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https://doi.org/10.1017/jrc.2016.5

“Well this is it. Just get on with it”: Pain willingness and activity engagement in people

with chronic pain.

Cecelia Titus, Queensland University of Technology

Herbert C Biggs, Queenlsand University ofr Technology

Abstract

Pain is recognised as a problem of significant concern worldwide and in the latest

Global Burden of Disease Study, low back pain was identified as the biggest contributor

worldwide to Years Lived with Disability. There is evidence to suggest that people who

accept their chronic pain have a higher quality of life, lower levels of disability and distress,

and function better emotionally, socially and physically. Findings on the specific pathways

linking pain acceptance to quality of life outomes are less clear. the two widely accepted pain

acceptance factors, pain willingness and activity engagement, have not been well explored in

qualitative studies on acceptance of chronic pain. To address this deficit in the literature, the

current study has two related aims: 1) to explore pain willingness and activity engagement in

the lives of people with chronic pain; and 2) to find out what people believe helps them to

successfully get on with life in spite of chronic pain.

Keywords: Chronic pain, low back pain, pain willingness, activity engagement, quality of

life.

Introduction

Pain is recognised as a problem of significant concern worldwide and in the latest

Global Burden of Disease Study, low back pain was identified as the biggest contributor

worldwide to Years Lived with Disability (YLDs) (Froud et al., 2014). People with chronic

pain may experience depression and anxiety, social isolation, stigma, and unemployment

(Institute of Medicine (US), 2011; MacNeela, Doyle, O’Gorman, Ruane, & McGuire, 2013;

Newton, Southall, Raphael, Ashford, & LeMarchand, 2013), and severe pain has been found

to have a stronger impact on health-related quality of life than nearly all other conditions

(Stewart, Woodward, Rosen & Cutler, 2008).

There is evidence to suggest that people who accept their chronic pain have a higher

quality of life, lower levels of disability and distress, and function better emotionally, socially

and physically (Esteve, Ramírez-Maestre, & López-Martínez, 2007; Gillanders, Ferreira,

Bose, & Esrich, 2013; LaChapelle, Lavoie, & Boudreau, 2008; McCracken & Eccleston,

2005; Morley, Davies, & Barton, 2005; Viane, Crombez, Eccleston, Devulder, & De Corte,

2004; Vowles, McCracken, & Eccleston, 2008). Findings on the specific pathways linking

pain acceptance to quality of life outomes are less clear. On the one hand, Viane et al. (2004)

found that acceptance had a unique contribution to mental health beyond that of pain severity

or catastrophising, but that it did not predict physical functioning. On the other hand,

Gillanders et al. (2013) found that acceptance mediated the relationship between pain and

physical dysfunction but not between pain and emotional dysfunction. These discrepant

findings suggest a need for additonal studies on the components of pain acceptance important

for quality of life outomes.

It is also unclear what the components of acceptance are and how acceptance

develops. For instance, Geiser (1992) identified two acceptance factors with strong

associations with patient outcomes: pain willingness and activity engagement. Pain

willingness involves being willing to experience pain without using unnecessary avoidance

and control, and activity engagement relates to participating in activities whether or not pain

is experienced (McCracken, Vowles, & Eccleston, 2004). Risdon, Eccleston, Crombez, &

McCracken (2003) considered chronic pain acceptance to include taking control, living day

to day, acknowledging limitations, empowerment, accepting loss of self, more to life than

pain, don’t fight battles that cannot be won, and spiritual strength. Participants in the Ojala et

al. (2014) study believed that chronic pain acceptance involved acknowledging that pain

would never go away, and ceasing denial and avoidance of pain. LaChapelle et al. (2008)

found chronic pain acceptance among women with arthritis and fibromayalgia to involve

realizing they needed help, receiving a diagnosis, realizing there was no cure for their pain,

and realizing the need to redefine what was ‘normal’ (LaChapelle et al., 2008). Acceptance

was seen as a process that began with a diagnosis, which was considered critical to achieving

acceptance. Kostova, Caiata-Zufferey, & Schulz (2014) also found that the absence of a

diagnosis hindered the acceptance process for people with rheumatoid arthritis.

More qualitative studies on personal meanings of acceptance held by those living with

chronic pain might address the gap in the literature about the qualities of acceptance

important for living well with pain (Osborn & Rodham, 2010). For instance, the two widely

accepted pain acceptance factors, pain willingness and activity engagement, have not been

well explored in qualitative studies on acceptance of chronic pain. To address this deficit in

the literature, the current study has two related aims: 1) to explore pain willingness and

activity engagement in the lives of people with chronic pain; and 2) to find out what people

believe helps them to successfully get on with life in spite of chronic pain.

Method

Research Design

The research was part of a larger study which also investigated illness beliefs of

people with chronic pain. An interview schedule was developed with questions about

participants’ beliefs about their pain, for use in the study on illness beliefs. A qualitative

approach was chosen for this study because such approaches enable flexible, in-depth

exploration of questions of interest (Smith, 2008). Thematic analysis was used because it “is

a method for identifying, analysing and reporting patterns (themes) within [qualitative] data”

(Braun & Clarke, 2006, p. 79), which the study required. Thematic analysis is often used

with interview data and is well suited for uncovering and clarifying participants’ perspectives

and experiences in relation to the phenomenon being studied. The approach does not have a

specific theoretical or epistemological foundation and can be used flexibly with different

theoretical approaches (Harper & Thompson, 2011). Thus, it was seen as an appropriate

choice for the current study.

Participants

Participants were a purposive sample of 11 adults self-reporting non-malignant pain

for at least six months. There were seven females and four males, aged between 30 and 58

(M = 48, SD = 9.43). Participants were recruited by word of mouth. A brief questionnaire

was used to gather demographic data (see Table 1).

Table 1. Participant demographics.

a Pain Duration = Number of years pain has been experienced. Where multiple pain sites exist, duration relates to site with longest duration. b Severity = Highest level of pain severity in last 30 days or in most recent pain episode, where 0=no pain and 10=most severe pain imaginable

Alias Age Race/ Ethnicity

Relationship Status

Main pain location

Durationa Severityb Occupation status

Sara 44 White Single Head 30 9 Part-time lecturer, left full-time sports teaching due to pain

Mike 58 African- Caribbean

Divorced Low back, shoulders, hips, knees, ankles, hands

40

8-9

Self-employed chiropractor full-time

Jan 55 White Married Back, neck, legs, arms

30 6 Manages a Bed & Breakfast, ceased full-time work due to pain

Karen 30 White Defacto relationship

Knee 5 7 Full-time student

Jenni 33 White Single Mid back 7 months 7 Full-time student

Will 54 White Defacto relationship

Left knee, lower left leg

15 4-5 Self-employed builder full-time

Fran 53 White Defacto relationship

Neck, right shoulder, jaw

28 5 Full-time employed as a mediator

Cynthia 49 White Defacto relationship

Back 6 4-5 Unemployed due to pain, previously full-time music teacher

Anne 53 Indigenous Australian

Single Left knee, lower left leg

2.5 5 Unemployed due to pain, previously teacher aide

Henry 56 White Married Whole body 5 10 Employed full-time, studying part-time

Daniel 43 White Married Left side, left leg 8 7-8 Previously marine biologist, retrained as a teacher due to pain

Ethical considerations

The study received ethical clearance from the Queensland University of Technology

Human Research Ethics Committee (Ethics Approval Number: 1400000560). Written

informed consent was obtained before beginning each interview.

Data collection

All interviews were conducted by the first author (CT) and were held at the

Queensland University of Technology (QUT), at a chiropractic clinic, and at public locations

negotiated with participants. Each interview began with a general question inviting the

participant to describe their pain experience from the beginning, followed by questions

tapping into illness beliefs and acceptance. The interviews were conversational, to allow in-

depth exploration of participants’ experiences. Throughout the interviews, prompts such as

‘can you tell me more about that?’, were used to encourage participants to expand on their

responses.

Purposive sampling was used to enhance the credibility and trustworthiness of the

data. Participants were recruited from a chiropractic clinic (1), the QUT fourth year

psychology cohort (2), and via word of mouth. Three individuals known to the first author

who self-identified as chronic pain sufferers were approached and they agreed to participate.

These individuals named other persons with chronic pain (5), all of whom agreed to

participate in the study.

Participants responded to questions in semi-structured interviews that ranged from 45

minutes to one hour in length. Interviews were recorded using the voice memo application

on an iPhone 4S, and recordings were uploaded to a laptop, after which they were deleted

from the iPhone. All interviews were conducted by the first author (CT). The interview

questions addressed the following topics: 1) whether the participant had been able to get on

with their lives and what they believed helped them to do so; 2) pain-related activity

limitations; 3) whether it was important to keep pain under control; 4) use of avoidance to

manage pain; and 5) what would help them to get on with life.

Data analysis

All interviews were transcribed verbatim using InqScribe transcription software

(2013). The data were coded and analysed using Atlas.ti qualitative data analysis and

research software (Atlas.ti, 2012). Thematic analysis followed the process recommended by

Braun and Clarke (2006) with minor variations, and included the following steps: 1)

familiarisation with the data, which involved listening to each recorded interview and reading

the transcripts; 2) initial coding of transcripts; 3) second coding of transcripts; 4) searching

for themes by reviewing codes, associated coded extracts and analytic memos, and by

analyzing thematic maps; 5) third round of coding; and 6) naming themes. Analytic memos

were also used throughout to record thoughts and impressions. Interview transcripts and

recordings were revisited a number of times. This immersion in the data gave us a deeper

sense of the participants’ experiences and meanings and facilitated identification of patterns

across the data. We used a primarily theoretical (rather than data-driven) thematic analysis

approach (Braun & Clarke, 2006), in that theory-informed interview questions were used to

elicit information about participants’ pain willingness and activity engagement and

experience of getting on with life. However, by using data from participants’ pain stories and

from the questions aimed at uncovering illness beliefs, our approach was also data-driven.

The second author was a decision partner in the selection of the coding and analysis

process for this research. The primary collection, coding and analysis was undertaken by the

first author, with the second author reviewing this output and providing second order analysis

to align respondent comment and intent with the final written description in this manuscript.

Analysis was iterative, with each round of analysis leading to refinement of codes and

themes. Extracts were coded and themes named on the basis of their relevance to theory and

study aims. Throughout the analysis, the authors communicated frequently to discuss

connections between codes, meaning units and themes, patterns in the data, and the naming

of themes.

Results

Pain willingness and activity engagement

Nine of the eleven (82%) participants gave specific examples of pain willingness and

activity engagement.

‘For example, once when mum came up to visit, and I had spondylolisthesis as well, in

my spine, so I was in a bad way. I could not sit up. But I figured, I really wanted to

show mum what it was like up north, so I remember planning “well, I’ll lie in the back

seat and put the seatbelt on. I’ll direct mum with the map and she can drive, and I can

get out” – cause I couldn’t sit, but I could lie or stand – “and then I’ll get out when we

get to the Curtis Figtree…’ - Sara (head and neck)

Jan spoke of choosing to continue to work against the advice of a specialist:

‘I went to a specialist because I’d get days where my back would just catch or I

couldn’t move or I’d vomit with the pain it was so extraordinary, and it was really

affecting my lifestyle… He basically said you have to change your lifestyle, relax, stop

working, which is ridiculous when you’re 40-odd and you need to earn an income. So I

didn’t stop working, of course.’ Jan (back, neck, legs and arms)

Mike (pain in multiple joints) works full-time as a chiropractor, and is setting

world records in powerlifting at 60 years old, which involves weight training four times a

week. Henry (whole body) works full-time and studies part-time. Daniel (left side and

left leg), a marine biologist who retrained as a teacher because of his pain, said:

‘I guess, what I found most interesting about that was... the teaching thing I thought

was gonna be, you know, a more sedentary lifestyle, uh, and look, I'm much busier and

more active than I was prior to having avascular necrosis.’

Our results correspond with those of other researchers. For example, participants

in the LaChapelle et al. (2008) study emphasised the importance of enduring pain in order

to have desired experiences. Also, like participants in the Ojala et al. study (2014), four of

our participants (36%) reported that avoiding and denying pain led to negative

consequences. However, it generally took years of living with pain for participants to

realize it was best to be active and engaged with life, as other researchers have found (e.g.,

Dickson, Knussen, & Flowers, 2008; Ojala et al., 2014). For instance, Sara (head and

neck) observed: ‘… it got to the point where I thought, “oh, stuff it. I’m not staying in bed

anymore, because I’ve got pain if I lie in bed and I’ve got pain if I go out”’. And Cynthia

said, ‘You know, eventually I said, ‘what choice do I have? I either lie in bed 4 days a

week or I get up and just make a go of it’. (back) Our participants also described activity

engagement and pain willingness fluctuations that depended on their position in the hope-

despair cycle (see Corbett, Foster, & Ong, 2007). These results suggest that acceptance,

too, fluctuates.

Pain avoidance and activity restrictions

Although participants gave clear examples of willingness to experience pain in order

to do things that were important to them, nine participants (82%) gave examples of activity

avoidance and unwillingness to experience pain.

‘When you're home and you're tired and you're achy and sore, and you have a barbecue

to go to and you've been working all week and your back is killing you and you don't

want to stand up or sit in the car and drive there. It's easier to stay home, put it off.’

Mike (pain in multiple joints)

And Henry said:

‘There's things where I think "oh, no. I just couldn't be bothered". I just don't, you

know, I would've normally loved to do that but I just... it's too hard.’ (whole body)

According to Daniel:

‘There's things that I just can't do. Like I can't walk long distances. Cos that's ... it's

just... it's not good for me anyway, but it also exacerbates the pain, like it just makes it

worse. So, there's some things that I don't do’. (left side and left leg)

Finally, from Fran: ‘So I have made certain decisions about what I will and will not do

to minimise the impact on my body. I don't want to damage it any further or make it

worse’. (neck, shoulder and jaw)

In many cases, the activities our participants usually avoided were recreational or

social activities. This effect of chronic pain on social participation is well-recognised

(Breivik, Collett, Ventafridda, Cohen, & Gallacher, 2006; Campbell & Guy, 2007; Dennis,

Larkin, & Derbyshire, 2013; Newton et. al., 2013). Although participants said they were

often too tired or in too much pain to attend social functions, social withdrawal was also a

response to previous experience (or fear) of not being believed or understood, an effect of

chronic pain found in research on the stigmatising impact of chronic pain (Holloway, Sofaer-

Bennett, & Walker, 2007). This stigmatisation is associated with loss of self and is a barrier

to adjustment to chronic pain (Holloway et al., 2007; Newton et al., 2013), both of which

were described by our participants Anne and Cynthia, who said they were not getting on with

their lives.

Use of medication. Most participants (73%) used over-the-counter or prescription

medication to manage their pain. For some, pain medication was used before activities where

they feared pain would increase, and several participants were on long-term opoid pain

medication. A number of participants also said they would try new pain medication or pain

management techniques if they became available. It is noteworthy that participants with very

high levels of pain said pain medication did little to reduce their pain, but they continued to

use them. One explanation for this behaviour is that any treatment, even short-lived or

ineffective treatment, reassures the individual that they are actively getting someone to help

them (Campbell & Guy, 2007). Thus, the use of medication can be seen not only as a pain

avoidance measure, but as a way of taking action to minimise the effects of pain, making

activity engagement possible.

In summary, avoidance and control of pain was evident even though participants also

gave examples illustrating acceptance of their pain. It is important to emphasize that the aim

of acceptance is to improve functioning in certain situations to facilitate values-based action

and is unlikely to be present all the time (McCracken & Vowles, 2014). Therefore,

determining whether specific behaviours are appropriate is important, and pain avoidance

should be evaluated based on whether it passes the ‘workability’ test; that is, whether it takes

the individual toward or away from values-based action (Dahl, Luciano, & Wilson, 2005).

However, it can be difficult for people with chronic pain to know when they are imposing

unnecessary restrictions on activities, or whether they should use medication, because of

shared social understandings about pain, incuding the belief that avoiding pain and restricting

activities is necessary. Education about pain might help with this, as other researchers have

found (see Meeus, Nijs, Van Oosterwijck, Van Alsenoy, & Truijen, 2010; Moseley, 2004).

Themes related to getting on with life

Three subthemes resulted from the data analysis: making necessary adjustments,

taking control, and finding meaning and purpose (see Table 2). Nine of the 11 participants

(82%) said they were getting on with their lives in spite of chronic pain, and two said they

had not been able to get on with life. The themes are considered next.

Table 2. Final themes and subthemes.

Theme Subtheme Codes used to define theme Getting on with life Making necessary adjustments Living with limitations,

workarounds, adjusting to pain, change over time, learning what helps, take it as it comes

Taking control You have a choice, alternative is unacceptable, distancing self from pain, pushing through, putting on a smile, controlling the impact

Finding purpose and meaning Helping others, meaningful action, better life now, what’s of value, new directions

Theme one: Making necessary adjustments

All of the participants reported that their lifestyles, activity levels or work situation

had changed because of their pain. Whilst nine (82%) acknowledged choice or recognized

the importance of adjusting, the two participants who were having the greatest difficulty

adapting to their pain felt forced to live with undesirable changes. As an example of

acknowledging the need to make changes, Sara said she arranged her work schedule to

manage her symptoms: ‘I work two days a week at the moment. But you see, I work in sort of

4 hour shifts. So that’s enough that I can actually manage what’s going on’. (head and neck)

‘You just have to be adaptable, I think... I guess I know what I can manage and I just do

what I can when I can. And even if I can't do as much as I want, I do a bit, which gets you

there eventually’. Fran (neck, shoulder and jaw)

‘Like, I take up a group of university students to Lizard Island every year. And there's a

really long hike that we do as part of that … I don’t do that hike. And I make that really

clear in any employment or any job that I take on that I can’t walk’. Daniel (left side and

left leg)

When people with chronic pain accept their pain-related limitations, they adjust better

to chronic pain. Accepting limitations was an important feature of getting on with life for

participants in our study, as in other research (e.g., Kostova et al, 2014; LaChapelle et al.,

2008; Risdon et. al., 2003). The negative impact of chronic pain on the ability (and in some

cases, the willingness) to engage in identity-related activities contributes to the loss of self

that can plague chronic pain sufferers (Crowe, 2010), which seemed to be the case for our

two participants who were struggling to adapt to their pain.

Theme two: Taking control

Participants needed to be active and assertive in the management of their chronic pain,

as described by Henry: ‘I’m going to control IT; it’s not going to control ME’. (whole body)

Henry explained that taking control meant controlling his life, rather than controlling pain.

For Daniel, reducing his medication helped him to have more control. He said:

‘I've actually weaned myself off of quite a few drugs. Off Lyrica and a few other things

that I found mentally, um, damaging. I just felt stupid on them, basically, so I prefer to

have more pain and be clear than have less pain and be dopey’ (left side and left leg).

Sometimes taking control meant following advice of health professionals, as Fran

explained: ‘I've learnt, like a couple of physios told me, don't do this, don't do this, so I'm

much more careful about what I do and don't do.’ (neck, shoulder and jaw). On the other

hand, for Karen (knee) taking control meant disregarding professional advice: ‘like if I was

told I should never run again, I don't think I'd take that advice, because I kind of need it for

my mental health’.

The loss of personal control and its impact on self and identity is well-documented in

the chronic pain literature (Crowe et al., 2010; LaChapelle et al., 2008; Rodham, McCabe,

Pilkington, & Regan, 2013) and four (36%) of our participants thought that regaining a sense

of control was an important aspect of successfully getting on with life. The salience of this

factor is supported by the experiences of the two participants in our study who still felt

controlled by pain: They said they had not been able to get on with life.

Theme three: Finding purpose and meaning

Some participants (36%) emphasised the importance of having a purpose, finding

meaning in their pain experience, or which helped them to live with their chronic pain. For

instance, Mike, a health professional who gets enormous satisfaction from the relief he is able

to offer other people who experience pain. He said, ‘the outcome you want is not the reason

you do it, right? It's the process, the day to day experience of doing that which has some sort

of meaning’ (pain in multiple joints). For Jenni (mid-back), passion for her university studies

and future career motivates her to get on with her life. She said ‘I know this is what I want to

do, whether I have pain or whatever, and I don't want to give it up’. Daniel said, ‘finding the

things that are of value gives you meaning and then having meaning helps make the whole

thing better’. (left side and left leg)

Pain had a positive meaning for some participants. Henry said,

‘In terms of focusing on what's real and what's important and what's, you know, useful in

your life, um, you know, it really does focus down very very very clearly on what is

important and I’ve used that, I’ve used the pain really nicely in that sense, so in some ways

I’ve really, I welcome the pain.’ (whole body)

Sara, too appreciates the positive impact of pain on her life. She said ‘I’m not stressed, and I

think, if I had not had that.. all those things happen, I’d be driving myself like a workaholic’.

(head and neck)

And Daniel explained,

‘If I didn't have the pain I wouldn't be searching for the meaning as clearly too, you know,

so that's why I don't see it as being a bad thing. So, um, if I didn't have the pain I wouldn't

be in the position that I'm at and apart from the pain, I'm pretty happy with that position’.

(left side and left leg)

The positive meaning of pain is supported by Ojala et al. (2014), whose participants

described ways they had grown as a result of pain. Our results are also consistent with

Aldrich and Eccleston’s (2000) findings on the diverse meanings of pain: In addition to

negative meanings of pain, pain can also provide opportunities for self- or spiritual growth.

Difficulties getting on with life

Two participants said they had not been able to get on with their lives. For instance,

Anne said, ‘No, because with the last job, you know, I felt… I was angry with myself for not

being honest about my knee and ... I guess I took it very sensitively.’ (left knee and lower

left leg)

Cynthia observed:

‘I don't know, because I've had to deal with all the trauma of it, because as soon as I start

thinking about it I get really upset and angry. And I'm still really angry… I don't know if I

could label it, because it sort of comes out as a traumatic thing, it's sort of very traumatic.

And because it wasn't my fault, it just ... I did nothing wrong. I mean … I didn't crash my

car into a brick wall or anything. I was quite innocent’. (back)

Cynthia and Anne were among four participants who said that they had been changed

negatively by pain, but Cynthia and Anne had a sense of loss that was a source of much

suffering for them, which was evident throughout their interviews. Cynthia said she was

once a strong, brave person who is not used to being a weakling sitting in the corner going

‘struggle, struggle, struggle’. She described herself now as an ‘injured chicken with a broken

wing’.

When asked what would help her to get on with her life, Anne (left knee and lower

left leg) said ‘I would have to be employed’. She also spoke of her anxiety about walking:

‘Um, I don’t walk… I used to walk, you know, just with the dogs, or do a 50 minute walk,

actually, in the morning and in the evening. Um, I did try and do that again but the

clicking clicks in and you feel like you're starting to become unstable, so.. and there's a

certain amount of pain where you have to sit down.’

Cynthia said:

‘I don't know, I've even thought of getting a private trainer. I thought maybe a private

trainer would know more about, you know, what I'm doing wrong. Um, no, I can’t see

anything, any sort of help. I do still get a fair amount of help already, so. Five or six

doctors I still see..’ (back)

Similar to other research (e.g., Morley et al., 2005; Smith & Osborn, 2007), this study

found that chronic pain can have a negative impact on the self and identity, which was

described by four participants, but was particularly problematic for Anne and Cynthia. They

can be considered to have experienced self-pain enmeshment, which involves believing the

future hoped-for self is dependent on the absence of pain. According to the self-pain

enmeshment theory, chronic pain entraps the sufferer’s self, which can result in high levels of

distress and illness behaviour (Pincus & Morley, 2001). Dickson et al. propose that accepting

the loss of the anticipated self is critical to adjustment to chronic pain (2008). Rather than

encouraging acceptance of the loss of the anticipated self, Acceptance and Commitment

Therapy (ACT) addresses attachment to the conceptualized self by teaching clients to see the

self as ‘a secure and continuous I who from which events are experienced’ (Luoma, Hayes, &

Walser, 2007, p. 19).

Implications for Chronic Pain Counselling Practice

Where counselling or clinical intervention does occur, ACT-based acceptance could

be taught and clients could be trained to assess their avoidance behaviours for workability.

Also, an ACT therapeutic process addressing the conceptualized self might help people to see

themselves as whole and separate from the events of their lives, including changes in their

bodies, roles, and activities. Health professionals who identify unnecessary pain avoidance

or activity restrictions in their patients could address this or refer to appropriately trained

mental health professionals. As previously discussed, education and training is also needed

by health professionals, who are sometimes the source of misinformation.

Strengths and Limitations

A strength of this study is that the study examined the two pain acceptance factors

using a qualitative methodology, providing a nuanced view of participants’ pain willingness

and activity engagement that we did not find in the extant literature. Additionally, because of

the recruitment method used and the qualitative study design, results from the study cannot

be generalised beyond the participants studied. However, the commonalities in participants’

responses suggest that the findings may be cautiously applied to other people with chronic

pain. A possible limitation of our research is that the expression “getting on with life in spite

of chronic pain” was used to draw out participants’ experiences of and views on acceptance,

but participants may have understood the expression to mean something other than what was

intended.

Future researchers would do well to investigate how people can achieve acceptance of

chronic pain both with and without professional intervention. Such research would facilitate

the development of appropriately targeted education, counselling and clinical interventions.

Conclusions

The current study suggests that people with chronic pain need education about chronic

pain, and, in particular, about the effects of social withdrawal and avoidance and control of

pain. The beliefs people hold about chronic pain, including its effects and how to manage it,

appear to lead to unnecessary restrictions, and contribute to distress and disability.

Acknowledgements

DELETED FOR PURPOSES OF BLIND REVIEW

Conflicts of interest

None.

Funding

This research received no specific grant from any funding agency, commercial, or not-for-

profit sectors.

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