302 Pain Management
3.Verbal persuasion by others.
4.Perception of a state of physiological arousal, which is in
turn partly determined by prior ef“cacy estimation.
Performance mastery experience can be created by en-
couraging patients to undertake subtasks that are initially at-
tainable but become increasingly dif“cult, and subsequently
approaching the desired level of performance (Dolce et al.,
1986). In a quota-based physical therapy system, the initial
goal is set below initial performance to increase performance
mastery. It is important to remember that coping behaviors
are in”uenced by the person•s beliefs that the demands of a
situation do not exceed their resources. For example, Council
et al. (1988) asked patients to rate their self-ef“cacy as well
as expectancy of pain related to performance during move-
ment tasks. Patients• performance levels were highly related
to their self-ef“cacy expectations, which in turn appeared to
be determined by their expectancies regarding levels of pain
that would be experienced.
Catastrophic Thinking
Catastrophizing„experiencing extremely negative thoughts
about your plight and interpreting even minor problems as
major catastrophes„appears to be a particularly potent way
of thinking that greatly in”uences pain and disability. Several
lines of research have indicated that catastrophizing and
adaptive coping strategies are important in determining a per-
son•s reaction to pain (Sullivan et al., 2001). People who
spontaneously used more catastrophizing thoughts reported
more pain than those who did not catastrophize in several
acute and chronic pain studies.
Coping
Self-regulation of pain and its effects depends on the individ-
ual•s speci“c ways of dealing with pain, adjusting to pain,
and reducing or minimizing pain and distress caused by pain;
in other words, their coping strategies (DeGood & Tait,
2001). Coping is assumed to be implemented by sponta-
neously employed purposeful and intentional acts, and it can
be assessed in terms of overt and covert behaviors. Overt, be-
havioral coping strategies include rest, medication, and use
of relaxation. Covert coping strategies include various means
of distracting yourself from pain, reassuring yourself that the
pain will diminish, seeking information, and problem solv-
ing. Coping strategies act to alter both the perception of in-
tensity of pain and your ability to manage or tolerate pain and
to continue everyday activities.
Studies have found active coping strategies (efforts to
function in spite of pain or to distract oneself from pain, such
as activity, or ignoring pain) to be associated with adaptive
functioning, and passive coping strategies (depending on oth-
ers for help in pain control and restricted activities) to be re-
lated to greater pain and depression (Boothby, Thorn, Stroud,
& Jensen, 1999). However, beyond this, there is no evidence
supporting the greater effectiveness of any one active coping
strategy compared to any other (Turk, Meichenbaum, & Gen-
est, 1983). It seems more likely that different strategies will
be more effective than others for some people at some times
but not necessarily for all people all of the time.
A number of studies have been demonstrated that if pa-
tients are instructed in the use of adaptive coping strategies,
their rating of intensity of pain decreases and tolerance of
pain increases (Boothby et al., 1999). The most important
factor in poor coping appears to be the presence of cata-
strophic thinking, not the nature of speci“c adaptive coping
strategies (Sullivan et al., 2001).
Given our discussion of the psychological factors that play
a role in pain, we can now consider how these factors can be
integrated within a multidimensional model of pain. Pain is a
complex subjective phenomenon comprising a range of fac-
tors, each of which contributes to the interpretation of noci-
ception as pain. Thus, each person uniquely experiences pain.
A signi“cant factor contributing to the current situation re-
lates to diagnostic uncertainty. The diagnosis of pain is not an
exact science. A major problem in understanding pain is that
it is a subjective (internal) state. There is nopain thermometer
that can accurately measure the amount of pain a person feels
or should be experiencing.
An integrative model of chronic pain and acute recurrent
pain needs to incorporate the mutual interrelationships
among physical, psychosocial, and behavioral factors and the
changes that occur among these relationships over time. A
model that focuses on only one of these sets of factors will
inevitably be incomplete. The physiological model proposed
by Melzack and Wall (1965) can be contrasted with the more
psychological, cognitive-behavioral (biobehavioral) model
that Turk and colleagues (Turk, 1996; Turk & Flor, 1999)
have proposed. Melzack and Wall focus primarily on the
basic anatomy and physiology of pain; whereas, Turk and
colleagues have emphasized the in”uence of psychological
processes on physical factors underlying the experience of
pain. Yet both incorporate physical and psychological factors
to account for the experience of pain.
The biopsychosocial model presumes some form of phys-
ical pathology or at least physical changes in the muscles,
joints, or nerves that generate nociceptive input to the brain.
At the periphery, nociceptive “bers transmit sensations that
may or may not be interpreted as pain. Such sensation is
not yet considered pain until subjected to higher order psy-
chological and mental processing that involve perception,