"Whether you think you can or think you can’t, you’re right."
- Henry Ford
Whether you're recovering from an injury or managing a chronic condition, an often overlooked factor is the role of attitudes and beliefs in your ability to improve. Our attitudes and beliefs factor into everything from our individual experience of pain, to our ability to manage long-standing health conditions. For some time, researchers have known that pain does not relate directly or exclusively to tissue damage. Rather, psychological factors such as the meaning we assign to pain and our attitude regarding our ability to improve also impacts pain perception.1 Beliefs about pain and the desire to avoid pain can also cause us to avoid certain activities, a phenomenon referred to by scientists as “fear-avoidance beliefs.”
If after an injury, or illness you feel that participating in physical activity or doing your daily activities might make your condition worse, you have some fear-avoidance beliefs.2
Furthermore, the level of fear-avoidance that a person demonstrates has been linked to their movement, activity, and long-term improvement (aka health outcomes). Interestingly, it has been shown that there is little relationship between a person’s fear-avoidance beliefs and the severity of pain they report, particularly among people with long-standing pain.3 Other research has shown that in those with recent-onset pain, a decrease in fear-avoidance beliefs can also decrease reported pain and predict decreased disability and improved sense of well-being.4
In other words, people may not avoid activity because of the severity of their pain, but rather because of their fear-avoidance beliefs and desire to avoid pain. Fear of pain can then become a major limiter to a person’s willingness to become or remain active.4
Some have gone so far as to suggest that “the first step to successful rehabilitation may be to overcome mistaken fear-avoidance beliefs.”3 Directly addressing or managing a person’s fear of pain and movement may be an important component of treatment and one that physiotherapists can and should address with all patients.5
After all, physical activity is good for you!
While it’s understandable that you might feel hesitant to get back out there after an injury or illness, it’s important to remember that physical activity might actually benefit you. Regular physical activity has been proven to improve health outcomes, physical abilities and general well-being for people with a wide variety of health conditions including back pain,6 cancer,7 diabetes,8 multiple sclerosis9 and chronic lung disease.10 That doesn’t mean that you should recklessly jump back into an intense exercise routine. It would be wise to follow a gradually progressive physical activity program and monitor your response over time, giving you confidence to continue to stay active.
A person’s belief in their own ability to manage a condition (sometimes referred to as self-efficacy) and their belief in the possibility of achieving a desired outcome have also been shown to be powerful predictors of health outcomes.11
Change your thoughts
Like Mr. Ford said, if you think you can, you’re right! What you believe about your current condition, your ability to manage it, and the likelihood of improvement matters. These beliefs will have a significant impact on your actual improvement in both symptoms and the ability to do the things you want to do.
"Change your thoughts and you change your world."
-Norman Vincent Peale
Similarly, optimism or the “tendency to expect positive outcomes even in the face of obstacles” has been shown to improve both health and well-being.6
Research shows that certain emotions can have a direct impact on your health by affecting the nervous and cardiovascular systems, which in turn alter your blood pressure and heart rate. Suppressing certain emotions can negatively impact these systems as well.13
Some may argue that a person’s emotions, thoughts, beliefs, and attitudes are determined by their personality and are unlikely to change. However, research into positive psychology suggests that an individual’s sense of well-being can be enhanced through the use of interventions aimed at supporting positive feelings, behaviours and thoughts,12 ultimately improving their outlook.
While these approaches have been applied to treat people with mental health concerns (which is beyond physiotherapy practice), the findings are compelling and also apply to the general population.7 Using these strategies to impact a person’s emotions may directly affect their health. Use of positive psychology strategies to develop an increased sense of well-being may also enhance self-efficacy, an important part of self-management of chronic conditions.13 A positive outlook can have an indirect effect by altering your sense of well-being and ability to cope with chronic conditions, making you more confident and engaged in managing your own health.
Work with your health-care provider
Developing an effective “therapeutic alliance” with your physiotherapist can also predict improvement, and an effective therapeutic relationship can help you gain the education and reassurance that’s needed to develop a positive outlook.
Research has found that patient empowerment and self-efficacy can be altered through patient education and effective communication between the patient and his or her health-care provider. For example, when health-care workers directly address patient uncertainty about their condition it can lead to better decision making,14 and help to reduce the patient’s fear and anxiety, enabling them to participate more effectively in their own treatment. Moreover, a positive relationship between patient and health-care provider has been associated with better outcomes.15,16
Whenever possible, patients and physiotherapists should directly discuss the patient’s beliefs and attitudes and work to increase the patient’s sense of self-efficacy to enhance their response to treatment.
- Loranger L. Understanding pain. Available at: https://www.physiotherapyalberta.ca/public_and_patients/the_you_movement_blog/understanding_pain Accessed on October 18, 2016.
- Sindhu BS, Lehman LA, Tarima S, Bishop MD, Hart DL, Klein MR, Shivakoti M, Wang Y-C. Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder. Physical Therapy 2012; 92(8):992-1005.
- Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993; 52:157-168.
- George S, Fritz JM, McNeil DW. Fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: Change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain. The Clinical Journal of Pain 2006; 22(2): 197-203.
- Hart DL, Werneke MW, Deutscher D, George SZ, Stratford PW. Effect of fear-avoidance beliefs of physical activities on a model that predicts risk-adjusted functional status outcomes in patients treated for a lumbar spine dysfunction. Journal of Orthopaedic & Sprots Physical Therapy 2011; 41(5):336-
- Choi BKL, Verbeek JH, Tam WWS, Jiang JY. Exercises for prevention of recurrences of low-back pain.Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD006555. DOI:10.1002/14651858.CD006555.pub2.
- Cheifetz O, Dorsay JP, Hladysh G, MacDermid J, Serediuk F, Woodhouse LJ. CanWell: Meeting the psychosocial and exercise needs of cancer survivors by translating evidence into practice. Psycho-Oncology 2014; 23:204-215.
- Canadian Institute for Health Information. Primary Health Care in Canada: A chartbook of selected indicator results, 2016. Ottawa, ON: CIHI; 2016.
- Latimer-Cheung, A.E.; Pilutti, L.A.; Hicks, A.L.; Ginis, K.A.M;Fenuta, A.M.; MacKibbon, K.A.; Motl, R.W (2013). Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with Multiple Sclerosis: A systematic review to inform guideline development. Archives of Physical Medicine and Rehabilitation; 2013; 94:1800-28.
- Criner GJ, Bourbeau J, Diekemper RL, et al. Executive Summary: Prevention of Acute Excerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest 2015; 147(4):883-893.
- Karademas EC. Self-efficacy, social support and well-being: The mediating role of optimism. Personality and Individual Differences 2006; 40:1281-1290.
- Sin NL, Lyubomirsky S. Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice-friendly meta-analysis. Journal of Clinical Psychology 2009;65(5):
- Danner DD, Snowdon DA, Friesen WV. Positive emotions in early life and longevity: Findings from the nun study. Journal of Personality and Social Psychology 2001; 80(5):804-813.
- Street RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling 2009; 74:295-301.
- Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Physical Therapy 2013; 93(4):470-478.
- Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Physical Therapy, 2010; 90(8):1-12.