Specific fears of hurting, harming, and further injury

Since the early-mid 1990s, there has been an increasing research focus on the role of fear and avoidance in the development and maintenance of disability, (Leeuw et al. 2007). Among people with chronic low back pain, pain-related fear has been found to be associated with reduced lumbar flexion (Geisser et al. 2004) and pain-related fear and pain catastrophizing have been found to be stronger predictors of overall disability than pain intensity. One study found that pain- related fear was also the strongest predictor of performance (van den Hout et al. 2001). However in acute low back pain only modest correlations between pain intensity, pain-related fear, avoidance behaviour and disability have been detected (Sieben et al. 2005) and more general perceptions about illness may also be influential (Foster et al. 2009).

Self-efficacy beliefs

According to self-efficacy theory, once a situation has been perceived as involving harm, loss, threat, or challenge and individuals have considered a range of coping strategies open to them, what they do will be dependent on what they believe they can achieve (Bandura, 1977). Asghari and Nicholas (2001) have shown that 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. Taken together, clinical and experimental investigations suggest that perceived coping inefficacy may lead to preoccupation with distressing thoughts and concomitant physiological arousal, thereby increasing pain, decreasing pain tolerance and leading to increased use of medication, lower levels of functioning, poorer exercise tolerance, and increased invalidism.

Such beliefs therefore would seem to have considerable potential as targets within clinical management.

Self-efficacy has been found to account for the greatest proportion of variance in physical performance even after anticipated pain and re-injury have been excluded although pain intensity was also a significant (albeit limited) predictor of performance (Lackner et al. 1996). Thus expectancies of harm and pain catastrophizing, rather than being primary causal determinants of function, may be components of one’s confidence of successful task performance (Nicholas 2007). Treatment recommendations derived from this interpretation emphasize the importance of goal and quota setting, and monitoring of pain and task performance as components of pain management and as such fit well within modern pain management and suggest further specific targets for advice and education.

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