washington state.
