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The Role of Psychosocial Aspects and Beliefs in Chronic Pain

The following presents some of the key points from my readings into the role of psychosocial aspects and beliefs in chronic pain. It is interesting to see that psychosocial aspects appear to be  far more important in predicting recovery (or non-recovery) from back pain than other “biomedical” measures.

I have previously posted regarding co-morbidities and the importance of screening for them as part of our examination and how they can play a part in prognosis and treatment.

As per previous posts, please see the references for further details/information.

Gatchel et al (2007)

  • Approximately two thirds of chronic nonspecific low back-pain sufferers avoid back straining activities because of fear of re-injury.
  • Pain-related fear was the best predictor of behavioral performance in trunk-extension, flexion, and weight-lifting tasks.
  • Fear of movement and (re)-injury was the best predictor of self-reported disability among chronic back-pain patients.
  • Pain-related fear and concerns about harm avoidance all appear to exacerbate symptoms.

Chou and Shekelle (2010)

  • The most helpful baseline predictors of persistent disabling low back pain included:
    • Maladaptive pain coping behaviours
    • Non-organic signs
    • Functional impairment
    • Low general health status
    • Presence of psychiatric comorbidities.
  • In contrast, low levels of fear avoidance and of functional impairment predicted recovery at 1 year.

Main et al (2010)

  • Beliefs about the extent to which pain can be controlled appear to be among the most powerful determinants of adjustment to pain or the development of incapacity.
  • Pain-related fear and pain catastrophising have been found to be stronger predictors of overall disability than pain intensity.
  • Pain self-efficacy beliefs are an important determinant of pain behaviours and disability associated with pain, over and above the effects of pain, distress and personality variables.
  • In general, those who believe more strongly that their pain means they should avoid physical activities and abandon normal roles report higher levels of disability than those with opposite beliefs.
  • Positive attitudes towards treatment and confidence in benefit from specific treatments have been shown to lead to a two to fivefold greater likelihood of improvement, although this finding is not consistent across all studies.
  • In addition, general outcome/recovery expectations, irrespective of treatment, have been shown to influence outcome.
  • Patients with very low baseline recovery expectations were 3 times more likely to be off work at 6 months.
  • Patients’ who expect their back pain to last a long time, who perceive serious consequences and who hold weak beliefs in the controllability of their back problem are more likely to have poor clinical outcomes 6 months after consultation.

Leeuw et al (2012) 

  • Pain catastrophizing has been linked to:
    • Pain-related fear, disability, pain intensity, depression, and psychological distress.
    • Amplified pain experiences and disability, back pain chronicity, and inception of LBP in pain-free workers.
  • Fear of movement/(re)injury is more strongly related to decreased performance on behavioural tasks, disability in daily life situations, and work loss, than biomedical symptoms and pain severity.
  • Fear avoidance beliefs are related to subsequent inception of LBP in pain-free people and course of LBP.

Nijs et al (2012)

  • Patients’ perceptions that the problem will last long, that many symptoms are related to their back problem, their weak beliefs about self-control and low confidence in their own ability to perform activities despite the pain, are even better predictors of disability at 6 months than fear avoidance, catastrophizing or depression.
  • Factors like pain catastrophizing, self-efficacy, depressive thoughts and physical inactivity are important psychosocial factors known to perpetuate chronic musculoskeletal pain.

Hallegraeff et al (2012)

  • The odds that adults with acute or subacute non-specific low back pain and negative recovery expectations will remain absent from work due to progression to chronic low back pain are two times greater than for those with more positive expectations.

Balague et al (2012)

  • Findings from other reports suggest that, within 3 weeks of the onset of non-specific low back pain, low recovery expectations can identify people at risk of a poor functional outcome up to 6 months later.
  • The strongest risk factor for future low back pain being previous low back pain.

O’Sullivan (2012)

  • Disability levels are more closely associated with cognitive and behavioural aspects of pain rather than sensory and biomedical ones.
  • Positive outcomes in randomised controlled trials (RCTs) are best predicted by changes in psychological distress, fear avoidance beliefs, self-efficacy in controlling pain and coping strategies.

 All of the above information continues to show how important it is that we assess and manage our patients in a biopsychosocial framework. In particular I think it imperative that we:

  • Explore patients beliefs, thoughts and emotions regarding their injury.
    • Use questionairres when needed. For example:
      • Orebro Musculoskeletal Pain Screening Questionairre
      • Brief Illness Perception Questionairre
  • Educate the patient regarding the effects their beliefs, thoughts and emotions can have on their pain and activity.
  • During the patient encounter the therapist should endeavor to:
    • Listen
    • Show empathy
    • Provide encouragement, hope and confidence
    • Use goal setting to encourage self efficacy

The above list could go on and on, my point being how important these skills are given the information presented earlier in this post.

Having said the above it is also important that we remember the “bio” in biopsychosocial. Edwards and Jones (2012) make the following important points:

  • Both foci of reasoning, “diagnostic” attending to patho-anatomical, movement and control features of the patient’s presentation, and “narrative” attending to the patient’s pain/disability experience (i.e. perspectives and emotions related to the lived experience of their problem), are essential to fully understand the problem and the person.
  • One can hardly understand a patient’s perspectives (e.g. beliefs, fears, anxiety) regarding their problem(s) without knowledge of their physical health and function, and similarly knowledge of patient perspectives (i.e. psychosocial) can be critical to understanding predisposing factors to the development and maintenance of problems while also highlighting areas of patient understanding and behaviour important to address to optimise self-management and minimise recurrence.
  • ……….to determine the contribution each has to the overall presentation and the effect each has on the other we need to be able to move between the physical and the psycho-social in our enquiry, reasoning and management and not ‘camp’ at one place or another.


Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91.

Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010 Apr 7;303(13):1295-302.

Edwards I, Jones M. Movement in our thinking and our practice, Manual Therapy (2012),

Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007 Jul;133(4):581-624.

Hallegraeff JM, Krijnen WP, van der Schans CP, de Greef MHC. Expectations about recovery from acute non-specific low back pain predict absence from usual work due to chronic low back pain: a systematic review. Journal of Physiotherapy 2012;58:165–72.

Leeuw M, Houben RM, Severeijns R, Picavet HS, Schouten EG, Vlaeyen JW. Pain-related fear in low back pain: a prospective study in the general population. Eur J Pain. 2007 Apr;11(3):256-66.

Main CJ, Foster N, Buchbinder R. How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Pract Res Clin Rheumatol. 2010 Apr;24(2):205-17.

Nijs J, Roussel N, Paul van Wilgen C, Köke A, Smeets R. Thinking beyond muscles and joints: Therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther. 2012 Dec 28. pii: S1356-689X(12)00244-5.

O’Sullivan P. It’s time for change with the management of non-specific chronic low back pain. Br J Sports Med. 2012 Mar;46(4):224-7.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

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