title: A systematic review of pain drawing literature: should pain drawings be used for psychologic screening?
abstract: OBJECTIVE
  The use of pain drawings to identify the psychologic "state" of patients has been advocated. They are used for psychologic screening before considering treatments, such as surgery. For pain drawings to be clinically useful as a psychologic screen they need good positive and negative predictive values. We systematically reviewed the literature that directly compared pain drawing scoring systems with measures of psychologic state.
  
  
  METHODS
  We searched 12 medical and social science databases, using key words and their derivatives. Nineteen articles were suitable for analysis. The majority focused on low back pain (79%) in secondary or tertiary care (90%). Pain drawings were evaluated against psychologic tools testing: somatization, depression, anxiety, and distress.
  
  
  RESULTS
  Three studies concluded that the association between pain drawings and psychologic state was sufficient for clinical use; of these only 1 showed reasonable sensitivity and specificity data. Six reported a statistical association and 10/19 studies reported inconclusive results and weak association. The pooled median sensitivity score was 56% (range 24% to 93%), specificity 79.5% (range 44% to 91%), positive predictive value 71.5% (range 28% to 94%), and negative predictive value 88% (range 35% to 100%). The predictive data were too low, wide-ranging, and inconsistent to accept the pain drawing as a clinical diagnostic tool to predict psychologic state.
  
  
  CONCLUSIONS
  We conclude that the available data do not support the assumption that unusual pain drawings or extensive marking indicate disturbed psychologic state. There is no high quality evidence to support pain-drawing use as a psychologic assessment tool; therefore, pain drawings are not recommended for this purpose.
authors.affiliation: Institute of Health Sciences Education, Barts and The London, Queen Mary's School of Medicine and Dentistry, London, UK. d.carnes@qmul.ac.uk
authors.forename: Dawn
authors.initials: D
authors.lastname: Carnes
authors.forename: Deborah
authors.initials: D
authors.lastname: Ashby
authors.forename: Martin
authors.initials: M
authors.lastname: Underwood
mesh_terms: D006801:Humans; D019992:Databases as Topic; D017116:Low Back Pain / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology; D008403:Mass Screening; D010147:Pain Measurement / Q000379:methods; D011237:Predictive Value of Tests; D011581:Psychological Tests / Q000706:statistics & numerical data; D012016:Reference Values; D015203:Reproducibility of Results; D012196:Review Literature as Topic; D012680:Sensitivity and Specificity