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Deconstructing chronicity of musculoskeletal pain: intensity-duration relations, minimal dimensions and clusters of chronicity

Marina M. Finnern, Dieter Kleinböhl, Herta Flor, Justus Benrath and Rupert Hölzl


Background and aims

Evaluating the degree to which pain has become chronic beyond mere duration poses several problems. The IASP Pain Taxonomy Axis IV employs intensity and duration combined to nine ordered categories. The Chronic Pain Grade links intensity and disability, but only the latter contributes to higher grades. The Mainz Pain Staging System includes temporal and spatial aspects, medication and health care utilization. Their interrelations, scale properties and construct validity are not always known or debatable. The study challenges the generality and homogeneity of the chronicity construct of musculoskeletal pain aiming at necessary and sufficient sub-constructs identified by separable marker clusters. We show chronicity to vary in content and structure with severity and duration and between different populations. This raises the question of validity conditions of general chronicity indices and requires further work on adequate chronicity measures.


Diagnostic entrance data of 185 patients with chronic regional vs. widespread musculoskeletal pain (unspecific back pain, fibromyalgia) from regional pain clinics and 170 active employees in a nationwide prevention program were included in a retrospective cross-sectional analysis of the combined marker sets of the three chronicity indices above. The samples of patients and employees provided intensity, duration and disability degrees over the whole range of the assumed chronicity. Intensity-duration relations were quantified by correlations and frequency distributions of successive duration classes. The dimensional structure of pain and chronicity variables was assessed by factor and cluster analyses.


Pain intensity distributions showed inhomogeneous courses from short to long durations – lowest intensities predominating at longer durations in patients and at shorter in employees. Moreover, pain intensity and duration related nonlinearly to Chronic Pain Grade and Mainz Pain Stage and differently in patients compared to employees, and these indices correlated only moderately to each other. Factor and cluster analyses revealed different dimensions and clusters of chronicity markers for patients and employees. In the former, three dimensions with four clusters were identified with clinical characteristics (intensity, temporal and spatial aspects) separated from direct consequences (disability/interference with activities, medication usage) and chronic development (duration, healthcare utilization). In employees, only two dimensions with three clusters were obtained and clinical pain characteristics clustered with direct consequences both separated from chronic development. Similar differences were shown between unspecific back pain and fibromyalgia but were less well defined.


There appears to be no coherent “chronicity” entity over the entire range of severity and duration for all pain populations with different clinical pictures and social contexts. Statements about chronicity must be differentiated with respect to those aspects relative to patient career.


General indices do not capture the complex and changing composition of chronicity. There is evidence for at least three weakly coupled core domains of chronicity, i.e. the primary clinical characteristics, the direct consequences of current interference with activities, and aspects of the patient history. Hence, multivariate assessment is recommended. The particular syndrome, the diagnostic context and the population under investigation should likewise be considered.

Corresponding author: Marina M. Finnern, M.Sc., Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Square J5, D-68159 Mannheim, Germany, Phone: +49 (0) 621 1703 6346, Fax: +49 (0) 621 1703 6305


The study is based on data collected in two projects of the Clinical Research Group KFO 107 “Neuroplasticity and Learning in Chronic Pain” (Projects HO 904/11; FL 156/26) of the Deutsche Forschungsgemeinschaft and project “Prevention of Work-related Musculoskeletal Pain” of the German Occupational Health Association, Section Nutrition and Gastronomy Business (Berufsgenossenschaft Nahrungsmittel & Gaststätten, BGN) awarded to RH. The great and congenial support of our colleagues and coworkers of the KFO 107 and the BGN is gratefully acknowledged.

  1. Authors’ statements

  2. Research funding: The study was funded by the Deutsche Forschungsgemeinschaft (Clinical Research Group 107 “Neuroplasticity and Learning in Chronic Pain”) and the German Occupational Health Association, Section Nutrition and Gastronomy Business (Berufsgenossenschaft Nahrungsmittel & Gaststätten, BGN). Marina Finnern was supported by a PhD grant from the Friedrich Ebert Foundation. None of the funders were involved in the data analysis or manuscript preparation. According to the privacy regulations employee data were collected and managed by the BGN and transferred pseudonomized to the Otto-Selz-Institute, University of Mannheim; pseudonomization documents remained with the BGN.

  3. Conflict of interest: The authors declare that there are no conflicts of interest associated with this manuscript.

  4. Informed consent: All participants were informed of the purpose of research and gave their informed consent.

  5. Ethical approval: The study was approved by the Local Ethics Committee. Patient data were partially acquired in connection with a clinical trial of combined behavioural and cannabinoid treatment for chronic pain ( Identifier: NCT00176163). The prevention program for the employees was conducted by the nutritional business and gastronomy section of the German employers’ liability insurance association (Berufsgenossenschaft Nahrungsmittel & Gaststätten, BGN) according to legal regulations.


[1] Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA, Kaasa S, Kosek E, Lavand’homme P, Nicholas M, Perrot S, Scholz J, Schug S, Smith BH, Svensson P, et al. A classification of chronic pain for ICD-11. Pain 2015;156:1003–07.25844555Search in Google Scholar

[2] Fordyce WE. Behavioral methods for chronic pain and illness. Saint Louis: Mosby, 1976.Search in Google Scholar

[3] IASP Taxonomy Working Group. Classification of chronic pain. . Accessed: 24 February 2017.Search in Google Scholar

[4] Korff M von, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–49.10.1016/0304-3959(92)90154-41408309Search in Google Scholar

[5] Pfingsten M, Schöps P, Wille T, Terp L, Hildebrandt J. Chronifizierungsausmaß von Schmerzerkrankungen: Quantifizierung und Graduierung anhand des Mainzer Stadienmodells [Classification of chronic pain: Quantification and grading with the Mainz Pain Staging System]. Der Schmerz 2000;14:10–7.Search in Google Scholar

[6] Sakinc N. Evaluierung des Chronifizierungsgrades bei Patienten mit langjährigen nicht- tumorbedingten Schmerzen [Evaluation of chronicity grade in patients with longtime non-cancer pain]. Dissertation. München, 1998.Search in Google Scholar

[7] Wittchen H-U, Zaudig M, Fydrich T. Strukturiertes Klinisches Interview für DSM-IV. Manual zum SKID-I und SKID-II [Structured clinical interview for DSM-IV. Manual for SCID-I and SCID-II]. Göttingen: Hogrefe, 1997.Search in Google Scholar

[8] Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, Fam AG, Farber SJ, Fiechtner JJ, Franklin CM, Gatter RA, Hamaty D, Lessard J, Lichtbroun AS, Masi AT, Mccain GA, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160–72.10.1002/art.17803302032306288Search in Google Scholar

[9] Wolfe F, Clauw DJ, Fitzcharles M-A, Goldenberg DL, Hauser W, Katz RL, Mease PJ, Russell AS, Russell IJ, Walitt B. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46:319–29.10.1016/j.semarthrit.2016.08.01227916278Search in Google Scholar

[10] Hölzl R, Baus D, Kiessling U, Becker S, Kleinböhl D, Bernhardt A. Prädiktoren der Chronifizierung muskuloskelettaler Schmerzen: Sequentielle Diagnostik von Stress und Komorbidität [Predictors of chronicity of musculoskeletal pain: sequential diagnostic of stress and comorbidity]. In: Grieshaber R, Stadeler M, Scholle HC, editors. 16. Erfurter Tage – Prävention von arbeitsbedingten Gesundheitsgefahren und Erkrankungen. Erfurt: Dr. Bussert & Stadeler, 2010.Search in Google Scholar

[11] Flor H, Rudy TE, Birbaumer N, Streit B, Schugens MM. Zur Anwendbarkeit des West Haven-Yale Multidimensional Pain Inventory im deutschen Sprachraum: Daten zur Reliabilitat und Validitat des MPI-D [The applicability of the West Haven-Yale multidimensional pain inventory in German-speaking countries: data on the reliability and validity of the MPI-D]. Der Schmerz 1990;4:82–7.Search in Google Scholar

[12] Deutsche Schmerzgesellschaft e.V. Deutscher Schmerzfragebogen [The German Pain Questionnaire]. . Accessed: 2 May 2017.Search in Google Scholar

[13] Nagel B, Gerbershagen HU, Lindena G, Pfingsten M. Entwicklung und empirische Überprüfung des Deutschen Schmerzfragebogens der DGSS [Development and evaluation of the multidimensional German pain questionnaire]. Der Schmerz 2002;16:263–70.10.1007/s00482-002-0162-1Search in Google Scholar

[14] Gerbershagen HU, Korb J, Nagel B, Nilges P. Das Mainzer Stadienmodell der Schmerz-Chronifizierung (MPSS): Auswertungsformular [The Mainz Pain Staging System: The Mainz Pain Chronicity Scoring System]. . Accessed: 2 April 2017.Search in Google Scholar

[15] Gerbershagen HU, Korb J, Nagel B, Nilges P. Das Mainzer Stadiensystem der Schmerzchronifizierung, Mainz Pain Staging System (MPSS): Testanweisung [The Mainz Pain Staging System (MPSS): Instructions for use of the MPSS-Scoring Form]. . Accessed: 2 April 2017.Search in Google Scholar

[16] Merskey H, Bogduk N, editors. Classification of chronic pain. Seattle: IASP Press, 1994.Search in Google Scholar

[17] Klasen BW, Hallner D, Schaub C, Willburger R, Hasenbring M. Validität und Reliabilität der deutschen Version des “Chronic Pain Grade Questionnaire” bei Rückenschmerzpatienten aus der primärärztlichen Versorgung [Validation and reliability of the German version of the Chronic Pain Grade questionnaire in primary care back pain patients]. Psychosoc Med 2004;1:1–12.Search in Google Scholar

[18] Mokken RJ. A theory and procedure of scale analysis: with applications in political research. The Hague: Mouton, 1971.Search in Google Scholar

[19] Sijtsma K, Molenaar IW. Introduction to nonparametric item response theory. Thousand Oaks, California: SAGE, 2002.Search in Google Scholar

[20] Korff M von. Epidemiologie and survey methods: chronic pain assessment. In: Turk DC, Melzack R, editors. Handbook of pain assessment, 2nd ed. New York: Guilford Press, 2001:603–18.Search in Google Scholar

[21] Gerbershagen HU, Waisbrod H. Chronic pain management: Part I: factors involved in comprehensive pain patient care evaluation. Der Schmerz: Halbjahresberichte zur interdisziplinären Behandlung chron. Schmerzerkrankungen 1986;2:55–9.Search in Google Scholar

[22] Hautzinger M, Bailer M. Allgemeine Depressionsskala [The German version of Center for Epidemiologic Studies Depression Scale]. Göttingen: Hogrefe, 1993.Search in Google Scholar

[23] Laux L, Glanzmann P, Schaffner P, Spielberger CD. Das State-Trait-Angstinventar (STAI) [The State-Trait-Anxiety-Inventory]. Göttingen, Bern: Hogrefe, 1981.Search in Google Scholar

[24] Simpson EH. The interpretation of interaction in contingency tables. J R Stat Soc Series B Stat Methodol 1951;13:238–41.Search in Google Scholar

[25] Cramer E, Kamps U. Grundlagen der Wahrscheinlichkeitsrechnung und Statistik [Principles of probability calculation and statistics]. 3rd ed. Berlin: Springer Spektrum, 2014.Search in Google Scholar

[26] Rosseel Y. lavaan: An R package for structural equation modeling. J Stat Softw 2012;48:1–36.Search in Google Scholar

[27] Schermelleh-Engel K, Moosbrugger H, Müller H. Evaluating the fit of structural equation models: tests of significance and descriptive goodness-of-fit measures. Meth Psych Res 2003;8:23–74.Search in Google Scholar

[28] Suzuki R, Shimodaira H. Pvclust: hierarchical clustering with p-values via multiscale bootstrap resampling. . Accessed: 30 December 2016.Search in Google Scholar

[29] Suzuki R, Shimodaira H. Pvclust: an R package for assessing the uncertainty in hierarchical clustering. Bioinformatics 2006;22:1540–42.10.1093/bioinformatics/btl117Search in Google Scholar

[30] Shimodaira H. An approximately unbiased test of phylogenetic tree selection. Syst Biol 2002;51:492–508.10.1080/1063515029006991312079646Search in Google Scholar

[31] Forseth KO, Husby G, Gran JT, Forre O. Prognostic factors for the development of fibromyalgia in women with self-reported musculoskeletal pain. A prospective study. J Rheumatol 1999;26:2458–67.10555910Search in Google Scholar

[32] Lapossy E, Maleitzke R, Hrycaj P, Mennet W, Muller W. The frequency of transition of chronic low back pain to fibromyalgia. Scand J Rheumatol 1995;24:29–33.10.3109/030097495090951517863275Search in Google Scholar

[33] Gerhardt A, Eich W, Janke S, Leisner S, Treede R-D, Tesarz J. Chronic widespread back pain is distinct from chronic local back pain: evidence from quantitative sensory testing, pain drawings, and psychometrics. Clin J Pain 2016;32:568–79.10.1097/AJP.000000000000030026379077Search in Google Scholar

[34] Boersma K, Linton SJ. How does persistent pain develop? An analysis of the relationship between psychological variables, pain and function across stages of chronicity. Behav Res Ther 2005;43:1495–507.1615959110.1016/j.brat.2004.11.006Search in Google Scholar

[35] Nilges P, Nagel B. Was ist chronischer Schmerz? [What is chronic pain?]. Deutsche medizinische Wochenschrift 2007;132:2133–38.10.1055/s-2007-985653Search in Google Scholar

[36] Frettlöh J, Maier C, Gockel H, Hüppe M. Validitat des Mainzer Stadienmodells der Schmerzchronifizierung bei unterschiedlichen Schmerzdiagnosen [Validation of the German Mainz Pain Staging System in different pain syndromes]. Der Schmerz 2003;17:240–51.10.1007/s00482-003-0227-9Search in Google Scholar

[37] Michalski D, Hinz A. Schmerzchronifizierung bei ambulanten Rückenschmerzpatienten: Anwendung des Mainzer Stadienmodells der Schmerzchronifizierung [Severity of chronic back pain: assessment with the Mainz Pain Staging System]. Der Schmerz 2006;20:198–209.10.1007/s00482-005-0433-8Search in Google Scholar

[38] Hasenbring MI, Verbunt JA. Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice. Clin J Pain 2010;26:747–53.10.1097/AJP.0b013e3181e104f220664333Search in Google Scholar

[39] Bustan S, Gonzalez-Roldan AM, Kamping S, Brunner M, Loffler M, Flor H, Anton F. Suffering as an independent component of the experience of pain. Eur J Pain 2015;19:1035–48.10.1002/ejp.70925857478Search in Google Scholar

[40] Elliott AM, Smith BH, Smith WC, Chambers WA. Changes in chronic pain severity over time: the Chronic Pain Grade as a valid measure. Pain 2000;88:303–8.1106811810.1016/S0304-3959(00)00337-7Search in Google Scholar

[41] Teasell RW. Compensation and chronic pain. Clin J Pain 2001;17:S46–64.10.1097/00002508-200112001-0001111783831Search in Google Scholar

[42] Ljutow A, Nagel B. Wie schätze ich die Rückenschmerzsituation meines Patienten ein? Die Mainzer Chronifizierungsstadien und ihre prognostische Bedeutung [How can I assess the back pain status in my patients? The Mainz chronic disease staging method and its prognostic value]. Z Orthop 2005;143:311–5.Search in Google Scholar

[43] Linton SJ, Halldén K. Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Clin J Pain 1998;14:209–15.10.1097/00002508-199809000-000079758070Search in Google Scholar

[44] Neubauer E, Junge A, Pirron P, Seemann H, Schiltenwolf M. HKF-R 10 – screening for predicting chronicity in acute low back pain (LBP): a prospective clinical trial. Eur J Pain 2006;10:559–66.10.1016/j.ejpain.2005.08.00216202634Search in Google Scholar

Supplementary Material

The online version of this article offers supplementary material (

Received: 2018-01-18
Revised: 2018-04-30
Accepted: 2018-05-04
Published Online: 2018-06-05
Published in Print: 2018-07-26

©2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.