Rehabilitation Research and Practice

Volume 2012 (2012), Article ID 206263, 9 pages

doi:10.1155/2012/206263

Clinical Study

The Relationship between Beliefs about Pain and Functioning with Rheumatologic Conditions

Tracey Pons,¹ Edward Shipton,¹ and Rodger Mulder²

¹Department of Anaesthesia, University of Otago, P.O. Box 4345, Christchurch 8140, New Zealand

²Department of Psychological Medicine, University of Otago, P.O. Box 4345, Christchurch 8140, New Zealand

Received 6 March 2012; Revised 12 April 2012; Accepted 29 April 2012

Academic Editor: K. S. Sunnerhagen

Copyright © 2012 Tracey Pons et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Pain beliefs influence understanding of pain mechanisms and outcomes. This study in rheumatologic conditions sought to determine a relationship between beliefs about pain and functioning. Participants in Arthritis New Zealand’s (ANZ) exercise and education programmes were used. Demographic data and validated instruments used included the Arthritis Impact Measurement Scale 2nd version-Short Form (AIMS2-SF) to measure functioning, and two scales of organic and psychological beliefs in Pain Beliefs Questionnaires (PBQ) to measure pain beliefs. 236 Members of ANZ were surveyed anonymously with AIMS2-SF and PBQ, with a 61% response rate; 144 responses were entered into the database. This study used α of 0.05 and a 1-β of 0.8 to detect for significant effect size estimated to be . Analysis revealed a significant relationship between organic beliefs scale of PBQ and functioning of AIMS2-SF, with an value of 0.32 and value of 0.00008. No relationship was found between psychological beliefs scale of PBQ and AIMS2-SF. Organic pain beliefs are associated with poorer functioning. Psychological pain beliefs are not. Beliefs might have been modified by ANZ programmes. Clinicians should address organic pain beliefs early in consultation. Causal links between organic pain beliefs and functioning should be clarified.

1. Introduction

Beliefs about pain are an emerging area of research in the biopsychosocial model of pain. Research shows that negative pain beliefs have a detrimental impact on patients’ overall health, self-efficacy, and function [1]. With the intervention of a self-management programme of exercise and relaxation for arthritis sufferers, positive changes from negative pain beliefs correlate with improvement in self-efficacy, [2]. The experience of pain is a significant problem in sufferers with rheumatoid arthritis; it has been recently shown to be an important predictor for psychosocial health in general [3]. Furthermore, for rheumatoid arthritis, both the extent of the disease and the belief that pain could be capably managed have been found to impact on functioning [4, 5].

Beliefs have been defined as personally or culturally shared cognitive configurations [6]. These differ from attitudes that are defined as feelings about events. Beliefs are thoughts or mental appraisals and understanding of these events. These form the preexisting concepts about the nature of reality for the individual. These thoughts may be generalised or specific to certain contexts, mould the individual’s perception of the environment, and shape the meaning of their experiences [7].

These thoughts can positively influence beliefs about the pain experience if, as perceived, there is control in managing the pain experience, confidence that the extent of harm and associated disability are not threatening, and expectations of recovery [8]. These thoughts can negatively influence beliefs about the pain experience if, as perceived, control is threatened and recovery is not possible [9]. The consequence can be emotional distress and catastrophising, as well as excessively negative and pessimistic beliefs and thoughts about the pain experience. Specific pain beliefs that contribute to poor compliance, motivation, and misunderstanding about pain have been identified [10]. These include catastrophising, limited perception of control over the pain experience, and emotional distress. Catastrophising has been shown to be associated with persistent pain; it is a predictor of poor outcomes in pain management interventions [5, 11]. Although catastrophising and emotional distress have common characteristics, it is difficult to separate them in the direction of effect. Thoughts about pain affect physical functioning and contribute to disability; physical functioning is predicted by the beliefs of physical capabilities and not by the experience of self-reported pain [12–14].

There is evidence that addressing negative pain beliefs in the management of persistent pain can affect treatment outcomes [4, 5, 15]. Negative pain beliefs can contribute to the transition from acute pain to persistent pain [6, 10].

It has been suggested that beliefs about persistent pain have two dimensions. These include organic pain beliefs (referring to the physiological pain experience indicating physical harm or threat to well-being) and psychological pain beliefs (referring to the internal influences and feelings affecting the experience of pain that can potentially threaten well-being); these dimensions are considered to accurately reflect the general population’s perception of the pain experience [16]. Both of these can potentially influence the beliefs about pain control either positively (having personal control over the pain experience) or negatively (feeling helpless to manage the potential threat to their well being).

The aim of this study was to determine the relationship between functioning and pain beliefs in patients with musculoskeletal pain or rheumatologic conditions. The primary hypothesis is that a relationship exists, whereby beliefs about persistent pain are associated with functioning. It is expected that a low score (less negative beliefs about pain) of the Pain Beliefs Questionnaire (PBQ) will be associated with better functioning in the Arthritis Impact Measurement Scale, second version, short form (AIMS2-SF). Likewise it is expected that a high score (greater negative beliefs about pain) of the PBQ will be associated with poorer functioning in the AIMS2-SF. The null hypothesis is that any observed relationship is simply due to chance.

2. Materials and Methods

Members of Arthritis New Zealand (ANZ) who attended an exercise class, an individual education session with an ANZ Educator, or an education seminar were asked to voluntarily complete an anonymous questionnaire containing 72 questions. All 236 members taking part in the above activities were personally approached to participate in the study. Data was collected over six months, from 01 May 2010 to 31 October 2010. Care was taken to ensure that no participant answered a questionnaire twice. Most returned the answered questionnaire by mail in a preaddressed stamped envelope. Two participants declined to take part in the study and were not issued with a questionnaire. Eighty-two participants responded as willing to participate, were issued with questionnaires, but did not return them. Ten questionnaires were returned with less than half completed; these participants had missed out the middle pages as they filled them in. These were not entered into the database. Only if more than 50% of the questionnaire had been completed was it entered into the database. A total sample of 144 participants completed the questionnaires (a response rate of 61%). A flow chart (Figure 1) shows the details of the data collection.

Figure 1: Flow chart: Method of data collection.

ANZ is a national voluntary organisation representing those with formal rheumatologic diagnoses. It functions as a charitable trust with modest government funding. Activities include member education on arthritis and pain management, exercise classes, and seminars [17]. Ethical approval was obtained from the Upper South Island A Regional Ethics committee (reference number URA/10/04/026). The process followed in this study was in accordance with the Helsinki Declaration of 1975, as revised in 1983.

The questionnaires consisted of the PBQ and the AIMS2-SF. In addition further questions were asked about the following: gender; duration of pain experience; age; number of months of physiotherapy intervention; type and frequency of regular exercise; enjoyment and confidence with exercise; ability to stop exercise; previous physical and athletic ability; anger about pain; duration of membership with ANZ; ethnicity (as defined by Statistics New Zealand) [18], education level; rheumatologic diagnosis; number of months off work; smoking habit; medication use.

2.1. Instruments to Measure Beliefs about Pain

Several questionnaires are used to measure the beliefs about pain. The Pain Beliefs Questionnaire (PBQ) is a validated and reliable questionnaire that taps into the two dimensions of pain beliefs (organic and the psychological beliefs) and was developed to describe these beliefs about pain [16, 19, 20]. It was chosen for this study as it allowed for differentiation between these two separate dimensions of pain beliefs, was easy to administer, and was not time consuming or lengthy for patients. The questions of the PBQ are listed in Table 1.

Table 1: PBQ organic and psychological pain beliefs of the PBQ.

Organic pain beliefs

    Persistent pain is the result of damage to tissues of the body

    Physical exercise makes the persistent pain worse

    It is impossible to do much for oneself to relieve persistent pain

    Persistent pain is a sign of illness

    Experiencing persistent pain is a sign that something is wrong with the body

    It is impossible to control your own persistent pain

    Being in persistent pain prevents you from enjoying hobbies and social activities

    The amount of persistent pain is related to the amount of damage

Psychological pain beliefs

    Being anxious makes persistent pain worse

    Thinking about persistent pain makes it worse

    When relaxed persistent pain is easier to cope with

    Feeling depressed makes persistent pain seem worse

The internal consistency of each scale of the PBQ has been shown to be 0.73 for the organic scale and 0.70 for the psychological scale [16]. A Likert scale of 1–5 was used to measure each question. The organic scale consists of eight questions; these measure the extent of the belief that that personal control of the pain is impossible (due to physical harm or injury believed to be associated with the pain experience). The psychological scale consists of four questions; these measure the extent of the belief that personal control of the pain is linked to the emotional feelings about the pain experience. The higher the summed score on the PBQ, the greater is the belief that harm and emotional feelings negate personal control of the pain experience.

There are other seven questionnaires that measure beliefs about pain; these were excluded, as they were either too lengthy, not specific to rheumatologic conditions, or outside the domain of this study. They were as follows: the Illness Perceptions Questionnaire (revised) [21]; the Back Beliefs Questionnaire [22]; the Fear Avoidance Beliefs Questionnaire (FABQ) [23]; the Survey of Pain Attitudes (SOPA) [24]; the Pain Beliefs and Perceptions Inventory (PBAPI) [25]; the Pain Cognitions Questionnaire [26]; the Cognitive Risk Profile [27].

2.2. Instruments to Measure Functioning

Research has shown that self-report questionnaires are valid measures for the assessment of functioning [28]. There are a wide variety of functioning measures that can be determined using questionnaires. The AIMS2-SF questionnaire was chosen for this project as (i) it is appropriate for the population sample of rheumatologic conditions; (ii) it is an instrument that measures upper limb, lower limb, and whole body functional movements (unlike most other instruments that do not); (iii) it is a suitable and reliable instrument for measuring disability in personal care for those suffering rheumatologic conditions [29]; (iv) the shortened version of the revised AIMS2 has been validated and is reliable with similar psychometric properties; it is easy to administer and is useful for assessing functioning status with other persistent conditions besides arthritis [30]. The AIMS2-SF is appropriate to use in this study, as it is symptom specific as well as able to reliably enquire about the broader areas of functioning.

The AIMS2-SF was developed in concordance with the World Health Organisation’s (WHO) International Classification of Functioning, Disability, and Health (ICF) [31] and has been widely used for measuring functioning in rheumatologic diseases [29, 32–34]. The scale includes a broad domain of functional ability with the combination of the five second-order scores. The second-order scores consist of (i) physical aspects (mobility level, walking, bending, arm/hand/finger function, self-care, household tasks); (ii) affect (level of tension and mood); (iii) self-reported pain; (iv) social interaction (social activity, support from family); (v) work.

The Health Assessment Questionnaire is another instrument applied to measuring functioning in rheumatologic conditions [35–37]. It was not chosen for this study as the AIMS2-SF covers broader areas of functioning, including work and affect. Fourteen other possible questionnaires considered for this study were excluded; the reasons for this varied. For example, they were not inclusive of both upper and lower limb functioning, addressed back pain only, addressed pain experiences as “sickness,” or restricted the age group involved. These other questionnaires were as follows: the Oswestry Disability Index [38, 39]; the Roland Morris Disability Scale [40]; the Acute Low Back Pain Screening Questionnaire [41, 42]; the Vermont Disability Prediction Questionnaire [42]; the Screening Questionnaire for predicting outcome in acute and subacute back pain [42]; the Orebro Musculoskeletal Pain Questionnaire [43, 44]; the Chronic Pain Coping Inventory [45]; the International Physical Activity Questionnaire [46]; the Pain Disability Index [47]; the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) [48]; the Sickness Impact Profile [49–51]; the Physical Activity Scale for the elderly (PASE) [52]; the Quebec Back Pain Disability Scale [53]; the Functional Disability Inventory [54].

The factorial validity of the AIMS2-SF has been verified [29]. The higher the total summed AIMS2-SF score, the poorer the functioning. The highest possible score is 120; this indicates exceptionally poor functioning. Such a person is highly dependent on assistance for all daily activities, has a high pain experience, and has low mood and poor social support. On the other hand, a low score indicates greater functioning with both upper and lower limbs, with whole body tasks, and with independence.

2.3. Analysis

The analysis for this study was to use simple linear regression between the sum of the AIMS2-SF and the sum of each of the two scales of the PBQ. This study used an α of 0.05, and a 1-β of 0.8 to detect for significant effect size, estimated to be .

3. Results

3.1. Demographic Data

A sample of 122 participants had been calculated for the effect size “” of 0.25 [55]; 144 responses (61% response rate) were entered into Statistica 9 for statistical analysis. The demographic data for all participants is summarised in Table 2 as predominant percentages of the full data set.

Table 2: Demographic predominant percentage data.

Ethnicity
NZ European 88%

Diagnosis
Osteoarthritis 36%

Rheumatoid arthritis 17%

Fibromyalgia 15%

Unknown 13%

Polymyalgia rheumatica 8%

Gender
Female 85%

Age
Mean: 65 years

Std Dev 11 years, 8 months

Highest recorded data: 91 years

Lowest recorded data: 22 years

Educational level
School only, 55%

Physiotherapy intervention for pain
54%

Membership with ANZ within last 3 years
61%

Smoking
93% non smokers

Time off work because of pain experience
32%

Number of years with pain
51% greater than 8 years

Mean: 130 months (almost 11 years)

Std dev: 125 months (10.4 years)

Highest recorded data: 55 years

Lowest recorded data: 2 months

The mean age of the participants was 65 years (SD 11 years, 8 months). Eighty-five per cent of the participants were females. The mean for participants’ duration of pain experience was 130 months (almost 11 years of pain). The standard deviation remained large. Most participants in this study were new members of Arthritis New Zealand (ANZ) where 61% of participants had joined the organisation in the past three years.

Eighty-eight per cent of all participants were classified as New Zealand European/Pakeha. The predominant group (36%) suffered from osteoarthritis. Other diagnoses included rheumatoid arthritis (18%), fibromyalgia (15%), no diagnosis given (12%), “undefined” arthritis (7%), inflammatory arthritis (2%), and temporal arteritis, systemic lupus, and other diagnoses (1%). Fifty-five per cent of participants received no formal qualification other than schooling.

3.2. Questionnaire Data for Primary Hypothesis Testing

3.2.1. AIM2-SF Scores

The AIMS2-SF has second-order scores consisting of (i) physical aspects (mobility level, walking, bending, arm/hand/finger function, self-care, household tasks); (ii) affect (level of tension and mood); (iii) self-reported pain; (iv) social interaction (social activity, support from family); (v) work. Each of these second-order scores was summed and correlated with the organic scale of the PBQ. The highest correlation was found with the work subscale, and . The physical activity, affect and pain experience correlated similarly with and . However social activity had a high correlation, but with no significance . This data is outlined in Table 3.

Table 3: Second-order AIMS2-SF scales and correlation with PBQ organic scale.

AIMS2-SF subscale
Mean
Std dev
Median
Correlation with PBQ organic scale
(linear fit)

Physical activity
295.2
42.3
297

Affect
10.8
4.2
10

Pain
9.8
2.8
10

Social
11.5
2.9
12

Work
3.1
1.7
2

The participants showed a reasonable distribution of summed AIM2-SF scores. A higher score is associated with a poorer functioning; a lower score is associated with greater functioning. Fourteen per cent of participants scored between 70 and 100, indicating greater disability; 9% of participants scored below 40, indicating excellent functional health. The mean score was 57 with a standard deviation of 12 points.

3.2.2. The Duration of Pain Experience

The mean for the participants’ duration of pain experience was 130 months (almost 11 years) of pain. The standard deviation is large with 125 months (10.4 years). The longest duration of pain recorded by a participant was 55 years and the lowest recorded was 2 months; 51% of participants had experienced 8 years or more of pain.

3.2.3. Beliefs Measured on the Organic Scale

The mean score in this project was 24 with a standard deviation of 6.

3.2.4. Beliefs Measured on Psychological Scale

The psychological scale of the PBQ mean score was 13 with a standard deviation of 4.

The data for the primary hypothesis testing is outlined in Table 4.

Table 4: Data for primary hypothesis testing.

Mean
Std dev
Max score
Min Score
Highest possible score

AIMS2-SF
57.3
12.7
101
27
130

PBQ organic belief scale
23.8
5.8
37
6
40

PBQ psychological belief scale
12.6
3.9
20
2
20

Duration of pain (years)
11.1
10.9
—
—
—

3.3. Hypothesis Testing for the Relationship of the PBQ and the AIMS2-SF

Simple linear regression analysis was applied with each of the subscales sum of the PBQ and the AIMS2-SF. The data showed two different relationships of scatter plot with simple linear regression for each subscale of the PBQ with the AIMS2-SF. The relationship between the organic beliefs subscale reached significance () with a modest correlation coefficient (). The Spearman Rank Order Correlation is 0.3297 for the relationship between the two variables “sum of AIMS” versus “sum of BELIEFS” and is significant at .

The relationship for the psychological scale showed no significance () and no correlation (). The scatter plot with the simple linear regression is shown in Figure 2.

Figure 2: Scatterplot with linear regressions of the sum of AIMS2-SF disability with both the psychological subscale of the PBQ and the organic subscale of the PBQ.

The primary hypothesis tests confirmed that organic beliefs about persistent pain are associated with functioning. A low score (less negative beliefs about pain) of the organic scale of the PBQ was associated with better functioning in the AIMS2-SF. A high score (greater negative beliefs about pain) of the organic scale of the PBQ was associated with poorer functioning in the AIMS2-SF. The psychological scale of the PBQ showed no relationship with disabled functioning.

4. Discussion

4.1. Outcomes Achieved

The primary hypothesis in this study is confirmed. There is a significant relationship between organic beliefs about pain and functioning. This was shown for participants in the Arthritis New Zealand exercise classes and education programmes. The sample consisted of patients with rheumatologic conditions with pain for 8 years and more (51%) and ranged from 22 to 91 years in age (mean age of 65 years; SD 11.7 years).

The participants in this study would have benefited from the education and support provided by ANZ for managing their pain and improving their exercise and functioning. It is not possible in this study to measure the modifying extent due to the participants’ involvement with the ANZ programmes. This correlation is nevertheless present despite the membership and participation with ANZ.

Data from this study show that patients with rheumatologic conditions who have had pain for more than 8 years and have a high score of organic beliefs are likely to exhibit poor functioning. High organic beliefs are the beliefs that the pain experience indicates harm or a threat to well being. The converse is also true. This strong evidence dissects organic beliefs from psychological beliefs for their respective influence on functioning. Furthermore, this study’s contribution is consistent with the current literature that the transition from acute to persistent pain is associated with cognitive-affective factors (such as negative beliefs and low self-efficacy) [56–59].

Beliefs contribute to the formation of an individual’s perception of reality. Pain beliefs are thoughts about the perceived control of the pain experience. These include the extent to which the pain experience is perceived to be harmful, the perceived disability associated with the pain experience, and the expectations of recovery [60]. Those who have a low score of organic pain beliefs are likely to have better functioning. This confirms the literature that organic beliefs about pain influence catastrophising and functional disability [60].

Organic pain beliefs contribute to the perception that pain is harmful and that control of pain is not possible; this weaves a common thread with catastrophising. Catastrophising is widely known to influence functional disability; it influences the perception of harm and disability associated with the pain experience and influences expectations of recovery [61]. It would make sense that high organic pain beliefs should have a relationship with poor functioning. Pain catastrophising plays a significant role in the experience of pain and predicts the persistence of pain [62–65]. This raises the possibility that organic pain beliefs have similar effects to catastrophising in influencing outcomes in those with persistent pain. The most recent literature about catastrophising shows that the relationship between coping, pain adjustment, and catastrophising is still not fully understood [66].

This study raises the differences between the two dimensions of pain beliefs (organic and psychological) and their relationship with functioning. Psychological and occupational factors can also contribute to persistence of the pain experience [10, 67–71]. In this sample, it is shown that psychological beliefs, the beliefs about the internal influences and feelings affecting the experience of pain, do not have any relationship with functioning. This is in contrast to systematic reviews that have shown psychological and occupational factors to have the highest reliability for prognostic factors contributing to persistence of the pain experience [10, 67–70]. There is a growing body of research supporting the model that the transition from acute to persistent pain is associated with serious life stressors including cognitive-affective factors [56]. When the PBQ was first developed it was noted that patients with persistent pain were more likely to support the organic beliefs items, while nonpatients were more likely to support the psychological beliefs items [16].

4.2. Strengths and Weaknesses

The strength of this study is the novel association of the two instruments, the AIMS2-SF and the PBQ for rheumatologic conditions, and the evidence that this relationship is consistent with international research. A correlation of these two instruments has not yet been applied. A further strength is the specific focus on ANZ with a moderate sample size within the larger population of rheumatologic conditions.

Several factors might account for the fact that the psychological beliefs do not show a relationship with functioning. The psychological beliefs scale has only 4 questions, in contrast to the 8 in the organic scale. It is perhaps a limitation of this questionnaire that the psychological beliefs are less featured or that specifically it is the organic beliefs rather than psychological beliefs that contribute to the persistent pain affecting functioning. The ANZ programmes and input could have influenced the data acquired. Sixty-one per cent of participants had joined the ANZ organisation over the previous three years. The functioning and psychological beliefs of responders may have been modified through their previous participation in the seminars and exercise groups, whereas the organic beliefs may not have been modified.

Since this study was not longitudinal in design, the direction of effects between the organic pain beliefs and functioning could not be determined. Furthermore, the sample group is limited to the members of ANZ in a small geographical area; these findings would need to be confirmed in wider areas. Nonresponders were 35% of those approached; there remains the possibility that their beliefs about pain and functioning may have differed from those of the responders.

There was a high percentage (85%) of female participants in the sample. Men might have different beliefs about pain and express them differently; their levels of functional ability associated with persistent pain might differ from those of women [72, 73]. The study only captured 4% of Maori participants, due to Christchurch being on the South Island with fewer Maori and Pacific Island populations. New Zealand health statistics generally show poorer health and socioeconomic status for the Maori and Pacific Island populations.

4.3. Implications for Clinical Practitioners

Research outcomes for evidence-based medicine are becoming more important for everyday clinical decisions and health funding. This study provides evidence that organic beliefs and functioning are indeed related. It is recommended that clinicians ask their patients about pain beliefs. It would be sensible to address organic pain beliefs early in their consultations, as patient beliefs about pain are influenced by interactions with health professionals [74–76]. The way to do this may be to make use of target questions to reveal underlying organic beliefs possibly contributing to poor functioning. For example, “Do you believe that it is impossible for you to control your pain,” or “do you believe that your pain means that there is something permanently wrong with your body?” Patients with rheumatologic conditions who respond in the affirmative should be encouraged to modify their organic beliefs. Information and education based on a biopsychosocial model have been shown to be effective in modifying beliefs, improving outcomes and in treatment compliance [77].

4.4. Implications for Future Research

These data show that organic beliefs and functioning are significantly related. However, psychological beliefs and functioning are not. Future research should determine the direction of this effect. The causal links between organic pain beliefs and functional ability for rheumatologic conditions could be further explored and relationships between organic beliefs and catastrophising investigated. The influences of organic and psychological pain beliefs with functioning in other medical conditions can be probed. Possible cultural and gender factors influencing pain beliefs in different populations (e.g., Maori and Pacific Islanders, refugees, other minority groups in New Zealand) could be considered as well.

This study confirmed a relationship between organic beliefs about pain and functioning (as shown by participants in the Arthritis New Zealand exercise classes and education programmes). As previously stated, the functioning and beliefs of responders may have been modified through their previous participation in the seminars and exercise groups. Particulary, how the programmes of ANZ influence and modify beliefs about pain or improve functioning as well as their variability in efficacy across the different geographic locations requires more investigation.

The instruments used in this study might not have been able to detect a relationship between the psychological beliefs about pain and functioning. On the other hand, rheumatologic conditions might have psychological features about their belief systems that differ from other population groups with pain. The influence of psychological feelings on the experience of pain in rheumatologic conditions should be explored as well.

5. Conclusion

This study confirmed a relationship between organic beliefs about pain and functioning for participants in the ANZ exercise classes and education programmes. The sample had a mean age of 65 years (SD 11.7 years); fifty-one per cent of participants had experienced more than 8 years of pain, and 61% had joined ANZ in the last three years. Organic pain beliefs (beliefs that the pain experience indicates harm or threat to well being) are significantly associated with poorer functioning. This was confirmed by linear regression with an -value of 0.32 (where α was 0.05 and 1-β was 0.8). Psychological pain beliefs (beliefs about the internal influences and feelings affecting the experience of pain) are not associated with functioning. In this study that beliefs could have been modified by the ANZ programmes.

When functioning is impaired organic beliefs about pain need to be addressed in the management of rheumatologic conditions. It is recommended that clinicians ask their patients about pain beliefs and address organic pain beliefs early in their consultations. Patients with rheumatologic conditions who respond positively to questioning should be encouraged to modify their organic beliefs.

Future research in rheumatologic conditions will determine the possible relationship between organic beliefs and catastrophising, as well as establish the causality between pain beliefs and functioning.

Disclosure

The authors report no financial disclosures, grant support, or conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References

C. J. Main, N. Foster, and R. Buchbinder, “How important are back pain beliefs and expectations for satisfactory recovery from back pain?” Best Practice and Research, vol. 24, no. 2, pp. 205–217, 2010.

M. V. Hurley, N. Walsh, V. Bhavnani, N. Britten, and F. Stevenson, “Health beliefs before and after participation on an exercised-based rehabilitation programme for chronic knee pain: doing is believing,” BMC Musculoskeletal Disorders, vol. 11, article 31, 2010.

D. S. Courvoisier, T. Agoritsas, J. Glauser, et al., “Pain as an important predictor of psychosocial health in patients with rheumatoid arthritis,” Arthritis Care & Research, vol. 64, no. 2, pp. 190–196, 2012.

T. J. Somers, R. A. Shelby, F. J. Keefe et al., “Disease severity and domain-specific arthritis self-efficacy: relationships to pain and functioning in patients with rheumatoid arthritis,” Arthritis Care and Research, vol. 62, no. 6, pp. 848–856, 2010.

M. Truchon, D. Côté, L. Fillion, B. Arsenault, and C. Dionne, “Low-back-pain related disability: an integration of psychological risk factors into the stress process model,” Pain, vol. 137, no. 3, pp. 564–573, 2008.

D. E. DeGood and R. Tait, “Assessment of pain beliefs and pain coping,” in Handbook of Pain Assessmen, D. C. Turk and R. Melzack, Eds., Guilford Press, New York, NY, USA, 2001.

R. A. Iles, M. Davidson, and N. F. Taylor, “Psychosocial predictors of failure to return to work in non-chronic non-specific low back pain: a systematic review,” Occupational and Environmental Medicine, vol. 65, no. 8, pp. 507–517, 2008.

A. Bandura, “Self-efficacy: toward a unifying theory of behavioral change,” Psychological Review, vol. 84, no. 2, pp. 191–215, 1977.

M. P. Jensen, “Research on coping with chronic pain: the importance of active avoidance of inappropriate conclusions,” Pain, vol. 147, no. 1–3, pp. 3–4, 2009.

A. Ramond, C. Bouton, I. Richard et al., “Psychosocial risk factors for chronic low back pain in primary care—a systematic review,” Family Practice, vol. 28, no. 1, pp. 12–21, 2011.

A. D. Abbott, R. Tyni-Lenné, and R. Hedlund, “The influence of psychological factors on pre-operative levels of pain intensity, disability and health-related quality of life in lumbar spinal fusion surgery patients,” Physiotherapy, vol. 96, no. 3, pp. 213–221, 2010.

A. Elfering, A. F. Mannion, N. Jacobshagen, O. Tamcan, and U. Müller, “Beliefs about back pain predict the recovery rate over 52 consecutive weeks,” Scandinavian Journal of Work, Environment and Health, vol. 35, no. 6, pp. 437–445, 2009.

D. C. Turk and R. Melzack, “The measurement of pain and the assessment of people experiencing pain,” in Handbook of Pain Assessment, D. C. Turk and R. Melzack, Eds., pp. 7–8, Guilford Press, New York, NY, USA, 2001.

G. Waddell, “Pain and disability,” in The Back Pain Revolution, G. Waddell, Ed., pp. 180–202, Churchill Livingstone, London, UK, 1998.

L. A. Mitchell and R. A. R. MacDonald, “Qualitative research on pain,” Current Opinion in Supportive and Palliative Care, vol. 3, no. 2, pp. 131–135, 2009.

L. C. Edwards, S. A. Pearce, L. Turner-Stokes, and A. Jones, “The pain beliefs questionnaire: an investigation of beliefs in the causes and consequences of pain,” Pain, vol. 51, no. 3, pp. 267–272, 1992.

Arthritis New Zealand, 2011, http://www.arthritis.org.nz/

Statistical Standard for Ethnicity, “Census,” 2006, http://search.stats.govt.nz/

T. J. Sloan, R. Gupta, W. Zhang, and D. A. Walsh, “Beliefs about the causes and consequences of pain in patients with chronic inflammatory or noninflammatory low back pain and in pain-free individuals,” Spine, vol. 33, no. 9, pp. 966–972, 2008.

H. Flor and D. C. Turk, “Chronic back pain and rheumatoid arthritis: predicting pain and disability from cognitive variables,” Journal of Behavioral Medicine, vol. 11, no. 3, pp. 251–265, 1988.

E. Broadbent, K. J. Petrie, J. Main, and J. Weinman, “The brief illness perception questionnaire,” Journal of Psychosomatic Research, vol. 60, no. 6, pp. 631–637, 2006.

T. L. Symonds, A. K. Burton, K. M. Tillotson, and C. J. Main, “Do attitudes and beliefs influence work loss due to low back trouble?” Occupational Medicine, vol. 46, no. 1, pp. 25–32, 1996.

G. Waddell, M. Newton, I. Henderson, D. Somerville, and C. J. Main, “A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability,” Pain, vol. 52, no. 2, pp. 157–168, 1993.

M. P. Jensen, P. Karoly, and R. Huger, “The development and preliminary validation of an instrument to assess patients' attitudes toward pain,” Journal of Psychosomatic Research, vol. 31, no. 3, pp. 393–400, 1987.

D. A. Williams and B. E. Thorn, “An empirical assessment of pain beliefs,” Pain, vol. 36, no. 3, pp. 351–358, 1989.

K. Boston, S. A. Pearce, and P. H. Richardson, “The pain cognitions questionnaire,” Journal of Psychosomatic Research, vol. 34, no. 1, pp. 103–109, 1990.

M. F. Lefebvre, “Cognitive distortion and cognitive errors in depressed psychiatric and low back pain patients,” Journal of Consulting and Clinical Psychology, vol. 49, no. 4, pp. 517–525, 1981.

R. J. Feise and J. M. Menke, “Functional rating index: literature review,” Medical Science Monitor, vol. 16, no. 2, pp. RA25–RA36, 2010.

P. M. T. Klooster, M. M. Veehof, E. Taal, P. L. C. M. van Riel, and M. A. F. J. van de Laar, “Confirmatory factor analysis of the arthritis impact measurement scales 2 short form in patients with rheumatoid arthritis,” Arthritis Care and Research, vol. 59, no. 5, pp. 692–698, 2008.

F. Wolfe, “Clinical, laboratory, and radiographic assessments,” Current Opinion in Rheumatology, vol. 5, pp. 138–145, 1993.

G. Stucki, “International classification of functioning, disability, and health (ICF): a promising framework and classification for rehabilitation medicine,” American Journal of Physical Medicine and Rehabilitation, vol. 84, no. 10, pp. 733–740, 2005.

K. A. Wallston, G. K. Brown, M. J. Stein, and C. J. Dobbins, “Comparing the short and long versions of the arthritis impact measurement scales,” Journal of Rheumatology, vol. 16, no. 8, pp. 1105–1109, 1989.

R. F. Meenan, J. H. Mason, J. J. Anderson, A. A. Guccione, and L. E. Kazis, “AIMS2. The content and properties of a revised and expanded arthritis impact measurement scales health status questionnaire,” Arthritis and Rheumatism, vol. 35, no. 1, pp. 1–10, 1992.

F. Guillemin, J. Coste, J. Pouchot, M. Ghézail, C. Bregeon, and J. Sany, “The AIMS2-SF: a short form of the arthritis impact measurement scales 2,” Arthritis and Rheumatism, vol. 40, no. 7, pp. 1267–1274, 1997.

J. F. Fries, P. Spitz, R. G. Kraines, and H. R. Holman, “Measurement of patient outcome in arthritis,” Arthritis and Rheumatism, vol. 23, no. 2, pp. 137–145, 1980.

E. Loza, L. Abásolo, J. A. Jover, and EPISER Study Group, “Burden of disease across chronic diseases: a health survey that measured prevalence, function, and quality of life,” Journal of Rheumatology, vol. 35, no. 1, pp. 159–165, 2008.

T. A. Stamm, A. Cieza, K. P. Machold, J. S. Smolen, and G. Stucki, “Content comparison of occupation-based instruments in adult rheumatology and musculoskeletal rehabilitation based on the international classification of functioning, disability and health,” Arthritis Care and Research, vol. 51, no. 6, pp. 917–924, 2004.

H. Deutsch, “The predictive value of the baseline Oswestry disability index in lumbar disc arthroplasty,” Neurosurgical focus, vol. 28, no. 6, article E7, 2010.

J. C. T. Fairbank and P. B. Pynsent, “The Oswestry disability index,” Spine, vol. 25, no. 22, pp. 2940–2953, 2000.

M. Roland and J. Fairbank, “The roland-morris disability questionnaire and the Oswestry disability questionnaire,” Spine, vol. 25, no. 24, pp. 3115–3124, 2000.

H. Heneweer, N. J. van Woudenberg, F. van Genderen, L. Vanhees, and H. Wittink, “Measuring psychosocial variables in patients with (sub) acute low back pain complaints, at risk for chronicity: a validation study of the acute low back pain screening questionnaire-dutch language version,” Spine, vol. 35, no. 4, pp. 447–452, 2010.

M. Melloh, A. Elfering, C. E. Presland et al., “Identification of prognostic factors for chronicity in patients with low back pain: a review of screening instruments,” International Orthopaedics, vol. 33, no. 2, pp. 301–313, 2009.

S. J. Linton and K. Halldén, “Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain,” Clinical Journal of Pain, vol. 14, no. 3, pp. 209–215, 1998.

C. P. Gabel, M. Melloh, M. Yelland, B. Burkett, and A. Roiko, “Predictive ability of a modified Örebro musculoskeletal pain questionnaire in an acute/subacute low back pain working population,” European Spine Journal, vol. 20, no. 3, pp. 449–457, 2011.

M. L. Verra, F. Angst, J. B. Staal et al., “Differences in pain, function and coping in multidimensional pain inventory subgroups of chronic back pain: a one-group pretest-posttest study,” BMC Musculoskeletal Disorders, vol. 12, article 145, 2011.

A. Bauman, B. E. Ainsworth, J. F. Sallis et al., “The descriptive epidemiology of sitting: a 20-country comparison using the international physical activity questionnaire (IPAQ),” American Journal of Preventive Medicine, vol. 41, no. 2, pp. 228–235, 2011.

R. Soer, M. F. Reneman, P. C. Vroomen, P. Stegeman, and M. H. Coppes, “Responsiveness and minimal clinically important change of the pain disability index in patients with chronic back pain,” Spine, vol. 37, no. 8, pp. 711–715, 2012.

I. Olsson, O. Bunketorp, S. G. Carlsson, and J. Styf, “Prediction of outcome in whiplash-associated disorders using West Haven-Yale multidimensional pain inventory,” Clinical Journal of Pain, vol. 18, no. 4, pp. 238–244, 2002.

M. Bergner, R. A. Bobbitt, W. E. Pollard, D. P. Martin, and B. S. Gilson, “The sickness impact profile: validation of a health status measure,” Medical Care, vol. 14, no. 1, pp. 57–67, 1976.

M. Monticone, P. Baiardi, T. Nava, B. Rocca, and C. Foti, “The italian version of the sickness impact profile-roland scale for chronic pain: cross-cultural adaptation, reliability, validity and sensitivity to change,” Disability and Rehabilitation, vol. 33, no. 15-16, pp. 1299–1305, 2011.

T. M. Gill and A. R. Feinstein, “A critical appraisal of the quality of quality-of-life measurements,” Journal of the American Medical Association, vol. 272, no. 8, pp. 619–626, 1994.

R. A. Washburn, K. W. Smith, A. M. Jette, and C. A. Janney, “The physical activity scale for the elderly (PASE): development and evaluation,” Journal of Clinical Epidemiology, vol. 46, no. 2, pp. 153–162, 1993.

J. A. Kopec, J. M. Esdaile, M. Abrahamowicz et al., “The Quebec back pain disability scale: conceptualization and development,” Journal of Clinical Epidemiology, vol. 49, no. 2, pp. 151–161, 1996.

R. L. Claar and L. S. Walker, “Functional assessment of pediatric pain patients: psychometric properties of the functional disability inventory,” Pain, vol. 121, no. 1-2, pp. 77–84, 2006.

J. Cohen, Statistical Power Analysis for the Behavioural Sciences, Academic Press, London, UK, 1977.

C. Y. Casey, M. A. Greenberg, P. M. Nicassio, R. E. Harpin, and D. Hubbard, “Transition from acute to chronic pain and disability: a model including cognitive, affective, and trauma factors,” Pain, vol. 134, no. 1-2, pp. 69–79, 2008.

D. C. Turk, K. S. Swanson, and E. R. Tunks, “Psychological approaches in the treatment of chronic pain patients—when pills, scalpels, and needles are not enough,” Canadian Journal of Psychiatry, vol. 53, no. 4, pp. 213–223, 2008.

F. J. Keefe, T. J. Somers, and L. M. Martire, “Psychologic interventions and lifestyle modifications for arthritis pain management,” Rheumatic Disease Clinics of North America, vol. 34, no. 2, pp. 351–368, 2008.

T. J. Somers, R. A. Shelby, F. J. Keefe et al., “Disease severity and domain-specific arthritis self-efficacy: relationships to pain and functioning in patients with rheumatoid arthritis,” Arthritis Care and Research, vol. 62, no. 6, pp. 848–856, 2010.

A. Elfering, A. F. Mannion, N. Jacobshagen, O. Tamcan, and U. Müller, “Beliefs about back pain predict the recovery rate over 52 consecutive weeks,” Scandinavian Journal of Work, Environment and Health, vol. 35, no. 6, pp. 437–445, 2009.

R. E. Johnson, G. T. Jones, N. J. Wiles et al., “Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial,” Spine, vol. 32, no. 15, pp. 1578–1585, 2007.

B. R. Goodin, L. McGuire, M. Allshouse et al., “Associations between catastrophizing and endogenous pain-inhibitory processes: sex differences,” Journal of Pain, vol. 10, no. 2, pp. 180–190, 2009.

A. J. Cook and D. E. DeGood, “The cognitive risk profile for pain: development of a self-report inventory for identifying beliefs and attitudes that interfere with pain management,” Clinical Journal of Pain, vol. 22, no. 4, pp. 332–345, 2006.

B. R. Goodin, L. M. McGuire, L. M. Stapleton et al., “Pain catastrophizing mediates the relationship between self-reported strenuous exercise involvement and pain ratings: moderating role of anxiety sensitivity,” Psychosomatic Medicine, vol. 71, no. 9, pp. 1018–1025, 2009.

M. J. L. Sullivan, B. Thorn, J. A. Haythornthwaite et al., “Theoretical perspectives on the relation between catastrophizing and pain,” Clinical Journal of Pain, vol. 17, no. 1, pp. 52–64, 2001.

R. Nieto, J. Miró, A. Huguet, and C. Saldaña, “Are coping and catastrophising independently related to disability and depression in patients with whiplash associated disorders?” Disability and Rehabilitation, vol. 33, no. 5, pp. 389–398, 2011.

M. P. Jensen, M. R. Moore, T. B. Bockow, D. M. Ehde, and J. M. Engel, “Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review,” Archives of Physical Medicine and Rehabilitation, vol. 92, no. 1, pp. 146–160, 2011.

N. Henschke, R. W. Ostelo, M. W. van Tulder et al., “Behavioural treatment for chronic low-back pain,” Cochrane Database of Systematic Reviews, vol. 7, article CD002014, 2010.

N. J. Stomski, S. MacKintosh, and M. Stanley, “Patient self-report measures of chronic pain consultation measures: a systematic review,” Clinical Journal of Pain, vol. 26, no. 3, pp. 235–243, 2010.

P. A. Forgeron, S. King, J. N. Stinson, P. J. McGrath, A. J. MacDonald, and C. T. Chambers, “Social functioning and peer relationships in children and adolescents with chronic pain: a systematic review,” Pain Research and Management, vol. 15, no. 1, pp. 27–41, 2010.

C. Gustavsson, E. Denison, and L. von Koch, “Self-management of persistent neck pain: a randomized controlled trial of a multi-component group intervention in primary health care,” European Journal of Pain, vol. 14, no. 6, pp. 630.e1–630.e11, 2010.

D. Côté and M. F. Coutu, “A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?” Disability and Rehabilitation, vol. 32, no. 2, pp. 87–102, 2010.

C. R. Green, S. K. Ndao-Brumblay, A. M. Nagrant, T. A. Baker, and E. Rothman, “Race, age, and gender influences among clusters of african american and white patients with chronic pain,” Journal of Pain, vol. 5, no. 3, pp. 171–182, 2004.

A. R. Daykin and B. Richardson, “Physiotherapists' pain beliefs and their influence on the management of patients with chronic low back pain,” Spine, vol. 29, no. 7, pp. 783–795, 2004.

B. Darlow, B. M. Fullen, S. Dean, D. A. Hurley, G. D. Baxter, and A. Dowell, “The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review,” European Journal of Pain, vol. 16, no. 1, pp. 3–17, 2012.

B. M. Fullen, G. D. Baxter, B. G. G. O'Donovan, C. Doody, L. Daly, and D. A. Hurley, “Doctors' attitudes and beliefs regarding acute low back pain management: a systematic review,” Pain, vol. 136, no. 3, pp. 388–396, 2008.

A. Dupeyron, P. Ribinik, A. Gélis et al., “Education in the management of low back pain. Literature review and recall of key recommendations for practice,” Annals of Physical and Rehabilitation Medicine, vol. 54, pp. 319–335, 2011.