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Resilience is a term used more and more by therapists, some might suggest it is a buzz word, so I wanted to put down my thoughts about this complex subject. I have wanted to write this blog for a while and the struggle I have had here is to keep it bloggy, not too academic and above all not too long! I have tried to strike a balance between research and also some personal experiences of resilience I have collected.

Before we get into it, there are 3 main points I would like to make in this blog.

Firstly, resilience is NOT about manning (or womaning) up, it is NOT SIMPLY about just keeping going. It’s a flexible, adaptable state that recognises the importance of specific actions, mental or physical, that have a positive impact on life.

Secondly, resilience is not a binary state between resilience and not resilient. It is a continuum that we move along dependent on a balance of internal and external factors.

Thirdly that resilience looks and feels different between people. What you may regard as resilience MAY NOT be the same as the person you are working with.

What is resilience?

Resilience is defined by Sturgeon *HERE* as,

“Maintenance of positive physical and emotional functioning in spite of significant difficulty or challenge”

So resilience is both a physical and psychological thing. It is important that we don’t separate the two however (much like pain!). Although physical things often signify resilience, they require a strong psychological component to achieve and also give a lot of psychological benefit.

This is also a good read *HERE*

Karoly *HERE* defines resilience as (2006) as

“Effective functioning despite the exposure to stressful circumstances and internal distress”

Both definitions use the word FUNCTIONING and ‘in spite’ or ‘despite’ of pain.

This makes resilience a REALLY individual thing that looks quite different between different folk. We should not make the mistake of assuming what signifies resilience to us is the same as someone else’s.

Pain is definitely a stressful circumstance for many, and it really becomes a problem when it interrupts our functioning. Focusing on the stressor, pain, however could be part of this problem. Essentially resilience should be seen as a problem of function rather than pain. This is an important distinction, as identification and engagement of functions must form the key focus (IMO) rather than the focus that many can have (patient & therapist), pain itself.

Sturgeon writes;

”Attempts to control a chronic stressor like chronic pain are often counterproductive and can magnify the negative effects of the stressor”

Sustainability

Goubert & Trompetter *HERE* introduce the concept of sustainability; this is defined as:

“ability of a person to move towards long-term positive outcomes in life in the presence of adversity”

Here is a nice graphic outlining sustainability vs recovery from their paper.

Sustainability targets the PERSON in pain rather than the pain itself. Perhaps sometimes the focus can be on the pain going away before function is resumed, but we could view this the other way around with functioning through resilience being the first step.

The concept of sustainability is important, as it looks more at positive traits rather than risk factors. This is a bit like Antonovsky’s Salutogenic approach *HERE* that focuses on health rather than disease.

So to sum up resilience, it is about PEOPLE and FUNCTION more than pain and withstanding pain (IMO). Working through ANY pain or injury will require some element of resilience. Acute back pain, one of the most prevalent painful issues, probably exemplifies the need for resilience, with the first line treatment for back pain being the advice to remain active and engage in your normal activities *HERE* .

Perhaps initial resilience may mediate the transition to more persistent pain states?

Adaptability & flexibility

Resilience should not be seen like a brick wall. A resilient person is not simply a cold piece of rock impervious to any stressor. It is not about toughness, it is instead a flexible and adaptive state.

It could be quite the opposite, in that resilient people might be willing to seek out help instead of the strong silent type who may not be as resilient as they appear externally, unable to appear weak or vulnerable by asking for help. Resilience maybe the ability to open the pressure valve and allow the excess to release and lower the stress by identifying things that allow them to do this or provide a balance with stressful situations.

Pain relief vs resilience

Therapy has long been driven by pain relief, and whilst there is no doubt this is a reason why people seek care, they also seek care because pain is disrupting their lives and functioning, perhaps even more so for this reason.

This paper by Ferrara found that disability was a greater reason for care seeking than pain intensity *HERE*

So perhaps to understand resilience we have to understand to understand our patients functioning and what THEY view as key markers to signify resilience. Traditionally VAS scales and physical measures such as strength have been used to measure clinical success. But do these measures capture valued activities and what resilience might mean for the person? Perhaps not. This paper looks at this subject of what is measured clinically vs peoples ACTUAL goals *HERE*.

So in order to help people BE resilient a good place to start is to find out more about how THEY view resilience, what defines their effective functioning and how we might bridge the gap between their current and desired states.

Resilience is PERSONAL

Valued activities may provide balance during stressful situations. Especially people that suffer with persistent pain can lose sight of things they used to do and the things that might define resilience. These are the people that may need a guide or a coach to find some meaning or goal again.

The sustained engagement in cherished activities, or stuff that MEANS stuff, seems to be a huge marker of resilience. To get a better idea of some of the meaningful activities, I asked some of the folk on social media (not in depth research I know) to let me know some of the things they found important during painful times.

Exercise seems to be a really important sign of resilience for people and it was amazing to hear so many success stories against some pretty adverse situations. On a side note, communicating  patient success stories to other patients, delivered at the right time and in the right way, can be a very powerful tool in my experience.

• Weightlifting
• Capoeira
• Yoga
• Pilates
• Boxing
• Bike riding
• Crossfit
• Running
• Walking
• Bouldering
• Various sports
• Gymnastics
• Dancing
• Making things
• Hiking

Work also featured heavily. Just day to day functioning seemed important. Much like exercise, our working lives are pretty varied  from being a therapist to nursing to simply driving. The concept of family also featured heavily with helping and providing for them forming  an important part of resilience for many.

Resilience seems to be a rich tapestry of different things. The clinical implication of this is being able to effectively listen and ask a few questions that allow us to find out more about what activities may signify resilience and then be able to guide someone towards them and also provide planning and support for engagement.

Here are some example questions I use:

“What would your perfect day without pain look like?”

“What have you stopped doing because of the pain?”

“Are there things you feel are important that you avoid because of the pain?”

I also picked out some quotes. I have not used any names : )

“For many years, my default position was to isolate myself, try to power through, and go out of my way not to seek out resources or strategies. I thought that was the way I was supposed to do it; “man up” and push through. For me, I think I discovered (still am) resilience when I learned about acceptance. Getting to acceptance, and I think I still struggle with that a bit to this day, was a difficult time as I had to admit that I could not do this on my own. I hated that feeling”

“Resilience is in all of us, but sometimes we need a guide to help us find our path forward, but there is always a path forward”

“I would say the thing that made me the most resilient was asking for help. From my mentors, friends, counsellors and family. Vulnerability helped me be more resilient”

“I love riding my bike but on a steep hill climb my pain would escalate 10 fold. I persisted and after 30 mins or so off cycling it would go back down to normal levels. The bike ride was more important for my mental well being than the back pain maybe that is why I persisted”

“Resilience for me is knowing that there are things you can and can't control and you put energy and focus into those things you can control/accept”

“Resilience is I get up everyday and work with injuries on others. Sometimes leaving bed is the hardest part”

 It could be balancing the stressful parts of life with things that bring us happiness and joy is most important and when we lose this balance is when we start to become more vulnerable and our job maybe to help with this process.

What components make up resilience?

Both Sturgeon and Goubert outline some positive elements AND some risk factors involved in resilience.

Lets first start with the positive elements.

Optimism & positive emotions

Optimism appears to be a key characteristic, with optimism being related to lower levels of pain and this may support why predicted expectations are related to outcomes. Optimism should be viewed both from a clinician and patient viewpoint and without doubt both viewpoint will interact within the 'third space'.

Here are some good papers *HERE* & *HERE*

Questions we can ask ourselves:

• Are you a generally optimistic clinician/person?
• How optimistic are you about a positive outcome?
• Do you discuss what a positive outcome might look like, especially in regards to improved function?
• Can we highlight positive aspects from the person’s story/history, previous positive experiences to be optimistic about?

Although it is important to not seem disingenuous, the need for positivity and a positive emotional perspective on life and activity should be highlighted, although this should probably come after a validation of normal negative responses to a tough situation such as persisting pain.

I feel it is also important to highlight the negative aspects of negative thinking and behaviour.

Pain acceptance & sustained engagement in valued activities

Pain acceptance is defined as acknowledging that one has pain, stopping attempts to control pain, and learning to live a richer life in spite of pain. This in turn can lead to more engagement in valued activities.

Sturgeon writes

“individuals with greater levels of activity engagement are better able to bolster their positive emotions through sustained pursuit of valued activities despite their pain”

This appears to be a key factor, both highlighted in the research and also in the in depth qualitative research I performed above on social media ; )

Social support

People who actively seek out social support seem to have lower levels of pain. We know from work such as Riikka Holopainen's *HERE* that people with persisting pain reported that their circle of life had shrunk and they had given up doing things they used to enjoy.

Pain can interrupt positive social interactions that are important for resilience, however pain can also narrow our ability to identify these positive social interactions and positive resilience resources in general.

Risk factors

Pain catastrophisation & avoidance

Higher levels of pain catastrophizing and fear are linked to higher levels of pain and pain catastrophizing can also lead to ineffective coping strategies such as an avoidance approach to coping. This behaviour is consistent with the affective-motivational side of pain that can often motivate people to avoid things such as social interactions and physical activities. Essentially this can limit the enjoyment and positive aspects gained from valued activities, often for fear of pain, and can reduce resilience behaviours. This prolonged avoidance can also lead to depression and disability.

I feel it is important to highlight avoidant approaches and also help someone to rationalise if they are actually helpful for them or not.

But it is also important NOT to simply label people avoiders. Avoidance like all things is complex. Some activities may display avoidance behaviours whilst other things are engaged in. It is a touch harsh to take an area of someone’s life they are struggling with and use it to define them.

Resilience or vulnerability

We must be mindful that resilience does not appear to be a stable state. People are not simply resilient or vulnerable. Instead they appear to have components of both aspects co-existing in a sort of balancing act. Sometimes we maybe more susceptible to vulnerability, even the most resilient is resilient until they are not. We may also be vulnerable in some areas of our lives but not in others. We could be physically resilient but emotionally vulnerable or the other way around. It could switch from day to day. The one thing we know about the experience of pain, and all the dimensions that go into it, is that it pain is predictably unpredictable.

Resilience should really be seen as a continuum. Different injuries may require different levels of resilience and the person will have a current resiliency state dependent on many factors in their life. Some people may be super resilient or the injury type or state may not require much resilience. As with all painful problems this relies on clinical reasoning to apply the right care at the right time.

Take homes

• Resilience IS NOT TOUGHNESS
• Resilience is about adaptability and physical and psychological flexibility
• Resilience lies on a continuum
• Resilience looks and feels different to different people
• Optimism is key
• Sustained engagement in valued activities is key
• Pain catastrophization and avoidance behaviour are risk factors

Self efficacy is a term banded around in therapy quite regularly at the moment especially as more active approaches to rehabilitation are being embraced.

So we have to ask exactly what does it mean, why does it matter and how do we improve it?

In fact my twitter friend/colleague Jerry Durham asked me this question whilst I was in the process of writing this blog, talk about great timing! It also shows that we often don’t have a well defined definition for a well used term.

Lets start with what does it mean?

It was a term first coined by Bandura in the 70’s, he described it is the 'belief of an individual on whether they have the ability to perform behaviours relative to a specific activity'. Self efficacy has also been described as a ‘resilient self belief system’.

I like to describe it as a sense that ‘I have got this’ or ‘I can do this”.

This could be self efficacy in relation to pain, such as the perception of the ability to remain functional and perform activities of daily living whilst you have pain, or it could be treatment related activities such as a specific activity or exercise.

So lets say that your kind therapist has suggested that you go to for a walk to help out with your back pain, do you think that you will be capable of doing this?

Maybe you don’t feel motivated?

Perhaps you don’t feel confident that you physically can?

Could be that you feel you can’t fit it into your busy life?

Low self efficacy may result in challenges, such as changes in behaviour, being seen a threats to be avoided rather than things that can be overcome.

Bandura identified a number of psychological process involved with self efficacy, these being cognitive, motivational and affective (emotional). Having valued goals and activities appears to be a associated with these factors as well and self efficacy and resilience literature points towards valued activities being an important part of this process HERE.

Bandura also identified four main sources of self efficacy.

Mastery

Previous mastery of an activity or action influences our future perception of capabilities. We are starting to learn that human beings use prediction based on past experiences to navigate the uncertain nature of the world around them. If we have been successful at something in the past then it is likely we will perceive that we can overcome it again. This is also related to the ease of the successes. If our successes have being easy then we maybe quickly dissuaded by obstacles. If the successes have been tough then we may also be used to overcoming any obstacles that come our way.

In line with this view we see that previous adherence and participation in exercise has been shown to be important in future exercise adherence HERE.

Experiences

The world around us also influences our perception of capabilities. If people surround you that you perceive as similar, who are achieving similar things that you are being required to achieve, then you will also be more likely see these things as attainable. This could be from the media that we consume to the involvement in social activities or our family circle, this underlines the social aspects of pain that appear to be pretty important.

This is a great recent paper on social factors in pain HERE

Persuasion

Now this can be both positive and negative, and of course it is easier to be influenced negatively than positively! But those that are persuaded, both verbally and experientially, that they are capable of achieving a task are more likely to be able to do so especially if we see previous success as a key factor.

Negative emotions

Strong negative feelings towards an activity or the negative perception around an activity also will influence the level of self efficacy someone has. Self doubt is often an emotion that influences behaviour negatively.

So we have to also ask, why is it important?

It appears that self efficacy has been linked in multiple papers to worse outcomes across various measures of pain and disability. Now we cannot suggest it is causative or even that improving it will simply improve outcomes at this moment in time. But if I were to go out on a limb I think it probably would : ), especially if we are promoting more active approaches to therapy.

Certainly exercise as a treatment relies on it being performed and evidence based medicine falls flat on its face if we cannot apply the treatment to the patient.

Foster, in 2010, found that for people with low back pain, low confidence in their ability to perform normal activities, or low self efficacy, was predictive of a worse outcome in terms of disability at 6 months, in fact better than fear avoidance, catastrophising or depression HERE.

Keedy, 2014, found that those without the ability to engage in pain management related behaviours, pain self efficacy, is related to the outcomes for back pain rehabilitation HERE.

Greater passive behaviour scores were also found to be associated with worse outcomes at a five year follow up for lower back pain by Chen, 2018 HERE. Passive coping strategies rely on external resources for pain control rather than internal resources such as our belief systems HERE that also influence self efficacy.

Self efficacy has also shown to be fundamental to the adherence of exercise interventions. These studies found that low self efficacy was a predictive factor for poor adherence to a home exercise program HERE & HERE. For all the focus on the nuts and bolts of exercise, it is a pretty redundant process if the person does not feel capable of doing it. Time spent in this area rather than a focus on sets and reps may drastically improve adherence and therefore outcomes.

I call this focusing on the hole rather than the donut (the whole!)

What can we do to alter it?

Success!

The first steps may simply be to create a successful experience!

Previous successful adherence and progress have been associated with increased self efficacy and this ties in with a Bayesian perspective of human function. So perhaps our aim for those that display low self efficacy should be to set a low threshold for activity that can lead to easy adoption and fast progress. We often aim for a dosage of activity that leads some kind of physical overload and adaptation. This could potentially lead to a negative experience for some and limit increased participation, without a positive initial experience they may not achieve longer term sustainable success. So essentially good for psychology but not so much for physiology in the short term but hopefully leading to greater longer term physiological impact through sustained participation.

It could be that just making an exercise session fun and not boring could be a very beneficial outcome. We often don’t place much importance on these things within medicine though. Why do people play sports? Maybe because they enjoy other aspects beyond just the physical exertion component.

People are often driven by challenge, fun & competition, how often do you incorporate these aspects into your training?

Some questions I often ask to gauge self efficacy around exercise & activity are:

“Would you describe your self as confident around moving and exercising?”

“Do you feel you are currently capable of increasing your activity levels if required?”

“Would you describe yourself as motivated with regards to activity and exercise?”

Motivation

Motivation also appears to be a key aspect to self efficacy. Helping people find something that actually motivates them could also be important and this could be through a goal setting process that identifies valued activities.  We could then break it down into more perceived manageable chunks that create little wins to help motivate the person.

I call this helping them find their ‘why’.

Lots of exercise programs don’t resonate with people, especially if they have not really participated in one before so exercise in itself is not enough of a ‘why’ for them.

We might ask “what would your perfect day look like with regards to activity?” or “what are some things you love to do that you don’t or can’t?”.

Autonomy is another factor factor associated with successful exercise, HERE , so also giving choices and options rather than a 'this is the exercise you have to do' approach.

Planning

Sitting down and planning with people when they might do things and how much might also have an impact on self efficacy. Being able to do this for themselves might be a limiting factor and the participation in activity may feel like too great a challenge without some guidance.

What days might be best?

What time of day?

What type?

For how long?

What kind of effort level?

Set a reminder on the smart phone?

How to progress?

Alternative options if you do not succeed?

Takeaways

• Previous experiences with behaviours is involved with future self efficacy
• Social environment and support is important
• Self efficacy can make or break an active approach to treatment
• Self efficacy is involved in outcomes for pain and disability
• Self efficacy is important for exercise adherence
• Create behavioural wins and good experiences
• Your input in terms of planning and motivation is vital if self efficacy is low

Undoubtably the disc can be a source of nociception and relevant in back pain. The plausability is not in question here.

WARNING - the data below is likely to leave things much murkier than clear!!!

We also see that more findings (3 or more) on an MRI report were more strongly associated with LBP than a single finding.

Diagnosis

Lumbar discogenic pain: state-of-the-art review

Diagnostic criteria for the clinical syndrome of internal disc disruption: Are they reliable?

Over the longer term for conditions such as disc degeneration the famous Battie twin study would suggest loading has limited influence.