Black Americans report more intense and disabling pain than White Americans, but differences in pain behavior have rarely been studied. The Structured Pain Behavior Test (SPBT), a standardized, video-recorded series of pain-inducing movements, assesses the behavioral expression of pain. We conducted the first test of whether Black Americans with chronic low back pain (CLBP) have greater pain behavior and increased self-reported pain intensity during the SPBT, compared to White Americans. Adults ( N  = 267) with CLBP (174 Black, 93 White; 57% female) rated their clinical pain severity and interference (Multidimensional Pain Inventory; MPI) and their current pain intensity (Numerical Rating Scale; NRS) both before and after engaging in the SPBT, which was coded for observed pain behavior. Consistent with prior research, Black participants reported greater MPI clinical pain severity and interference (large effect). More importantly, during the SPBT, Black participants had greater pain behavior (medium effect) and reported a greater increase in pain intensity (NRS; small-medium effect) than did Whites. Racialized differences in all pain measures remained significant after controlling for multiple variables (including depressive symptoms and pain catastrophizing), and differences in observed pain behavior remained after also controlling for self-reported pain intensity (NRS) or MPI clinical pain severity. We conclude that greater self-reported pain severity and interference among Black Americans is accompanied by greater pain behavior and increased pain intensity in response to pain-inducing movements. Research should examine possible mechanisms of this racialized difference, including differential access and care, racism as pain exacerbator, and the social communication of pain.

Black Americans with chronic back pain have greater self-reported pain severity than White Americans and greater pain behavior during the Structured Pain Behavior Test, even after controlling for self-reported pain and other variables. Black Americans’ elevated pain may reflect poorer health care, racism-induced pain exacerbation, and/or social communication of need.