Jump to ContentJump to Main Navigation
Show Summary Details
More options …
New at De Gruyter

Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

4 Issues per year

CiteScore 2017: 0.84

SCImago Journal Rank (SJR) 2017: 0.401
Source Normalized Impact per Paper (SNIP) 2017: 0.452

See all formats and pricing
More options …
Volume 17, Issue 1

Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic

Eva-Britt Hysing / Lena Smith / Mans Thulin / Rolf Karlsten / Stephen Butler / Torsten Gordh
Published Online: 2017-10-01 | DOI: https://doi.org/10.1016/j.sjpain.2017.09.008


Background and aims

Patients suffering from chronic nonmalignant pain constitute a heterogeneous population in terms of clinical presentation and treatment results. Few data are available about what distinguishes different groups in this huge population of patients with chronic persistent pain (CPP). A subgroup that is poorly studied, consists of the most severely impaired chronic pain patients. At the Uppsala University Hospital Pain Clinic, there is a specialized department accepting the most complex patients for rehabilitation. In the endeavour to improve and evaluate treatment for this subgroup, a better understanding of the complex nature of the illness is essential. This prospective study aimed to describe the characteristics of this subgroup of patients with CPP.


Seventy-two consecutive patients enrolled in the Uppsala programme were evaluated. We collected data on demographics, type of pain and experienced symptoms other than pain using a checklist of 41 possible symptoms. Psychiatric comorbidity was assessed by a psychiatrist using a structured clinical interview. Quality of life (QoL), pain rating and medication/drug/alcohol usage were measured by validated questionnaires: SF-36, NRS, DUDIT and AUDIT. Concerning physical functioning and sick leave, a comparison was made with data from the Swedish Quality Register Registry for pain rehabilitation (SQRP).


The cohort consisted of 61% women and the average age was 45 (range 20-70) years. For this cohort, 74% reported being on sick leave or disability-pension. In the SQRP 59% were on sick leave at the time they entered the rehabilitation programmes [1]. On average, the study-population reported 22 symptoms other than pain, to be at a high rate of severity. Patients treated in conventional pain-rehabilitation programmes reported a mean of 10 symptoms in average. Symptoms reported with the highest frequency (>80%), were lethargy, tiredness, headache and difficulties concentrating. Seventy- six percent were diagnosed with a psychiatric disorder. Sixty-nine fulfilled the criteria for depression or depression/anxiety disorder despite that most (65%) were treated with psychotropic medication. Alcohol/drug abuse was minimal. Seventy-one percent were on opioids but the doses were moderate (<100 mg) MEq. The pain rating was ≥7 (out of a maximum of 10) for 60% of the patients.


This study describes what makes the subgroup of pain patients most affected by their pain special according to associated factors and comorbidity We found that they were distinguished by a high degree of psychiatric comorbidity, low physical functioning and extreme levels of symptom preoccupation/hypervigilance. Many severe symptoms additional to pain (e.g. depression/anxiety, tiredness, disturbed sleep, lack of concentration, constipation) were reported. The group seems hypervigilant, overwhelmed with a multitude of different symptoms on a high severity level.


When treating this complex group, the expressions of the illness can act as obstacles to achieve successful treatment outcomes. The study provides evidence based information, for a better understanding of the needs concerning these pain patients. Our result indicates that parallel assessment and treatment of psychiatric comorbidities and sleep disorders combined with traditional rehabilitation, i.e. physical activation and cognitive reorganization are imperative for improved outcomes.

Keywords: Characterization of patients with severe; chronic persistent pain; Subgrouping patients with chronic; persistent pain; Severely impaired patients with chronic; pain; Psychiatric comorbidity; Physical dysfunction; Systemic symptoms other than pain


  • [1]

    Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999;354:1248–52.Google Scholar

  • [2]

    Eriksen J, Jensen MK, Sjogren P, Ekholm O, Rasmussen NK. Epidemiology of chronic non-malignant pain in Denmark. Pain 2003;106:221–8.Google Scholar

  • [3]

    Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain (London, England) 2006;10:287–333.Google Scholar

  • [4]

    Gore M, Sadosky A, Stacey BR, Tai K-S, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine 2012;37:E668–77.Google Scholar

  • [5]

    Gustavsson A, Bjorkman J, Ljungcrantz C, Rohdin A, Rivano-Fischer M, Sjolund KF, Mannheimer C. Socio-economic burden of patients with a diagnosis related to chronic pain - register data of 840,000 Swedish patients. Eur J Pain 2012;16:289–99.Google Scholar

  • [6]

    Annagur BB, Uguz F, Apiliogullari S, Kara I, Gunduz S. Psychiatric disorders and association with quality of sleep and quality of life in patients with chronic pain: a SCID-based study. Pain Med 2014;15:772–81.Google Scholar

  • [7]

    Andersson HI. Increased mortality among individuals with chronic wide spread pain relates to lifestyle factors: a prospective population-based study. Disabil Rehabil 2009;31:1980–7.Google Scholar

  • [8]

    Terkelsen AJ, Molgaard H, Hansen J, Finnerup NB, Kroner K, Jensen TS. Heart rate variability in complex regional pain syndrome during rest and mental and orthostatic stress. Anesthesiology 2012;116:133–46.Google Scholar

  • [9]

    Tracy LM, Ioannou L, Baker KS, Gibson SJ, Georgiou-Karistianis N, Gium-marra MJ. Meta-analytic evidence for decreased heart rate variability in chronic pain implicating parasympathetic nervous system dysregulation. Pain 2016;157:7–29.Google Scholar

  • [10]

    Nitter AK, Forseth KØ. Mortality rate and causes of death in women with selfreported musculoskeletal pain: results from a 17-year follow-up study. Scand J Pain 2013;4:86–92.Google Scholar

  • [11]

    Eccleston C, Williams AC, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2009:Cd007407.Google Scholar

  • [12]

    Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015;350:h444.Google Scholar

  • [13]

    Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain.Spine 1987;12:632–44.Google Scholar

  • [14]

    Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976) 2002;27:E109–20.Google Scholar

  • [15]

    Hoogendoorn WE, van Poppel MN, Bongers PM, Koes BW, Bouter LM. Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine 2000;25:2114–25.Google Scholar

  • [16]

    Heiskanen T, Roine RP, Kalso E. Multidisciplinary pain treatment - which patients do benefit? Scand J Pain 2012;3:201–7.Google Scholar

  • [17]

    Nyberg V, Sanne H, Sjolund BH. Swedish quality registry for pain rehabilitation: purpose, design, implementation and characteristics of referred patients. J Rehabil Med 2011;43:50–7.Google Scholar

  • [18]

    Jonsson T, Christrup LL, Højsted J, Villesen HH, Ahlbjerg H, Ravn-Nielsen LV, Sjogren P. Symptoms and side effects in chronic non-cancer pain: patient report vs. systematic assessment. Acta Anaesthesiol Scand 2011;55: 69-74.Google Scholar

  • [19]

    Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36).I.Conceptual framework and item selection. Med Care 1992;30: 473-83.Google Scholar

  • [20]

    Sullivan M, Karlsson J, Ware Jr JE. The Swedish SF-36 Health Survey - I. Evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden.Soc Sci Med 1995;41:1349–50.Google Scholar

  • [21]

    Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 1995;61:277–84.Google Scholar

  • [22]

    Jensen MP, Smith DG, Ehde DM, Robinsin LR. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317–22.Google Scholar

  • [23]

    Farrar JT, Young Jr JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149–58.Google Scholar

  • [24]

    Mercadante S, Caraceni A. Conversion ratios for opioid switching in the treatment of cancer pain: a systematic review. Palliat Med 2011;25:504–15.Google Scholar

  • [25]

    Federico A, Tamburin S, Maier A, Faccini M, Casari R, Morbioli L, Lugoboni F. Multifocal cognitive dysfunction in high-dose benzodiazepine users: a cross-sectional study. Neurol Sci 2017;38:137–42.Google Scholar

  • [26]

    Bergman H, Kallmen H. Alcohol drinking habits assessed by the AUDIT test. Reduced maximum levels doubled the number of women with dangerous alcohol drinking. Lakartidningen 2000;97:2078–84.Google Scholar

  • [27]

    Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption - II. Addiction 1993;88:791–804.Google Scholar

  • [28]

    Ballard HS. Hematological complications of alcoholism. Alcohol: Clin Exp Res 1989;13:706–20.Google Scholar

  • [29]

    Berman AH, Bergman H, Palmstierna T, Schlyter F. Evaluation of the Drug Use Disorders Identification Test (DUDIT) in criminal justice and detoxification settings and in a Swedish population sample. Eur Addict Res 2005;11:22–31.Google Scholar

  • [30]

    Gentleman R. Lexical scope and statistical computing. J Comput Graph Stat 2000;9:491–508.Google Scholar

  • [31]

    Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain 2006;125:172–9.Google Scholar

  • [32]

    Donnelly S, Walsh D. The symptoms of advanced cancer. Semin Oncol 1995;22(Suppl.3):67-72.Google Scholar

  • [33]

    Homsi J, Walsh D, Rivera N, Rybicki LA, Nelson KA, Legrand SB, Davis M, Naughton M, Gvozdjan D, Pham M. Symptom evaluation in palliative medicine: patient reportvs systematic assessment. Support Care Cancer 2006;14:444–53.Google Scholar

  • [34]

    Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med 2003;163:2433–45.Google Scholar

  • [35]

    Arnow BA, Hunkeler EM, Blasey CM, Lee J, Constantino M, Fireman B, Kraemer H, Dea R, Robinson R, Hayward C. Comorbid depression, chronic pain, and disability in primary care. Psychosom Med 2006;68:262–8.Google Scholar

  • [36]

    Richards HJ, Benson V, Donnelly N, Hadwin JA. Exploring the function of selective attention and hypervigilance for threat in anxiety. Clin Psychol Rev 2014;34:1–13.Google Scholar

  • [37]

    Craig AD. A new view of pain as a homeostatic emotion. Trends Neurosci 2003;26:303–7.Google Scholar

  • [38]

    Beck AT, Clark DA. An information processing model of anxiety: automatic and strategic processes. Behav Res Ther 1997;35:49–58.Google Scholar

  • [39]

    Lautenbacher S, Huber C, Schofer D, Kunz M, Parthum A, Weber PG, Roman A, Griessinger N, Sittl R. Attention and emotional mechanisms related to pain as predictors of chronic postoperative pain: a comparison with other psychological and physiological predictors. Pain 2010;151:722–31.Google Scholar

  • [40]

    Spielberger CD. State-trait anxiety inventory and state-trait anger expression inventory; 1994. p. 292-321.Google Scholar

  • [41]

    Boonstra AM, Schiphorst Preuper HR, Balk GA, Stewart RE. Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain 2014;155:2545–50.Google Scholar

  • [42]

    Hirschfeld G, Zernikow B. Cut points for mild, moderate, and severe pain on the VAS for children and adolescents: what can be learned from 10 million ANOVAs? Pain 2013;154:2626–32.Google Scholar

  • [43]

    Rhodin A. Increased use of opioids can lead to tolerance development. Great need for new guidelines and increased collaboration between health care providers. Lakartidningen 2014;111:1974–7.Google Scholar

  • [44]

    Manchikanti L, Cash KA, Malla Y, Pampati V, Fellows B. A prospective evaluation of psychotherapeutic and illicit drug use in patient presenting with chronic pain at the time of initial evaluation. Pain Phys 2013;16:E1–13.Google Scholar

  • [45]

    Ekholm O, Kurita GP, Hojsted J, Juel K, Sjogren P. Chronic pain, opioid prescriptions, and mortality in Denmark a population-based cohort study. Pain 2014;155:2486–90.Google Scholar

  • [46]

    Fishbain DA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med 2008;9:444–59.Google Scholar

About the article

Department of Surgical Science, Uppsala University, SE-751 85 Uppsala, Sweden

Received: 2017-06-28

Revised: 2017-09-08

Accepted: 2017-09-09

Published Online: 2017-10-01

Published in Print: 2017-10-01

Funding: Uppsala University Hospital, Uppsala University, Uppsala Berzelii Center.

Ethical issues: The study was performed in full accordance with the Declaration of Helsinki (1965 and later revisions). The study was approved by the Regional Ethical Review Board in Uppsala, Sweden (Dnr 2010/182). The patients included in the study were informed and gave written informed consent.

Conflict of interest: No conflicts of interest.

Authors’ contribution: EBH and LS oversaw and participated in all data collection, TG and EBH designed the protocol, and wrote the manuscript, RK and SB provided technical and interpretational advice and edited the manuscript and MT analyzed the data and performed the statistical analyses. All authors approved the final manuscript.

Citation Information: Scandinavian Journal of Pain, Volume 17, Issue 1, Pages 178–185, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2017.09.008.

Export Citation

© 2017 Scandinavian Association for the Study of Pain.Get Permission

Citing Articles

Here you can find all Crossref-listed publications in which this article is cited. If you would like to receive automatic email messages as soon as this article is cited in other publications, simply activate the “Citation Alert” on the top of this page.

Danielle Jacobson, Emily Glazer, Robin Mason, Deanna Duplessis, Kimberly Blom, Janice Du Mont, Navmeet Jassal, Gillian Einstein, and Marja Tiilikainen
PLOS ONE, 2018, Volume 13, Number 11, Page e0206886

Comments (0)

Please log in or register to comment.
Log in