I’m taking a tiny detour from the world of catastrophising – but only a tiny one because catastrophising is associated with greater levels of pain behaviour, and of course, discussion about pain behaviour is how I came to begin my exploration of catastrophising anyway!
There have been several schools of thought, or models of treatment, for people with pain. While the current focus and the one over the past five to ten years or so has been strongly cognitive in focus (let’s help people understand their thoughts about pain and how these influence emotions and subsequently affect behaviour), well before then in the origins of pain management, a behavioural approach dominated. Wilbert Fordyce is credited with developing the first pain management programme based on modifying what people do in response to pain rather than working to reduce pain itself. (Here’s a link to one of his papers)
I’m a bit of a fan of behavioural approaches because to me the true test of a treatment is whether the person begins to do “normal” things again – go out and have fun, return to work, be with family and so on. They also seem to be effective – for example, graded exposure is very effective for pain-related anxiety and avoidance.
In this study by Martel, Thibault and Sullivan (2010), people with back pain were recorded on two separate occasions (on averge 22 days apart) while carrying out two lifting tasks designed to elicit pain behaviours. These recordings were reviewed by trained observers who recorded the number of pain behaviours in each segment of film using a standardised coding scheme (developed by Keefe and Block, 1982). Participants in the lifting tasks also completed a range of questionnaires – the Tampa Scale for Kinesiophobia, the McGill Pain Questionnaire, and the Pain Catastrophising Scale.
Before I describe the findings, in this study two different forms of pain behaviour were identified – communicative behaviours are things like grimacing, speaking, sighing, moaning and so on; while protective behaviours are things like guarding, holding, touching, or rubbing.
What the researchers found was that pain behaviours are pretty stable irrespective of sex, pain severity or psychological characteristics, but that different forms of pain behaviour demonstrated different degrees of stability.
- Pain behaviours identified as primarily about communicating were more stable from time one to time two than those identified as being mainly about protecting the body part.
- Women’s protective pain behaviour varied more than men’s protective pain behaviour, while both men and women demonstrated stable communicative pain behaviour.
- Pain severity and the number of pain behaviours varied consistently – but, interestingly, individuals with higher levels of pain behaviour at time one also demonstrated higher levels of pain behaviour at time two irrespective of pain intensity.
- Significant positive relationships were found between psychological variables such as catastrophising and fear of movement and pain behaviours. Even more interesting was that even when changes in catastrophising and fear of movement reduced over time, pain behaviours remained consistent.
What do these findings mean?I think they suggest that giving information, educating or even working hard on cognitive aspects of coping may not change the behaviours that signal to other people “Hey! I’m sore!”.
This could be because of long-standing motor patterns that take a while to change, or actually need to be deliberately replaced with new or different patterns.
It could also be because behaviours are reinforced by other people – and as a result of intermittent reinforcement being so effective at strengthening behaviour, pain behaviours may persist.
Whatever the underlying reason for this finding, I’m sure we need to direct our focus more on specifically addressing pain behaviours in the future.
Martel, M., Thibault, P., & Sullivan, M. (2010). The persistence of pain behaviors in patients with chronic back pain is independent of pain and psychological factors Pain, 151 (2), 330-336 DOI: 10.1016/j.pain.2010.07.004