Pain Medicine 2016; 17: 1079–1093
doi: 10.1111/pme.12929
Cognitive-Motivational Influences on Health
Behavior Change in Adults with Chronic Pain
Ryan J. Anderson, PhD,* Robert W. Hurley, MD,
PhD,† Roland Staud, MD,‡ and Michael E.
Robinson, PhD*
*Department of Clinical and Health Psychology,
University of Florida, Gainesville, Florida; †Department
of Anesthesiology, Pain Medicine, Medical College of
Wisconsin, Wauwatosa, Wisconsin; ‡Department of
Medicine, University of Florida, Gainesville, Florida,
USA
Correspondence to: Michael E. Robinson, PhD,
Department of Clinical and Health, Psychology,
Center for Pain Research and Behavioral Health, 101
South Newell Dr, Room 3141, University of Florida,
Gainesville, FL 32611, USA. Tel: 352-273-6153; Fax:
352-273-6156; E-mail: [email protected].
Disclosure and conflict of interest: There are no sources of support to declare for this study. Authors have
no conflicts of interest to declare.
practiced the health behaviors (22–26% improvement), but they required twice that (47–54%
improvement) to make it worth their while to commit
to practicing them. Participants expected to get the
most symptom relief from relaxation and activity
pacing, but they were most confident and motivated
to eat a healthy diet. In a subsample of participants
who provided data for psychometric analysis, the
BET-CP demonstrated strong test-retest reliability
across 7 days and adequate convergent validity.
Conclusion. While patients with musculoskeletal
pain have outcome expectancies that are nearly in
line with research on behavioral pain treatments,
their stringent requirements for symptom benefit
may impede engagement in the health behaviors
recommended for their pain-related symptoms.
Additional psychometric study with larger sample
sizes is needed to further validate the BET-CP.
Key Words. Psychology; Behavior; Expectation;
Self-efficacy; Motivation; Exercise
Abstract
Introduction
Objective. The primary aim was to assess the psychological factors that influence engagement in
health behaviors in individuals with chronic pain
using a new measure, the Behavioral Engagement
Test for Chronic Pain (BET-CP). A secondary aim
was to determine preliminary psychometric properties of the BET-CP.
Subjects. Participants were 86 adults with chronic
musculoskeletal pain recruited from University of
Florida pain clinics and the community.
Methods. Participants completed a battery of selfreport instruments online, including the BET-CP
and measures of related constructs. Items on the
BET-CP assessed motivation, self-efficacy, outcome
expectations, and the symptom benefit required to
engage across four health behaviors: exercise, diet,
sleep, and pain self-management (e.g., relaxation
and activity pacing).
Results. Participants reported modest expectations
of pain-related symptom improvement if they
In recent decades, unhealthy behaviors (e.g., poor diet,
inactivity, smoking, risky sexual behaviors) have been
implicated in many of the major causes of mortality and
chronic disease [1]. Promotion of healthy behaviors has
therefore played an important role in the prevention and
management of chronic health conditions. In chronic
pain, behavioral treatments have served as effective
adjuncts to biomedical interventions [2]. With the goal of
improved functioning and increased engagement in life,
traditional components of cognitive-behavioral therapy
for pain include relaxation skills training, activity pacing,
behavioral activation, and cognitive restructuring [3].
More recently, other behaviorally mediated health problems have been targeted to improve management of
chronic pain. Specifically, obesity, physical inactivity,
and sleep problems have been shown to increase risk
for chronic musculoskeletal pain [4,5], and to worsen
pain-related symptom severity and disability once the
condition has developed [6–10]. Behavioral sleep interventions [11,12] and lifestyle weight loss treatments
(e.g., diet and exercise) [13–15] have shown promise in
affecting pain-related outcomes in musculoskeletal pain
conditions.
C 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected]
V
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However, sustained engagement can be challenging for
patients as behavioral interventions may conflict with
long-standing pain-coping behaviors. Not surprisingly
then, dropout or noncompliance to behavioral medicine
treatments are common, and attrition can be as high as
60% [16,17]. While some efforts have been made to
individualize prescription of exercise in chronic pain
patients [14,18], other providers may not take the time
to understand a patient’s motivation, abilities, or expectations about behavioral treatments, which can potentially also contribute to treatment nonadherence.
Through the creation of a clinically relevant self-report
measure, the present study seeks to understand the
chronic pain patients’ expectations and beliefs with
regard to engaging in health behaviors. This information
can be used to understand individual differences in
health behavior change, and ultimately may be used as
targets for intervention to improve motivation for and
adherence to behavioral interventions for pain.
The study was informed by two related literatures:
patient-centered outcomes and health behavior change
in chronic pain. Patient-centered health care strives to
take into account the needs, preferences, and values of
the individual patient. It does this by improving doctor–
patient communication, by focusing on biopsychosocial
outcomes that are important to the patient, and by
understanding a patients’ expectations and beliefs
about their treatment [19]. The subjective nature of
chronic pain makes a patient-centered approach to its
assessment and treatment essential. Often complete
symptom remission is not possible in chronic pain conditions, and patients and providers can differ on the
degree of symptom improvement that they consider
successful treatment. Thus, increasing attention has
been paid to the development of alternate and individualized criteria by which to judge the effectiveness of a
treatment. To this end, Robinson et al. created the
Patient Centered Outcomes Questionnaire (PCOQ) [20]
to assess patients’ definition of treatment success and
expectations for improvement. The instrument has been
used in a variety of chronic pain populations, and results
demonstrated that the chronic pain patient’s definition
of treatment success tends to be stringent, and their
high expectations for treatment-related improvement are
greater than what pain treatments can provide [20,21].
This mismatch between patient expectations and treatment effectiveness can contribute to frustration on the
part of patient and provider, and may increase the
chance for treatment noncompliance or dropout.
Behavioral pain researchers have also made efforts to
apply theories of health behavior change to chronic pain
populations, including the Transtheoretical Model (TTM)
[22,23] and Social Cognitive Theory (SCT) [24].
Consistent with the mission of patient centered care,
this may lead to a better understanding of individual differences in engagement in behavioral pain coping.
Using factors specified in these theories, researchers
have found good evidence for the importance of selfefficacy, motivation, and outcome expectancies in
1080
explaining pain coping behavior [25–27]. In a clinical trial
context, motivation has predicted completion of behavioral treatment for chronic pain [28,29], and all three factors have been shown to mediate the outcomes of
behavioral treatment [30–33]. Included in this line of
research was the creation of two self-report measures
(Pain Stages of Change Questionnaire and the
Multidimensional
Pain
Readiness
to
Change
Questionnaire) that assess patients’ readiness to adopt
pain coping behaviors [27,34]. Use of these questionnaires helped to establish the importance of patient
motivation to behavioral treatment outcomes and
attrition.
In 2003, Jensen et al. organized the components of the
behavior change theories into one hybrid model: the
Motivational Model of Pain Self-Management [35]
(Figure 1). The model posits that motivation is a malleable psychological process that initiates and maintains
pain coping behavior, and is influenced by the SCT factors of perceived importance (beliefs about the importance of changing behavior) and self-efficacy (patients’
confidence in their ability to actually perform the behavior). Results of two cross-sectional studies were supportive of the model [36,37].
The current study extends patient-centered outcomes
research, and draws upon the behavior change literature to further understand the psychological factors that
influence health behavior engagement in chronic pain.
To help achieve this aim, the study developed and
tested a new measure of health behavior change [the
Behavioral Engagement Test for Chronic Pain (BETCP)]. The BET-CP represents an operationalization of
the Motivational Model for Pain Self-Management as it
uses the model as theoretical grounding for the
assessed constructs. The BET-CP differs from existing
measures in several ways. Existing measures of behavior change in chronic pain assess only motivation in the
context of traditional pain coping behaviors [27,34]. The
BET-CP assesses motivation and the cognitive determinants of motivation to practice not only the behaviors
taught in specialized psychological therapy (i.e., relaxation and activity pacing), but also the health behaviors
commonly prescribed by primary care and pain management physicians to address obesity, inactivity, and
sleep disturbance in individuals with chronic pain.
Additionally, while existing expectancy scales measure
expectations about treatment broadly defined [38,39],
the BET-CP is specific to behavioral treatment in a
chronic pain population, and uses pain-related symptom
scales to assess patient beliefs about practicing health
behaviors. Also of note, the study introduces a concept
novel to the pain behavior change literature—the benefit
requirement to engage—a domain most closely related
to a personal cost-benefit analysis.
Thus, the primary aim of the present study is to assess
the psychological factors that influence health behavior
engagement in individuals with chronic pain (e.g., motivation, self-efficacy beliefs, outcome expectations, and
Influences on Health Behavior Change
Figure 1 Motivational
Model of Pain SelfManagement [24].
beliefs about the benefit required to engage) across four
health behavior domains [physical activity, diet, sleep
behaviors, and pain self-management (i.e., relaxation
and activity pacing)] using a newly developed measure,
the BET-CP. A secondary aim is to perform preliminary
psychometric analyses on the BET-CP.
Methods
status, and employment status. Additionally, they were
asked to provide information regarding their pain condition, including: diagnosis, duration of their pain symptoms, and location of their pain. To indicate the location
of their pain, participants examined a body diagram divided into 20 sections, and answered “yes” or “no” as to
whether or not they are experiencing pain in each of
those areas.
Participants
Behavioral Engagement Test for Chronic Pain
Participants were adults with chronic musculoskeletal
pain recruited from the outpatient Rheumatology and
Pain & Spine Clinics affiliated with the University of
Florida in Gainesville, Florida. Patients presenting to the
two clinics were screened in-person for eligibility and
interest in the study. Participants were also identified by
posting study flyers around hospitals and medical clinics
in the Gainesville area. Individuals responding to the
flyers were screened for eligibility over the phone and
over email. Inclusion criteria for the study consisted of:
1) adults aged 18 years or older, 2) musculoskeletal
pain lasting at least 3 months in duration, 3) the ability
to read and comprehend English, and 4) access to a
computer with a connection to the internet. Exclusion
criteria for the study included participants who were
unable to provide informed consent, and those with a
current or recent cancer diagnosis. The study was
reviewed and approved by the Institutional Review
Board of the University of Florida. Prior to enrolling in
the study, all participants provided informed consent in
accordance with the Institutional Review Board. All participants received financial compensation following their
completion of the study, and this may have provided
incentive for them to participate.
Measures
Demographic and Clinical Characteristics
Participants provided the following demographic information: age, gender, race, years of education, marital
Item construction of the Behavioral Engagement Test
for Chronic Pain (BET-CP) was informed by the PCOQ
[20] and preliminary tests of the motivational model of
pain self-management [36,37]. BET-CP content is divided into two sections: a current functioning section that
assesses current pain-related symptom levels and
recent engagement in four health behavior domains,
and a beliefs section that examines patient beliefs and
motivation regarding the practice of the four health
behaviors. The measure is constructed in this manner to
obtain a snapshot of what and how a patient is doing
now, and then what it might take for them to change
their health behaviors. This information may potentially
be used by the pain management clinician when prescribing behavioral treatments, and by the patient to
help him or her clarify their beliefs and motivation to
practice health behaviors (Appendix 1).
In section 1, participants rate their usual levels of pain,
fatigue, emotional distress, interference in daily functioning, and sleep disturbance on 101-point numerical rating scales (0 ¼ none, 100 ¼ worst imaginable).
Numerical rating scales for pain have demonstrated
good convergent validity, are sensitive to treatment
effects, and are easy to administer [40]. Robinson and
colleagues have also used a one-item numerical rating
scale to measure usual levels of fatigue, emotional distress, and interference [20,21,41,42], and Brown et al.
demonstrated good concurrent validity of the one-item
ratings of usual symptom levels with standardized
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Anderson et al.
measures of the symptoms [41]. Additionally, retrospective ratings of usual pain have shown strong correlations
(r ¼ 0.78 or higher) with hourly ratings of pain over the
course of two weeks [43,44]. To ascertain the extent to
which patients are already practicing health behaviors,
section 1 of the BET-CP also asks participants to indicate their recent level of engagement in physical activity,
healthy diet, good sleep habits, relaxation, and activity
pacing on a 0 (never) to 100 (daily) numerical rating
scale.
Section 2 of the BET-CP begins by informing patients
that engaging in certain health behaviors can improve
their pain-related symptoms. It then lists the behaviors
(physical activity, sleep, diet, and pain self-management
via relaxation and activity pacing), and further defines
them by specifying practice recommendations. The
practice recommendations provide patients with frequency recommendations and concrete goals to give
them a basis for gauging their ratings of self-efficacy,
motivation, outcome expectancy, and benefit requirement to engage. For example, the physical activity recommendation of “30 min of moderate intensity physical
activity (e.g., brisk walking) on 5 out of 7 days a week”
is taken from the U.S. Department of Health & Human
Services 2008 Physical Activity Guidelines for Americans
[45]. Similarly, dietary recommendations were culled
from the U.S. Departments of Agriculture and Health
and Human Services 2010 dietary guidelines for
Americans [46]. The healthy sleep recommendations are
the common components of CBT for insomnia [47], and
the pain self-management recommendations of relaxation and activity pacing are two of the most common
strategies taught in behavioral therapy for pain [3].
Section 2 of the BET-CP then asks participants to rate
their beliefs regarding the importance of behavior
change (i.e., their outcome expectancy and benefit
requirement), their self-efficacy, and their readiness to
engage for each of the four health behaviors separately,
and for all behaviors as a package. Outcome expectancy and benefit requirement beliefs are assessed for
the pain intensity domain for individual health behaviors,
and they are assessed across four symptom domains
(pain, fatigue, emotional distress, and interference) for all
health behaviors combined. Using the same 0 (none) to
100 (worst imaginable) scale used to measure their
usual symptom levels, the outcome expectancy question asks participants to rate where they would expect
their symptom levels to be if they were to engage in the
behavior: “If I were to practice (insert behavior) regularly,
I would expect that my usual level of (insert symptom)
would be ____.” Participants with optimistic expectations might provide symptom ratings that are lower than
their usual ratings, while those who are more pessimistic
might expect that their symptoms would not change or
would even worsen if they engaged in the behavior.
The benefit requirement construct is novel and potentially taps into an internal cost-benefit dialogue that the
patient may be having in deciding whether to engage in
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these behaviors. The construct is related to the decisional balance literature in health behavior change,
which suggests that individuals weigh the anticipated
pros versus anticipated cons in deciding whether or not
to engage in a behavior. The benefit requirement question seeks to determine how much symptom benefit is
worth it to offset the costs of time and effort that it will
take to engage in the health behavior. Using the same 0
(none) to 100 (worst imaginable) scale, the benefit
requirement question asks participants to complete the
following sentence: “I WOULD practice (health behavior)
if doing so would improve my usual level of (symptom)
to ______.” The questions on outcome expectancy and
benefit requirement were positioned directly next to
each other (and next to a listing of their usual symptom
levels) to make it easier for the participants to gauge
current level symptoms vs expected level of symptoms
vs symptom level required to make it worth it to practice
the behaviors.
The question on self-efficacy assesses the participants’
perceived ability to engage in each behavior by asking,
“On a scale of 0 (not at all capable) to 100 (fully capable), how capable are you of regularly practicing ______
(insert health behavior).” Similarly, to assess participants’
motivation to engage in each health behavior, they are
asked, “On a scale of 0 (not at all ready) to 100 (fully
ready), how ready are you to regularly practice ______
(insert health behavior).”
Patient Centered Outcomes Questionnaire
Participants completed the patient centered outcomes
questionnaire (PCOQ) [20] to assess their definition of
treatment success, their expectation for treatment outcome, and importance of seeing improvement across
five symptom domains: pain, fatigue, emotional distress,
interference in functioning, and sleep disturbance. Items
on the PCOQ have demonstrated good construct validity, good test–retest reliability, and are sensitive to treatment-related change [20,41]. We expected that items
on the BET-CP and PCOQ assess similar constructs
involving treatment expectation and success from the
patient perspective. So for purposes of this study, the
PCOQ served as a measure to establish the convergent
validity of the new BET-CP.
Pain Self-Efficacy Questionnaire
The pain self-efficacy questionnaire PSEQ [48] consists
of 10 items assessing the respondent’s confidence in
their ability to participate in various activities despite
their chronic pain. Participants indicated their confidence on a 7-point Likert scale ranging from 0 (“not at
all”) to 6 (“completely confident”). A total score
(maximum ¼ 60) is obtained by summing the scores
from each of the 10 items. Higher scores indicate stronger self-efficacy beliefs. While the types of activities
Influences on Health Behavior Change
assessed on this questionnaire are more general in
nature (e.g., “I can enjoy things despite the pain” and “I
can do most of the household chores despite the pain”)
than the behaviors assessed on the BET-CP, it represents an established measure of self-efficacy beliefs,
and can therefore help to establish the convergent validity of the self-efficacy items on the BET-CP.
Multidimensional Pain Readiness to Change
Questionnaire
Guided by the motivation-related stages of behavior
change as outlined in the Transtheoretical Model of
Behavior Change, the Multidimensional Pain Readiness
to Change Questionnaire (MPRCQ2) [34] assesses the
chronic pain patient’s readiness to adopt common pain
coping strategies taught in cognitive behavioral therapy.
It consists of 69 statements about pain coping (e.g.,
“break up tasks into smaller pieces to get more done”)
rated on a 7-point Likert scale corresponding to the
stages of behavior change [1 ¼ “I am not doing this
now, am not interested in ever doing it” to 7 ¼ “I have
been doing this for a long time (at least 6 months)”].
Nine subscale scores are obtained, and in the current
study, only items from the relevant subscales of exercise
(7 items), relaxation (7 items), and pacing (6 items) were
completed by participants. These subscales were used
to help establish the convergent validity of the BET-CP
items assessing participants’ readiness to engage in the
health behaviors.
Procedures
The study was completed entirely online. Eligible and
interested participants were provided with a unique
username and password, and instructed to navigate
their internet browsers to a secure web address where
they inputed their username and password to access
the online study. Here, they provided informed consent
then completed the battery of self-report measures
described above. To address study aim two, a subset
of 25 participants returned to the website one week
later to complete the BET-CP again to provide test–
retest reliability data.
Statistical Analyses
Descriptive means and standard deviations were calculated for continuous demographic and clinical variables,
as well as for participants’ responses to each item on
the BET-CP. Frequency statistics were calculated for
the categorical variables of gender, race, marital status,
employment status, and self-reported diagnosis. A
repeated measures analysis of variance (RANOVA) (with
Sidak correction for multiple comparisons) was used to
test whether the mean ratings of practice frequency (as
assessed by 101-point numerical scales) differed across
the 4 health behaviors. RANOVAs (with Sidak correction)
were also used to test whether the degree of expected
or required symptom change differed by type of health
behavior or by symptom domain. The RANOVA test
was chosen because, in each of these circumstances,
we wanted test whether there were differences in mean
scores across 3 or more conditions where the sample
means are not independent (i.e., the same participants
provided ratings across the conditions). A series of
paired samples t-tests were used to test whether participants’ usual symptom levels were different than their
expected and benefit required symptom levels.
To establish the reliability of the BET-CP over time (i.e.,
test–retest reliability), the Pearson product-moment correlation coefficient was used to correlate participant
responses on each item of the BET-CP at time 1 with
their responses a week later at time 2. To establish the
convergent validity of the BET-CP, participant responses
to items on the BET-CP were correlated (using Pearson
product-moment correlation coefficients) with their
responses on existing measures of the associated phenomenon. Specifically, outcome expectancy and benefit
requirement responses on the BET-CP were correlated
with the treatment expectation and treatment success
questions on the PCOQ. Levels of readiness to engage
in exercise and relaxation/activity pacing as assessed by
the BET-CP were correlated with the exercise, relaxation, and pacing subscale scores of the MPRCQ2.
Finally, ratings of self-efficacy to engage in each of the
four health behaviors were correlated with their Pain
Self-Efficacy Questionnaire total score.
Results
Eighty-six adults with chronic musculoskeletal pain provided data for the analyses. Fifty-one participants
(59.3%) responded to print advertisements posted in
the Gainesville community, 26 (30.2%) were recruited
from the University of Florida Pain and Spine Clinic, and
9 (10.5%) were recruited from the University of Florida
Rheumatology Clinic. Of the 86 participants, 25 completed the BET-CP a second time to provide BET-CP
test–retest data.
Demographic and Clinical Characteristics
Demographic characteristics of the sample are displayed in Table 1. The sample was predominantly middle aged (average age ¼ 49.0 years), female (72.1%),
and Caucasian (77.9%). Approximately one-half the
sample was married (52.3%) and employed (41.9%),
and the sample was, on average, college educated
(mean level of education ¼ 15.0 years). Clinically, participants indicated that they had been experiencing pain
for an average of 9.5 years (SD ¼ 10.0, range ¼ 0.5–
40.0). On average, they endorsed 6.7 (SD ¼ 5.2,
range ¼ 1–20) areas of pain on the body diagram, suggesting that their pain was often not contained to one
area of their body. Of those who reported a diagnosis
for their pain, the most common conditions included
Fibromyalgia syndrome (N ¼ 18), herniated disc (N ¼ 9),
unspecified arthritis (N ¼ 7), osteoarthritis (N ¼ 7),
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Anderson et al.
Table 1 Demographic characteristics of the
sample (N ¼ 86)
Mean Age in Years
Female Gender
Race/ethnicity
Caucasian
Hispanic
African American
Asian
Indian
American Indian or
Alaskan Native
Other
Marital Status
Married
Divorced
Separated
Living with a partner
Single
Mean Years of Education
Employment
Employed
Unemployed
Retired
Homemaker
Disabled
Student
N
%
62
72.1
67
7
4
2
3
2
77.9
8.1
4.7
2.3
3.5
2.3
1
1.2
45
5
2
10
24
52.3
5.8
2.3
11.6
27.9
Years
49.0 (SD ¼ 16.9)
15.0 (SD ¼ 2.4)
36
7
15
7
12
9
41.9
8.1
17.4
8.1
14.0
10.5
degeneration of the cervical, thoracic, or lumbar disc
(N ¼ 6), and unspecified back pain (N ¼ 4).
Study Aim 1: Characterizing Participant Responses to
the BET-CP
Frequency of Health Behavior Engagement
Participant responses to the BET-CP are summarized in
Tables 2 and 3. Table 2 displays the self-reported frequency of engagement in the four healthy behaviors
over the past 12 months. The RANOVA found a significant main effect for health behavior (F3,83 ¼ 5.7,
P ¼ 0.001), and individual comparisons revealed that
participants’ reported frequency of healthy eating was
significantly greater than their engagement in physical
activity (P ¼ 0.004).
requirement levels to practice all health behaviors. A
series of paired samples t-tests revealed that, for each
symptom domain, participants expected that practicing
all health behaviors would result in a significant degree
of symptom improvement compared to their usual levels
(P < 0.001 for all comparisons). Additionally, participants
required a significantly greater degree of improvement
than they expected to get from practicing all health
behaviors (P < 0.001 for all comparisons).
To better characterize these differences, change scores
(relative to usual symptom levels) were calculated for
both expected symptom levels and benefit requirement
levels to practice all health behaviors. Table 3 displays
these values. The average expected levels of symptom
improvement if participants practiced all health behaviors ranged from 8.7 to 11.7 points (22.1–26.3%
improvement), depending on the symptom, and the
average required symptom improvement to engage in
all health behaviors ranged from 17.8 to 28.3 points
(47.6–53.9% improvement). RANOVAs (with Sidak correction for multiple comparisons) were conducted on
the difference scores determine whether there were differences by symptom domain. An RANOVA on the
expected change scores indicated a significant main
effect for symptom domain (F3,255 ¼ 3.2, P ¼ 0.02), and
individual comparisons revealed that the amount of
expected improvement in emotional distress was significantly less than the expected amount of expected
improvement in fatigue (P ¼ 0.01). Similarly, an RANOVA
on the benefit requirement change scores revealed a
significant main effect for symptom domain (F3,77 ¼ 8.5,
P < 0.001), and individual comparisons indicated that
the amount of required improvement in emotional distress was significantly less than the amount of required
improvement in pain, fatigue, and interference in daily
functioning (P < 0.001 for all comparisons).
In summary, participants expected to improve by 22–
26% if they practiced all health behaviors, and they
would require even more improvement than that (47–
54%) to make it worth their while to practice all health
behaviors. While the absolute magnitude of expected or
required improvement was less for emotional distress
than it was for the other three symptoms, when viewed
as a percentage of the usual symptom levels, the percentage of expected and required improvement is similar for all four symptoms. This pattern of results can be
explained by the lower ratings of usual emotional distress compared to usual ratings of pain, fatigue, and
interference. The lower levels allowed less room for participants to adjust the levels of expected or required
improvement in emotional distress compared to that of
the other three symptoms.
Usual Pain, Expectation, and Benefit Requirement to
Practice All Behaviors
As displayed in Table 3, participants reported moderate
levels of usual pain, fatigue, emotional distress, and
interference in daily functioning. Table 3 also displays
participants’ expected symptom levels and their benefit
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Expectation and Benefit Requirement to Practice
Individual Health Behaviors
Expectation and benefit requirement for improvement in
pain was also assessed for each health behavior
Influences on Health Behavior Change
Table 2
Participant responses to BET-CP: self-reported practice of health behaviors over the past year
Practice of health behaviors over the past year: 0 (never) to 100 (daily)
Physical activity
Good sleep habits
Healthy diet
Pain self-management(relaxation, activity pacing)
Mean
SD
Observed range
54.9
59.5
67.2†
58.6
34.5
30.6
24.0
31.8
0.0–100.0
0.0–100.0
0.0–100.0
0.0–100.0
*Test–Retest
correlation
0.90
0.84
0.76
0.81
*Pearson r correlation between participant responses at Time 1 and their retest responses 7 days later at Time 2 (N ¼ 25).
†
P < 0.05 compared to physical activity, good sleep habits, and pain self-management.
separately. These values are displayed in Table 3, along
with their corresponding change scores from usual pain.
When asked to think about practicing the healthy
behaviors individually, participants’ average amount of
expected improvement in pain ranged from 11.3 to 17.8
points (21.5–33.8% improvement), depending on the
health behavior, and their average amount of required
improvement in pain ranged from 21.8 to 23.8 points
(41.4–45.2% improvement). RANOVA revealed a significant main effect for health behavior for degree of
expected change (F3,255 ¼ 6.5, P < 0.001), and individual
comparisons suggested that the amount of expected
improvement in pain was significantly greater for the
practice of pain self-management (i.e., relaxation and
activity pacing) than it was for physical activity or for
eating a healthy diet (P < 0.05 for both comparisons).
The RANOVA conducted on the degree of required
change did not find a significant main effect for health
behavior, indicating that participants required approximately the same degree of improvement in pain across
the four health behaviors.
In summary, participants expected their pain to improve
by 21–34% if they practiced the health behaviors individually, and they would require even more improvement
than that (41–45%) to make it worth their while to practice the health behaviors individually. While participants’
required improvement in pain did not differ by individual
health behavior, they expected that relaxation and activity pacing would provide them greater pain relief than
the other health behaviors.
Motivation and Self-Efficacy
Participants were asked to rate how capable (i.e., selfefficacy) and how ready (i.e., motivated) they were to
practice each health behavior separately and all of them
together on 101 point numerical scales. Table 3 displays
these results. Ratings of self-efficacy ranged from 68.3
(physical activity) to 82.6 (healthy diet), and ratings of
motivation ranged from 72.3 (physical activity) to 82.4
(healthy diet). RANOVAs were conducted to determine if
ratings of self-efficacy or motivation differed by health
behavior. In the self-efficacy analysis, there was a significant main effect for health behavior (F4,82 ¼ 6.7,
P < 0.001), and individual comparisons revealed that
participants rated their capability to eat a healthy diet
significantly higher than their capability to engage in
physical activity (P < 0.001), good sleep habits
(P ¼ 0.005), and all health behaviors together
(P ¼ 0.001). A significant main effect for health behavior
was also found in the RANOVA on ratings of motivation
(F4,82 ¼ 3.6, P ¼ 0.009). Individual comparisons revealed
that participants rated their motivation to eat a healthy
diet as higher than their motivation to engage in physical
activity (P ¼ 0.009).
Study Aim 2: Test–Retest Reliability and Convergent
Validity of the BET-CP
Twenty-five participants provided data for the test–retest
analysis. Tables 2 and 3 display the Pearson r values for
each item correlating participant responses at time 1
with their responses at time 2. Test–retest reliability was
moderate too strong for all items on the BET-CP
(Pearson r correlation range ¼ 0.63–0.94); correlation
values exceeded 0.70 for 27 of the 34 items, and they
exceeded 0.60 for all 34 items.
Results of the convergent validity analyses are displayed
in Table 4 and were based on data provided by a subsample of 55 participants. Responses on established
measures of expectation, success criteria, self-efficacy,
and motivation showed convergence (via consistently
moderate strength correlations) with similar constructs
on the BET-CP. Participants’ expectation of symptom
response to practicing all the health behaviors demonstrated moderate correlations (Pearson r ¼ 0.30–0.47)
with responses to the PCOQ item assessing expectation
about symptom response to unspecified treatment for
their pain. Similarly, the BET-CP item assessing participants’ symptom benefit requirement to make it worth
their while to practice all the health behaviors demonstrated
moderate
correlations
(Pearson
r
correlations ¼ 0.41–0.47) with their criteria for successful
treatment as assessed by the PCOQ. In both analyses
relating the BET-CP with the PCOQ, the pain intensity
symptom showed the weakest correlations (Pearson
r ¼ 0.30 and 0.41, respectively), while emotional distress
demonstrated the strongest correlations (Pearson
r ¼ 0.47 and 0.47, respectively).
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Anderson et al.
Table 3 Participant responses to BET-CP: usual symptom levels, and expectation, benefit requirement,
self-efficacy, and motivation to practice health behaviors
Raw values:
mean (SD)
Observed
range
Change from usual
symptom levels:
raw value (% change)*
52.6
52.5
37.4
50.2
(24.2)
(27.5)
(27.6)
(27.2)
4.0–100.0
3.0–100.0
0.0–100.0
3.0–100.0
–
–
–
–
Expectation of symptom levels if practiced all health behaviors‡
Pain
40.9 (24.9)
Fatigue
38.7 (29.4)
Emotional Distress
28.7 (25.7)
Interference in Daily Function
39.1 (28.9)
0.0–100.0
0.0–100.0
0.0–100.0
0.0–100.0
Usual symptom levels‡
Pain
Fatigue
Emotional distress
Interference in daily function
Benefit requirement of symptom levels to practice ALL health behaviors‡
Pain
27.3 (24.0)
0.0–95.0
Fatigue
24.2 (23.3)
0.0–95.0
Emotional Distress
19.6 (21.4)
0.0–90.0
Interference in Daily Function
23.5 (26.6)
0.0–95.0
†
Test–Retest
Correlation
0.88
0.89
0.74
0.73
11.7 (22.2%)
13.8 (26.3%)
8.7 (23.3%)
11.1% (22.1%)
0.73
0.65
0.70
0.69
25.2
28.3
17.8
26.7
(47.9%)
(53.9%)
(47.6%)
(53.2%)
0.69
0.88
0.85
0.78
Expectation of pain level if practiced individual health
Physical activity
Good sleep habits
Healthy diet
Pain self-management (relaxation, activity pacing)
behaviors‡
41.3 (27.0)
36.5 (24.9)
39.1 (24.9)
34.8 (24.9)
0.0–100.0
0.0–90.0
0.0–100.0
0.0–90.0
11.3
16.1
13.5
17.8
(21.5%)
(30.6%)
(25.7%)
(33.8%)
0.63
0.69
0.89
0.85
Benefit requirement of pain level to practice individual
Physical activity
Good sleep habits
Healthy diet
Pain self-management (relaxation, activity pacing)
health behaviors‡
30.8 (26.3)
0.0–100.0
30.2 (26.2)
0.0–90.0
28.9 (25.5)
0.0–90.0
28.8 (25.5)
0.0–90.0
21.8
22.4
23.7
23.8
(41.4%)
(42.6%)
(45.1%)
(45.2%)
0.67
0.81
0.82
0.86
Self-efficacy (capability) to practice health behaviors§
Physical activity
Good sleep habits
Healthy diet
Pain self-management (relaxation, activity pacing)
All health behaviors
68.4
70.0
82.6
74.9
72.7
(29.8)
(29.1)
(23.3)
(27.1)
(20.9)
0.0–100.0
0.0–100.0
0.0–100.0
0.0–100.0
0.0–100.0
–
–
–
–
–
0.85
0.71
0.89
0.91
0.84
Motivation (readiness) to practice health behaviors#
Physical activity
Good sleep habits
Healthy diet
Pain self-management (relaxation, activity pacing)
All health behaviors
72.3
75.6
82.4
76.3
73.7
(30.2)
(29.5)
(22.0)
(27.7)
(24.5)
0.0–100.0
0.0–100.0
0.0–100.0
0.0–100.0
0.0–100.0
–
–
–
–
–
0.69
0.80
0.89
0.94
0.85
*Percent change values were derived by subtracting participants’ expected or required symptom levels from their usual levels,
then dividing that number by their usual levels and multiplying by 100.
†
Pearson r correlation between participant responses at Time 1 to their re-test responses 7 days later at Time 2 (N ¼ 25).
‡
Rating scale: 0 (none) to 100 (worst imaginable).
§
Rating scale: 0 (not at all capable) to 100 (fully capable).
#
Rating scale: 0 (not at all ready) to 100 (fully ready).
1086
Influences on Health Behavior Change
Table 4 Convergent validity: participants’ responses on the BET-CP correlated with their responses on
the PCOQ, PSEQ, and MPRCQ-2 (N ¼ 55)*
Pearson r value
P value
BET-CP expectation of symptom levels if practiced all health behaviors correlated with PCOQ expectation item†
Pain
0.30
0.03
Fatigue
0.39
0.004
Emotional distress
0.47
<0.001
Interference in daily function
0.42
0.001
BET-CP benefit requirement of symptom levels to practice ALL health behaviors correlated with PCOQ success criteria
item‡
Pain
0.41
0.002
Fatigue
0.44
0.001
Emotional Distress
0.47
<0.001
Interference in Daily Function
0.41
0.002
BET-CP ratings of self-efficacy (capability) to practice each healthy behavior correlated with PSEQ total score§
Physical activity
0.55
<0.001
Good sleep habits
0.25
0.07
Healthy diet
0.47
<0.001
Pain self-management (relaxation, activity pacing)
0.36
<0.006
All healthy behaviors
0.46
<0.001
BET-CP ratings of motivation (readiness) to engage in physical
0.44
0.001
activity correlated with MPRCQ-2 exercise subscale#
BET-CP ratings of motivation (readiness) to practice pain
0.49
<0.001
self-management correlated with MPRCQ-2 relaxation subscale
BET-CP ratings of motivation (readiness) to practice pain
0.37
0.007
self-management correlated with MPRCQ-2 pacing subscale
*Responses from 55 participants were used in the convergent validity analyses. Responses from the other 31 participants were
not used in these analyses due to the potential confounding effects of a brief psychoeducational intervention that was performed
prior to their completion of the validity measures. Description and results of the intervention are beyond the scope of this report.
†
Text of PCOQ expectation item: “We would like to know what you expect your treatment to do for you. On a scale of 0 (none) to
10 (worst imaginable), please indicate the levels you expect following treatment”.
‡
Text of PCOQ success criteria item: “On a scale of 0 (none) to 10 (worst imaginable), please indicate the level each of these
areas would have to be at for you to consider treatment successful.”.
§
Example of a PSEQ item: “I can do most of the household chores (e.g., tidying-up, washing dishes, etc.), despite the pain.”
Items are rated on a 0 (not at all confident) to 6 (completely confident) scale.
#
Example of an MPRCQ-2 item: “Exercise for at least 30 min, 3 times per week or more.” Items are rated on a 1 (I am not doing
this now, and am not interested in ever doing it) to 7 (I have been doing this for a long time (at least 6 months) scale.
Participant ratings of self-efficacy to practice the health
behaviors demonstrated small to moderate associations
with their PSEQ total score. Capability to practice good
sleep habits showed the smallest correlation (Pearson
r ¼ 0.25) with the PSEQ measure, while capability to
engage in physical activity demonstrated the largest correlation (Pearson r ¼ 0.55). Finally, to analyze the convergent validity of the BET-CP assessment of
motivation, BET-CP ratings of readiness to engage in
physical activity were moderately correlated (Pearson
r ¼ 0.44) with the MPRCQ-II exercise subscale, while
ratings of readiness to practice pain self-management
demonstrated moderate correlations with the relaxation
subscale (Pearson r ¼ 0.49) and the pacing subscale
(Pearson r ¼ 0.37).
Discussion
The present study describes an assessment of the cognitive-motivational influences on health behavior change
in adults with chronic pain using a new self-report
instrument (the BET-CP) designed to measure the level
of motivation to practice health behaviors, as well as the
beliefs that drive this motivation. Among the beliefs
assessed include those of outcome expectancies, and a
novel measure of cost-benefit: the symptom benefit that
patients require to make it worth their while to engage
in the health behaviors. Findings suggest that patients
are indeed able to make a distinction between these
two concepts, and results revealed the discrepancy
between the amount of symptom improvement
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Anderson et al.
expected versus required from practicing the health
behaviors. While participants endorsed modest expectations of symptom improvement if they did practice the
health behaviors (22–26% improvement), they required
twice that (47–54% improvement) to make it worth their
while to commit to practicing them. Thus, while participants’ expectations for symptom improvement are more
in line with the reality of behavioral pain treatment effectiveness, their stringent benefit requirement suggests
that they may never actually engage in the behaviors, or
may drop from behavioral treatment once they have a
chance to sample its effectiveness. This result is consistent with previous studies on Robinson’s PCOQ [20],
which found that patients do not require 100% symptom abatement to consider pain treatment a success,
but they may require larger reductions in their pain than
existing treatments are able to provide.
Participants’ stringent benefit requirement beliefs did not
necessarily translate into an absence of motivation or
complete refusal to practice the health behaviors in this
sample. On average, participants reported practicing the
behaviors at least some of the time. There are several
possibilities that may explain this pattern of results. First,
the group means reported in the results do not capture
individual variability in responses. Second, benefit
requirement beliefs (and their relationship to expectations and behavioral practice frequency) may not be an
all-or-none phenomenon. A patient with benefit requirements that exceed expectations might practice the
behavior, but do so with less frequency or less sustained effort. Third, as detailed in the Motivational Model
for Pain Self-Management, benefit requirement beliefs
are only one factor that contributes to motivation to
practice behaviors. Other factors like self-efficacy or
environmental and medical barriers can also account for
the variance in practice frequency. Finally, the relationship between patient beliefs and frequency of behavioral
engagement may be more apparent when examining
these issues longitudinally rather than cross-sectionally.
Benefit requirement beliefs may be more relevant in predicting future behavior, like dropout or adherence, particularly when assessed just prior to initiating practice of
the health behavior.
The BET-CP also allows for the differentiation of beliefs
by health behavior. On average, participants expected
to benefit most from the practice of relaxation and activity pacing and benefit least from engaging in physical
activity. This result may, in part, be explained by the literature on kinesiophobia; individuals with chronic musculoskeletal pain commonly fear that movement will
exacerbate their pain and lead to further damage
[49,50] and may favor more sedentary activities as a
result. Consistent with this fear, in the current sample,
11 (12.7%) of the 86 participants expected that regular
exercise would worsen their pain, and an additional 25
participants (29.1%) expected that exercise would result
in no change to their pain levels. Extrapolating clinically,
psychoeducation on the benefits of exercise (to painrelated symptoms, and to other health variables like
1088
weight, mood, and cognitive functioning) may help to
counteract fear-avoidance beliefs and potentially
increase patients’ benefit to cost ratio with regard to
engaging in physical activity. A graded exposure
approach to the prescription of physical activity may
also help to correct these beliefs and mitigate dropout
from an exercise regimen.
While participants expected to get the most symptom
relief from practicing relaxation and activity pacing, they
were most confident and motivated to eat a healthy
diet, and both motivation and self-efficacy correlated
with their recent practice frequency of the behaviors.
This may be related to a greater familiarity with the
actions involved in eating healthy. Dieting is a ubiquitous
health behavior discussed in popular culture and prescribed frequently by physicians, while relaxation, activity pacing and sleep behaviors are less commonly
prescribed in medical settings and typically reserved for
specialty behavioral health treatment. The health benefits associated with healthy eating also extend well
beyond pain management, so participants may have
been eating healthy for reasons other than pain-related
symptom relief.
Participants reported moderate to high levels of motivation, self-efficacy, and recent practice frequency for
each of the health behaviors. Historically, self-report of
health behavior practice is subject to an over-reporting
bias and has not correlated highly with objective measures [51]. With this in mind, the relatively high levels of
self-efficacy, motivation, and behavioral practice frequency reported in the current study should be interpreted with caution as they may not correlate precisely
with actual practice frequency. Instead the responses
might be best viewed as a general guide to the clinician
and patient, suggesting generally what the patient has
been doing more or less of recently, and what they are
confident and motivated to practice in the future.
Preliminary psychometric analyses suggest that the constructs measured on the BET-CP are stable and can be
reliably assessed over time. Test-retest reliability over 7
days was strong (Pearson r .70) for 27 of the 34
items, and moderate to strong (Pearson r ¼ .63 .69)
for the remaining items. Expectation and benefit requirement items showed some variability in reliability.
Generally, these two constructs may be less familiar to
participants than the others, and require a certain
degree of hypothetical prognostication in gauging their
responses. Thus, patients may not be as reliable in their
responses to these items.
The BET-CP also demonstrated convergence with existing measures of similar constructs via consistently moderate strength correlations. The moderate correlation
values were large enough to demonstrate that the BETCP taps into its hypothesized constructs of expectation
of treatment response, self-efficacy, and motivation, but
not so large as to suggest redundancy in the measures.
Notably, with regard to self-efficacy, even though the
Influences on Health Behavior Change
PSEQ and BET-CP are not assessing the same behaviors, the two measures nonetheless demonstrated moderate strength correlations. This suggests that
behavioral self-efficacy may be a generalizable state for
individuals with chronic musculoskeletal pain. As they
gain confidence in their ability to participate in one
behavior, it may lead to confidence in others as well.
Limitations
The study has several limitations. First, the sample size
is relatively small to establish the psychometric properties of a new measure. As such, findings on the reliability and validity of the BET-CP should be considered
preliminary. Further psychometric study is needed with
larger sample sizes. Discriminant validity of the BET-CP
needs to be established, in addition to examining the
test-retest reliability of beliefs using a longer betweentest interval. Second, the design of the study did not
allow for corroboration of pain diagnosis by physician or
medical chart in the subset of participants who
responded to community advertisements. Diagnoses
were dependent upon the veracity of self-report which
may be subject to error in knowledge or memory.
Further, while the sample is diverse with regard to age,
setting, and type of musculoskeletal pain, participants
were predominantly White Caucasian and welleducated. It is unknown if results are generalizable to
other types of pain or to populations with more ethnic
or educational diversity. Additionally, our one-item
assessment of recent practice of health behaviors is not
ideal, and may compromise accuracy in favor of brevity.
Self-report is a historically inaccurate method of assessing health behavior practice, subject to biases in memory. A one-item assessment using a prolonged time
period of retrospection (i.e., one year) may compound
this problem. Finally, the BET-CP is not a measure that
captures all factors involved with behavioral treatment
adherence. It focuses on patient psychological factors,
and does not take into account the environmental influences (finances, safety, travel distance from gym),
patient medical factors (type and location of pain,
comorbidities), or clinician characteristics (e.g., personality) that may affect adherence to treatment.
Conclusion and Future Directions
Use of a new measure of the psychological influences
on health behavior change revealed that, to make it
worth their while to commit to practicing health behaviors, patients with chronic musculoskeletal pain require
approximately two times more treatment-related symptom improvement than they expect to get from the
practice of the behaviors. This mismatch in behavioral
treatment outcome expectancies and benefit requirement may negatively impact adherence to and satisfaction with treatment. Consistent with patient-centered
care, the results highlight the need for pain clinicians to
open a dialogue with their patients about what they
expect and need from their treatment, and how
confident and motivated they are to adhere to their
prescribed regimen. The BET-CP represents a vehicle
for the provider to ask about these issues in a behavioral treatment context.
Future work is needed to determine the clinical importance of a discrepancy between patient outcome
expectations and benefit requirement beliefs related to
the practice of health behaviors. Future work should
also test whether or not unrealistic beliefs about the
effectiveness of behavioral treatments for pain are able
to be altered. With regard to the BET-CP, further psychometric studies are needed using larger sample sizes
that establish the discriminant validity of the measure.
The BET-CP could also benefit from a revision. This
might include improving the specificity of healthy diet
practice recommendations, using a smaller retrospective
time period to ask patients about their recent practice
frequency of the health behaviors, and asking separately
about the behaviors of relaxation and activity pacing
rather than combining them.
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APPENDIX 1
The Behavioral Engagement Test For Chronic Pain
(BET-CP)
BET-CP Section One
ON A SCALE OF 0 (NONE) TO 100 (WORST
IMAGINABLE) PLEASE RATE YOUR USUAL LEVEL
OF:
Pain ______ Fatigue______ Emotional Distress ______
Interference in daily functioning _____ Sleep disturbance
______
ON A SCALE OF 0 (NEVER) TO 100 (DAILY),
GENERALLY IN THE PAST YEAR HOW OFTEN HAVE
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SYMPTOM RATING SCALE: 0 (none) to 100 (worst imaginable)
Your usual level of symptoms:
Compared to your usual levels of
symptoms, what would you expect
to happen to your symptoms if you
practiced ALL the healthy
behaviors?Complete this statement
for each symptom below: “If I were
to practice ALL the healthy behaviors daily, I would EXPECT that my
usual level of . . . ”
Pain ______
Fatigue ______
Emotional distress______
Interference in daily functioning ______
Pain would be ____
Fatigue would be ____
Emotional distress would be ______
Interference in daily functioning would
be ____
YOU BEEN
BEHAVIORS?
ENGAGING
IN
THE
FOLLOWING
Moderate physical activity (i.e., brisk walking) for 30
min ______
Good sleep habits (i.e., go to bed and wake up at the
same times everyday; no napping, limit activities in the
bed to only sleep or sex; no caffeine in the evening;
no tobacco or alcohol within 2 h of bedtime) ______
Eating a healthy diet ______
Practice self-management of your pain: relaxation
exercises (e.g., deep breathing, muscle relaxation) and
activity pacing (i.e., alternating periods of activity with
rest to avoid exacerbating pain) ______
BET-CP Section Two
There is compelling evidence to suggest that managing
your chronic pain through the practice of healthy behaviors is effective in improving your pain, fatigue, emotional
distress, and ability to function. These healthy behaviors
include:
EXERCISE:
n 30 min of moderate physical activity (i.e., brisk
walking) on 5 out of 7 days a week
GOOD SLEEP HABITS:
n Go to bed and wake up at the same times
everyday
n No napping
n Limit activities in bed to only sleep or sex
n No caffeine past noon
n No tobacco, alcohol, heavy meals or exercise
within 2 h of bedtime
EAT A HEALTHY DIET everyday with the goal of
achieving a normal weight:
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Compared to your usual levels of
symptoms, how much symptom
improvement would make it worth
your while to practice ALL the
healthy behaviors
regularly?Complete this statement
for each symptom below: “I would
practice ALL the healthy behaviors
daily if doing so would improve
my usual level of . . . ”
Pain to ____
Fatigue to ____
Emotional distress to ______
Interference in daily functioning to
____
n More fruits, vegetables, whole grains and lean
meat
n Less saturated fat and sodium
RELAXATION AND ACTIVITY PACING:
n Daily relaxation exercises (e.g., deep breathing and
muscle relaxation)
n Daily activity pacing (alternating periods of activity
with rest to avoid exacerbating pain)
Practicing All Healthy Behaviors
First we’d like to ask you about practicing ALL of the
above healthy behaviors. As you answer the questions
below in the table, you should refer to the above
explanations of the behaviors AND the column listing
your usual levels of symptoms. Please read each item
carefully.
Practicing Individual Healthy Behaviors
Now we would like to ask you about practicing each of
the healthy behaviors separately. As you answer the
questions below in the table, you should refer to the
explanations of the behaviors above AND the column
listing your usual level of symptoms. Please read each
item carefully.
Finally, we’d like to ask you how capable and how
ready you are to practice each healthy behavior individually, and all of them together.
On a scale of 0 (not at all capable) to 100 (fully capable),
how CAPABLE are you of regularly practicing each of
the healthy behaviors below?
Exercise ______
Good sleep habits ______
Influences on Health Behavior Change
SYMPTOM RATING SCALE: 0 (none) to 100 (worst imaginable)
Your usual levelof symptoms:
Compared to your usual level of pain,
what would you EXPECT to happen to
your pain if you practiced each healthy
behavior regularly?Complete this
statement for each healthy behavior
below: “IF I WERE TO . . .
Pain ______
Exercise, I would EXPECT that my
usual level of pain would be ______
Practice good sleep habits, I would
EXPECT that my usual level of pain
would be ______
Eat a healthy diet, I would EXPECT
that my usual level of pain would be
______
Practice relaxation and activity pacing, I would EXPECT that my usual
level of pain would be ______
A healthy diet ______
Relaxation and activity pacing ______
ALL of the healthy behaviors ______
On a scale of 0 (not at all ready) to 100 (fully ready), how
READY are you to regularly practice each of the healthy
behaviors below?
Compared to your usual level of pain,
how much improvement in your
pain would make it worth your
while to practice each of the healthy
behaviors regularly?Complete this
statement for each healthy behavior
below: “I WOULD . . . ”
Exercise, IF DOING SO WOULD
IMPROVE my usual level of pain to
______
Practice good sleep habits, IF DOING
SO WOULD IMPROVE my usual level
of pain to ______
Eat a healthy diet, IF DOING SO
WOULD IMPROVE my usual level of
pain to ______
Practice relaxation and activity pacing, IF DOING SO WOULD IMPROVE
my usual level of pain to ______
Exercise ______
Good sleep habits ______
A healthy diet ______
Relaxation and activity pacing ______
ALL of the healthy behaviors ______
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