Pain behaviours persist…
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


  1. Hi All

    This post is interesting (as are all previous) one. If pain persisits and the goal of therapy is to increase particiaptiona nd start enjoying life again etc, then why would people also want to decrease their pain behaviour and let others know they still find the pain difficult.

    I couldnt help thinking a a pain inservice I went to in a few years ago that successful interviensions would meant he client stopped using pain behavours and got on with life, not becasue they didint have any pain but because it would make it easier for others to be around them.

    Just a thought

    Cheers Maree

    1. I hope I’m reading your comment correctly – if I don’t, let me know! As I interpret what you’ve said, you think that if people start doing things, they might want to retain pain behaviours so that others can still be aware they have problems with pain?
      I think it’s helpful to work on reducing pain behaviours mainly because pain behaviours can in themselves limit participation (just try walking with a limp or holding your arm closely, moving slowly or tensing your back muscles deliberately!). People on the pain management programme clearly identify that other people treat them “differently” because of their pain behaviour – and that this means they can be identified as “that woman/man with pain” rather than “Jane” or “Jack” or whatever. Yes, it’s probable that other people would find it easier to be around them if they stopped using pain behaviours – but as you’ve pointed out, minimising pain behaviours doesn’t mean the pain is gone at all!
      I guess it’s worth thinking about: does a person want to be known by their diagnosis or functional limitations, or by who they are? Our tack is to ask the participants to reflect on the “good” and “not so good” of demonstrating pain behaviours (and also talking about their pain) and let them arrive at their own decision. Given that many of them are unaware of the degree to which they do pain behaviours, they can be quite surprised at how easily other people can identify what they do – and the effect that has on their interactions.

      1. The question about how people perceive you is such an important one! I struggled with it a lot when I started using a cane, which of course very visibly identifies me as a person with some sort of problem/disability. I don’t know if it counts as “pain behavior”, but it seems like it may be ;-)The reason I use it is because it triples my standing/walking time, defined as “the amount of time I can stand or walk before I experience serious consequences such as limping or drastic pain increases lasting for many days in a row”. I guess the deciding bit for me was that people reacted to my cane better than to my limping. Limping, by the way, is an uncontrollable body reaction for me – when it starts, I hate it, but cannot actually do much about it no matter what I try. And I did notice that it frightened people about me, because they tended to assume that I must be in very severe pain to limp like that.

        Anyway, I did find that using a cane also changes the reactions that I get from some people, who tend to over-react and unintentionally exclude me though making assumptions about what I can or cannot do. But I also discovered that sometimes I don’t mind. A good example would be a crowded shop or airport – I got a lot more nasty looks and outright pushes from people in a hurry whose way I was blocking with my slow progress than I do when I have a cane as a visible indicator of a problem.

        So I guess I am choosing one pain behavior over another here 😉 But as using a cane also made specific and very noticeable improvements to what I can do (e.g., deliver a presentation without experiencing a multi-day flare-up), I decided to put up with the changed interactions with some people…

      2. It’s definitely an individual and personal matter, I think – and only you can weigh up the costs and benefits, while as health professionals all we can do is provide options and help people consider the unintended costs (usually delayed consequences that only show up gradually). I just hope your cane isn’t fluorescent pink or something!! Although one person I know used one of those hiking sticks that was a pretty impressive Kermit green!

      3. Well, not fluorescent pink 😉 But it has a pretty enough color and pattern that people comment on it occasionally, and a couple of times actually took it for some strange accessory rather than a mobility aid, which suits me just fine 😉

  2. Hi,
    I think I’m a little confused. cognitive behaviour therapy attempts changing behaviours by educating people to change their beliefs, attitudes and therefore behaviours. What is different here? are we just working on changing behaviours by constant reminders not to do the same behaviour? I think I am missing some part but I have not yet read the articles. maybe I will understand better then. Very interesting material. I really like your posts

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