Resilient – or simply scared?

In a recent discussion with a medic, I suggested that there is a group of people who have ongoing pain that simply don’t seek treatment.  I suggested that these people are resilient – that is, they cope well with adversity, or as Merriam-Webster dictionary says tending to recover from or adjust easily to misfortune or change’.  The medic thought that instead, people who don’t seek treatment might be fearful of being misunderstood, reluctant to be exposed to cognitive behavioural approaches instead of being diagnosed and having their pain removed, or simply unable to ask for help.

I agree there are probably people who have longterm pain who are fearful of being misunderstood, who don’t want to learn to manage their pain and instead sincerely want their pain removed, and yes, there are some who are unable to ask for help.  At the same time I think there are some people who live very well despite their pain, remaining active, enjoying life and accepting that pain is part of life and doesn’t have to get in the way of participating in meaningful activities.

So, how do I know this?  Well there are several studies I can draw on that show pain intensity, duration and treatment seeking don’t always correlate – actually more than several, but a couple I want to cover very briefly today.  The first is a very recent paper by Ingrid Demmelmaier, Per Lindberg, Pernilla Asenlof and Evan Denison (2008).  This is one of a series of papers by these authors located in Uppsala University, Sweden.  In this study, the authors survey 5000 people living in Sweden, aged between 20 – 50 years.  The response rate, as you’d expect in a postal survey, was quite low (39%), but still numbered 1815 and over a thousand of these reported they had experienced nonspecific spinal pain in the previous 12 months.

Using a large number of questionnaire measures, both validated and nonvalidated, and carrying out principle component analysis (take a look here at a great tutorial on PCA if you’re not certain of it), 22 items were analysed, resulting in 8 components with an eigenvalue greater than 1.0.  These were: (1) work satisfaction (2) pain vigilance (3) prevent/decrease pain (4) pain confrontation (5) physically demanding work (6) pain expectations (7) exercise and (8) everyday exercise.

This group of respondents was compared with a Swedish musculoskeletal pain population previously studied (SCB. Disease and healthcare. 1980-2005. Statistics Sweden; 2006).

To summarise, we have two groups of people reporting musculoskeletal pain, one group that has been identified as seeking treatment, and the other group taken from the general population.

What was found?  After controlling for pain intensity, the groups differed in terms of depression, catastrophising, pain expectations, and perceived social support.  Longer pain duration was related to higher levels of catastrophising and pain expectations, and people who had pain longer than 12 months reported lower levels of social support.

In terms of pain duration, two variables were important: catastrophising and pain expectations.  So thinking the worst and expecting pain to continue tend to correlate with long-term pain.  This makes sense to me – if you’ve had pain for a while, you’ll probably expect it to continue! At the same time, research in other groups such as workers and people on sick leave show that low expectations of recovery predict poor recovery.

A surprising result in this study was that pain duration alone was not associated with disability and distress.  This is quite a different finding from other studies where pain duration is related to future disability and distress such as Dunn & Croft (2006), and Kovacs, Abraira, Zamora et al (2005).  The authors of this study suggest that this could be because this group were recruited from a general population rather than a clinical population, or perhaps the study instruments were not as sensitive to participants who were not severely disabled.

In several studies cited by the authors of this work, treatment-seeking is distinguished from experiencing pain (e.g. Mortimer, Ahlberg & MUSIC-Norrtalje group, 2003; Cote, Cassidy & Carroll, 2001).  What is interesting about these two studies is that pain intensity alone did not predict who asked for treatment – instead, high disability did in the MUSIC study (OR 7.4 (CI 5.0 – 11.0) for women, 4.9 (CI 3.3 – 7.1) for men) ( Mortimer, Ahlberg & MUSIC-Norrtalje group, 2003).

In the Canadian study, it was found that ‘disabling neck or back pain, digestive disorders, worse bodily pain and worse physical-role-functioning’ were predictive of seeking help (Cote, Cassidy & Carroll, 2001).

In the general population, Karoly and Reuhlman found that 320 participants in a nationwide sample of 2407 people met their criteria for ‘resilience’ – that is, they had high pain intensity but low interference with their lives.  The resilient people were less likely to use guarding as a coping strategy, and more likely to use positive self-talk and task persistence to maintain focus than those in the non-resilient group.

In addition, those people who were found to be less resilient reported higher levels of  ‘insensitivity’ and ‘interference’ from other people in their lives.

Pain behaviour is a biopsychosocial phenomenon – it’s not surprising that pain intensity, disability, attitudes as well as social interactions are related to whether someone seeks treatment or not. 


Cote, P., Cassidy, D., Carroll, L. (2001). The treatment of neck and low back pain – who seeks care? who goes where? Medical Care (39:9), 956-967.

Demmelmaier, I., Lindberg P., Asnelof, P., Denison, E. (2008). The associations between pain intensity, psychosocial variables and pain duration/recurrence in a large sample of persons with nonspecific spinal pain. Clinical Journal of Pain, 24(7), 611-619.

Karoly, Paul; Ruehlman, Linda S. Psychological “resilience” and its correlates in chronic pain: Findings from a national community sample. Pain. Vol 123(1-2) Jul 2006, 90-97

Mortimer, M., Ahlberg, G. (2003). To seek or not to seek? Care-seeking behaviour among people with low-back pain.  Scandinavian Journal of Public Health, 31(3), 194-203.

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