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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

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Volume 18, Issue 3

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

Marina M. Finnern
  • Corresponding author
  • Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
  • Email
  • Other articles by this author:
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/ Dieter Kleinböhl
  • Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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/ Herta Flor
  • Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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/ Justus Benrath
  • Clinic of Anaesthesia and Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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/ Rupert Hölzl
  • Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Published Online: 2018-06-05 | DOI: https://doi.org/10.1515/sjpain-2018-0021


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.

This article offers supplementary material which is provided at the end of the article.

Keywords: chronicity; Chronic Pain Grade; Mainz Pain Staging System; IASP Taxonomy of Chronic Pain; musculoskeletal pain; validity


  • [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.PubMedWeb of ScienceGoogle Scholar

  • [2]

    Fordyce WE. Behavioral methods for chronic pain and illness. Saint Louis: Mosby, 1976.Google Scholar

  • [3]

    IASP Taxonomy Working Group. Classification of chronic pain. http://www.iasp-pain.org/files/Content/ContentFolders/Publications2/ClassificationofChronicPain/Part_I-Scheme+Topics.pdf. Accessed: 24 February 2017.

  • [4]

    Korff M von, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–49.PubMedCrossrefWeb of ScienceGoogle 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.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.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.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.CrossrefPubMedGoogle 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.CrossrefPubMedWeb of ScienceGoogle 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.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.Google Scholar

  • [12]

    Deutsche Schmerzgesellschaft e.V. Deutscher Schmerzfragebogen [The German Pain Questionnaire]. http://www.dgss.org/fileadmin/pdf/pdf_2/DSF_Anamnese_V2015_2_Muster.pdf. Accessed: 2 May 2017.

  • [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.CrossrefGoogle 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]. http://www.drk-schmerz-zentrum.de/mz/pdf/downloads/mpss_eng.pdf. Accessed: 2 April 2017.

  • [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]. http://www.drk-schmerz-zentrum.de/mz/pdf/downloads/mpss_testinstructions.pdf. Accessed: 2 April 2017.

  • [16]

    Merskey H, Bogduk N, editors. Classification of chronic pain. Seattle: IASP Press, 1994.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.Google Scholar

  • [18]

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

  • [19]

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

  • [22]

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

  • [24]

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

  • [25]

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

  • [26]

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

  • [28]

    Suzuki R, Shimodaira H. Pvclust: hierarchical clustering with p-values via multiscale bootstrap resampling. https://cran.r-project.org/web/packages/pvclust/pvclust.pdf. Accessed: 30 December 2016.

  • [29]

    Suzuki R, Shimodaira H. Pvclust: an R package for assessing the uncertainty in hierarchical clustering. Bioinformatics 2006;22:1540–42.CrossrefGoogle Scholar

  • [30]

    Shimodaira H. An approximately unbiased test of phylogenetic tree selection. Syst Biol 2002;51:492–508.CrossrefPubMedGoogle 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.PubMedGoogle 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.CrossrefPubMedGoogle 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.CrossrefPubMedWeb of ScienceGoogle 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.CrossrefPubMedGoogle Scholar

  • [35]

    Nilges P, Nagel B. Was ist chronischer Schmerz? [What is chronic pain?]. Deutsche medizinische Wochenschrift 2007;132:2133–38.CrossrefGoogle 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.CrossrefGoogle 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.CrossrefGoogle 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.CrossrefWeb of SciencePubMedGoogle 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.CrossrefPubMedGoogle 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.PubMedCrossrefGoogle Scholar

  • [41]

    Teasell RW. Compensation and chronic pain. Clin J Pain 2001;17:S46–64.PubMedCrossrefGoogle 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.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.CrossrefPubMedGoogle 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.PubMedCrossrefGoogle Scholar

About the article

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

Received: 2018-01-18

Revised: 2018-04-30

Accepted: 2018-05-04

Published Online: 2018-06-05

Published in Print: 2018-07-26

Authors’ statements

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.

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

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

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 (ClinicalTrials.gov 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.

Citation Information: Scandinavian Journal of Pain, Volume 18, Issue 3, Pages 363–377, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1515/sjpain-2018-0021.

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