Nursing and Health Care (ISSN: 2573-3877)

Commentary :

Is the Pain Real or Not?

Nelson Hendler


Chronic pain (constant pain lasting 6 months or longer) is a subjective experience, which is influenced by many pre-morbid (before the onset of pain) psychological problems. However, chronic pain often can produce depression, anxiety, and marital difficulties [1]. Although physical examination and other studies, including x-ray studies, 3D-CT, electromyelograms (EMG), nerve conduction velocity studies and MRI [2-4] in many cases may document an organic basis of chronic back pain, some organic syndromes defy definition by objective tests [5]. This may be a greater problem for women, where physician prejudice can result in a significantly less extensive evaluation of their complaints of back pain [6] Also, any litigation may influence symptoms [7] and the type of litigation may influence outcomes [8]. Therefore, there is a need to differentiate between “organic” and “functional” (negative physical and laboratory examination) back pain [9,10].

Many of the articles in the medical literature devote their efforts to measuring pain, rather than addressing the presence or absence of organic pathology. This research tries to correlate the subjective severity of pain with work capacity or failure to improve [11,12]. More importantly, 40%-71% of chronic pain patients are misdiagnosed [13-15]. However few articles appear in the medical literature that actually correlate perceived pain with the presence or absence of documented organic pathology, as measured by objective testing. Everyone just assumes that a broken leg is painful, and the X-ray is positive to confirm that. Likewise, many articles try to correlate psychological disturbance with the absence of organic pathology [16-20], while failing to recognize that severe organic pathology produces psychiatric problems in a previously well-adjusted individual [1,10,21-23]. Consistently, clinicians keep asking the wrong question.

Since pain is a subjective experience, there is actually no objective way to measure pain. [24]. This produces a real issue for medical care, since patients use the complaint of pain to obtain narcotics. In recent years, there has been an increasingly stringent effort by the Drug Enforcement Agency (DEA), and local police departments to “crack down” on physicians, who they perceive as “drug pushers.” [25]. While there are instances where physicians may establish “prescription mills” that indiscriminately hand out narcotic prescriptions to anyone who claims to have a pain, often without an examination, or where narcotics were prescribed to someone who was not a patient, or prescribe narcotics in quantities deemed unacceptable by the DEA, these instances are rare [25]. However, the arrest and subsequent jail terms for physicians in highly publicized cases has sent a chilling message to all physicians who prescribe narcotics [25]. Compounding this issue is the finding that most physicians are not able to detect deception very well [26]. Finally, the various techniques used for deceiving the physician, in order to obtain narcotic medication, are legion [25,26].

 Increasing, physicians and nurses need to protect themselves from deceptive patients. These clinicians need to document that they are participating in some effort to avoid being deceived. Recent recommendations have been requiring a narcotics contract, obtaining random urine testing to determine the quantity of narcotics in the system, and not prescribing narcotics until there is clear-cut evidence of organic pathology. Unfortunately, the last criteria is fallacious, since between 40%-71% of chronic pain patients are misdiagnosed [13-15]. As an example, the false negative rate of MRIs for detecting painful disc pathology is 75%-78% [27]. This is due to the fact there are painful fibers in the rear portion of the annulus which can produce pain when the nucleus polpusa herniates into this area, without producing any distortion to the anatomy of the disc [28]. This has been termed Internal Disc Disruption (IDD) by Bogduk and his colleagues [28]. Therefore, this painful pathology fails to produce abnormal MRI or CT since there is no external disc distortion, and can be detected only by using a physiological test, such as the provocative disco gram, rather than an anatomical test [28].

On the other hand, since the advent of the requirement to document the severity of pain in patients, the so-called 5th vital sign, physicians are obliged to provide pain relief [29]. Failure to do so have resulted in law suits against physicians [30], with awards as high as $1,500,000. So now physicians are caught between the DEA and the trial lawyers - the proverbial rock and hard place.  

In an effort to provide a consistent method of assessing patients with chronic pain, a group of physicians from Johns Hopkins Hospital developed the Pain Validity Test [31-35]. This test is available, in English or Spanish, over the Internet at It takes only 5 minutes of secretarial time to set up a computer to administer the test, and turn the computer over to the patient. It takes an unattended patient only 15 minutes to complete the 32 question Pain Validity Test, and results are available 5 minutes after the patient completes the test. The Pain Validity Test can predict the presence of abnormal medical testing with 95% accuracy, and the absence of abnormal medical testing with 85%-100% accuracy [31-35]. The Pain Validity Test can be used to determine if a patient should have additional medical testing, or is faking or malingering. The Pain Validity Test can detect “drug seeking behavior” with 95% accuracy, and has been admitted as evidence in over 30 legal cases in 8 states [36]. Finally, the Pain Validity Test can predict that a surgeon will find intra-operative pathology with 93% accuracy [37].

For any clinician in a busy office or Emergency Department, facing with the determination of prescribing narcotics, or ordering additional medical testing, or dismissing a patient, the Pain Validity Test lends a degree of objectivity to the decision making process.  


1. Hendler N, Long D and Wise T.  The four stages of pain, diagnosis and treatment of chronic pain (1982) Wright Wright-PSG Publishing Co, London 1-8.

2. Hendler N, Uematsu S and Long D. Thermographic validation of physical complaints in “psychogenic pain” patients (1982) Psychosomatics 23: 283-287.

3. Hender N, Zinreich J and Kozikowski J. Three-dimensional CT validation of physical complaints in “psychogenic pain” patients (1993) Psychosomatics 34: 90-96.

4. Uematsu S, Hendler N, Hungerford D, Long D and Ono N. Thermography and electromyography in the differential diagnosis of chronic pain syndromes and reflex sympathetic dystrophy (1981) Electromyogr Clin Neurophysiol 21: 165-182.

5. Brown BR Jr. Diagnosis and therapy of common myofascial syndromes (1978) JAMA 239:646-648.

6. Armitage KJ, Schniederman LJ and Bass RA. Response of physicians to medical complaints in men and women (1970) JAMA 241: 2186-2187.

7. Daus AT, Freeman WW, Wilson J. Psychological variable and treatment outcome of compensation and auto accident patients in a multidisciplinary chronic spinal pain clinic (1984) Orthop Rev 13: 596-605.

8. Talo S, Hendler N and Brodie J. Effects of active and completed litigation on treatment results: Workers compensation patients compared with other litigation patients (1989) J Occup Med 31: 265-269.

9. Southwick SM and White AA. The use of psychological tests in the evaluation of low-back pain (1983) J Bone Joint Surg 65: 560-565.

10. Hendler N and Talo S. Current Therapy of Pain (1989) (ed) Foley K and Payne R, BC Decker Inc., Philadelphia, USA 14-22.

11. Chen C, Hogg-Johnson S and Smith P. The recovery patterns of back pain among workers with compensated occupational back injuries (2007) Occup Environ Med 64: 534-540.

12.Patel S, Greasley K and Watson PJ. Barriers to rehabilitation and return to work for unemployed chronic pain patients: A qualitative study (2007) Eur J Pain 11: 831-840.

13. Hendler N and Kozikowski J. Overlooked physical diagnosis in chronic pain in litigation (1993) Psychosomatics 34: 494-501.

14. Hendler N, Bergson C and Morrison C. Overlooked physical diagnoses in Chronic Pain Patients Involved in Litigation, Part 2 (1996) Psychosomatics 37: 509-517.

15. Hendler N. Differential Diagnosis of Complex Regional Pain Syndrome (2002) Pan Arab J Neurosur 1-9.

16. Engle GL. Psychogenic pain and the pain prone patient (1959) Am J Med 25: 899-918.

17. Armentrout DP, Moore JE, Parker HC, Hewett JE and Feltz C. Pain-patient MMPI subgroups: The psychological dimensions of pain (1982) J Behav Med 5:201-211.

18. Leavitt F and Garron DC. Patterns of psychological disturbance and pain report in patients with low back pain (1982) J Psychosom Res 26: 301-307.

19. McGill JC, Lawlis GF, Selby D, Mooney V and McCoy CE. The relationship of Minnesota Multiphasic Personality Inventory (MMPI) profile clusters to pain behaviors (1983) J   Behav Med 6: 77-92.

20. Sternback R, Wolfe SB, Murphy RW and Akeson WH. Traits of pain patients: The low back “loser” (1973) Psychosomatics 14: 226-229.

21. Maruta T, Swanson D and Swanson W. Pain as a psychiatric symptom: Comparison between low back pain and depression (1976) Psychosomatics 17: 123- 127.

22. Edwin DH, Pearlson GD, Long DM. Psychiatric symptoms and diagnosis in chronic pain patients (1984) Pain 2: 180.

23. Hendler NH. Depression caused by chronic pain (1984) J Clin Psychi 45: 30-36.

24. Hendler, N. Why 40%-80% of chronic pain patients are misdiagnosed and how to correct that, chapter 18, Measuring Pain (2018) Nova Science Publishers, New York 281-292.

25. Tierney J. The case of the United States v. William Eliot Hurwitz (2007) New York Times, New York.

26. Boisaubin EV. The assessment and treatment of pain in the emergency room (1989) Clin J Pain 2: 19-24.

27. Sandhu HS, Sanchez-Caso LP, Parvataneni HK, Cammisa FP Jr, Girardi FP and et al., Association between findings of provocative discography and vertebral endplate signal changes as seen on MRI (2000) J Spinal Disord 13: 438-443.

28. Bogduk N and McGuirk C. Pain Research and Clinical Management (2002) Elsevier, Amsterdam, 119-122.

29. Fishman SM. Pain as the fifth vital sign: how can I tell when back pain is serious (2005) J Pain Palliat Care Pharmacother 19: 77-79.

30. Yi M. Doctor found reckless for not relieving pain: $1.5 million jury verdict for family of cancer patient who went home to Hayward to die (2001) Chronicle, San Francisco, USA.

31. Hendler N, Mollett A, Viernstein M, Schroeder D, Rybock J, Campbell J et al., A comparison between the MMPI and the “Hendler Back Pain Test” for validating the complaint of chronic back pain in men (1985) J Neurol Orthop Med Surg 6: 333-337.

32. Hendler N, Mollett A, Viernstein M, Schroeder D, Rybock J, Campbell J and et al., A comparison between the MMPI and the “Mensana Clinic Back Pain Test” for validating the complaint of chronic back pain in women (1985) Pain 23: 243-251.

33. Hendler N, Mollett A, Talo S and Levin S. A comparison between the MMPI and the “Mensana Clinic Back Pain Test” for validating the complaint of chronic back pain (1988) J Occup Med 30: 98-102.

34. Hendler N, Cashen A, Hendler S, Brigham C, Osborne P, LeRoy P and et al., A multi-center study for validating the complaint of chronic back and limb pain using the “Mensana Clinic Pain Validity Test” (2005) Forensic Examiner 14: 41-49.

35. Hendler N. Validating and Treating the complaint of chronic pain: The mensana clinic approach, in clinical neurosurgery (1989) (ed) P Black, Williams and Wilkens, Baltimore 35: 385-397.

36. Hendler N. An Internet based questionnaire to identify drug seeking behavior in a patient in the ED and office (2017) J Anesth Crit Care Open Access.

37. Davis R, Hendler N and Baker A. Predicting medical test results and intra-operative findings in chronic pain patients using the on-line “Pain Validity Test” (2016) J Anesth Crit Care Open Access.

*Corresponding author: 

Hendler N. Former assistant professor of neurosurgery, Johns Hopkins University School of Medicine, USA, Tel: 443-277-0306, E-mail:


Hendler N. Is The Pain Real or Not (2018) Nursing and Health Care 3: 45-46


Chronic pain, organic pathology, X-ray


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