Patients who display protective pain behaviors are viewed as less likely to return to work

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If you see someone rubbing his back after lifting something or holding it while moving from a sitting to standing position what are your thoughts? Would you consider that this type of behaviour would influence your rating of a patient’s level of pain and ability to return to work? These types of actions can be described as protective pain behaviours, which refer to the various actions or postural displays that are enacted during the experience of pain. A study by Martel et al (2012) was conducted to examine the influence of protective pain behaviours on observers’ judgements about patients’ pain intensity and readiness to work.

Here’s what they did

A sample of 70 undergraduate psychology students (age range 18-54 years; mean = 23.9 years; SD = 6.4 years) viewed randomly presented video sequences of 24 patients with chronic back pain who agreed to be videotaped while performing a standardised lifting task designed to elicit pain behaviours. Pain behaviour was coded by 2 independent judges based on a pain behaviour coding system. Protective pain behaviours included bodily movements such as guarding, touching, holding, or rubbing.

Participants were first asked to make ratings about the level of pain experienced by the patients depicted in the video sequences and their readiness to return to work. Ratings about patients’ readiness to work were made using an 11-point scale with the endpoints 0 (not ready to work) and 10 (ready to work).

Here’s what they found

office worker holding back grimacing

Patients who present with protective pain behaviours are more likely to be judged as “unready” to work

Results of correlational analyses revealed a significant negative correlation between observers’ ratings of pain intensity and observers’ ratings of readiness to work (r = −0.39, P < 0.005), indicating that higher ratings of pain intensity were related to lower ratings of readiness to work. In other words, patients who were perceived as having high levels of pain were perceived as being less ready to work.

Results indicated that patients’ pain behaviours explained up to 70% of the variance in observers’ ratings of pain, which is consistent with the notion that observers rely heavily on pain behaviours when making judgements about the intensity of others’ pain.

The authors concluded

“The findings suggest that patients who present with protective pain behaviours (e.g. guarding, holding, or rubbing) might be more likely to be judged as “unready” to work than patients who present with other forms of pain behaviour.”

The Musculoskeletal Elf’s view

The Musculoskeletal Elf

One factor that has to be noted is that the study used a sample of undergraduate students, which limits the generalisability of the findings to other populations and settings. Particularly as undergraduate students do not have the same degree of familiarity with respect to judgements about patients’ pain and readiness to work as experienced clinicians.

However, the study’s findings raise an interesting conundrum, as considerable research indicates that protective pain behaviours are only moderately correlated with patients’ self-reports of pain severity. This, therefore, suggests that other factors might also account for the link between protective pain behaviours and occupational disability.

Have you considered how much emphasis you place on patients’ protective pain behaviours? Have you tried to correlate your perceptions of a patient’s level of pain with their self-report on the same? Do you think that if a patient exhibited protective pain behaviours you would advise them to stay off work? 

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community.


Martel, Marc O., Timothy H. Wideman, and Michael JL Sullivan. “Patients who display protective pain behaviors are viewed as less likable, less dependable, and less likely to return to work.” Pain (2012). [PubMed abstract]

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Heather Gray

I am currently the Head of Physiotherapy & Paramedicine at Glasgow Caledonian University and Chair of the Chartered Society of Physiotherapy's Professional Committee. I have worked at the University of Glasgow in several research positions. I am on the Editorial Board of the Journal of Physical Therapy Education. Other work in which I have been involved is as an Educational Consultant with NHS Education for Scotland. Prior to moving into academia I worked in the National Health Service (NHS) in Scotland as a physiotherapist for 11 years.

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