Amy S. Hammerich, Susan A. Scherer, Mark A. Jones
Influence of Stress, Coping and Social Factors on Pain and Disability in Musculoskeletal Practice
Like individuals with any other health condition, individuals with either acute or chronic and recurring musculoskeletal conditions may need to adjust their behaviours and lifestyles while trying to maintain basic physical, social, vocational and recreational activities. To manage their musculoskeletal condition, individuals must try to understand the nature of their problem, create or learn self-care strategies for dealing with pain, manage and attempt to overcome functional problems and identify and utilize available support and resources wisely. Chapter 4 reviews some of the psychological factors needed by individuals to influence positive treatment outcomes (e.g. self-efficacy) and reduce fears that may hinder outcomes. Individual coping characteristics are evidenced by the behaviours patients demonstrate in order to manage their condition. To date, the general musculoskeletal literature lacks a strong theoretical foundation for understanding health behaviours, particularly in comparison with research in other areas of chronic disease (Painter et al., 2008; Allegrante and Marks, 2003; Taal et al., 1993; Andersen, 2002; Black and White, 2005; Blank and Bellizzi, 2008).
This chapter explores behavioural factors associated with the two main sources of stress in individuals with musculoskeletal disorders: pain and disability. The theoretical framework of this chapter is guided by the stress and coping model (Lazarus and Folkman, 1984b) and focuses on both individual-level and social-level factors that influence the experience of disability in patients with musculoskeletal conditions.
Theoretical Framework
A theoretical framework can help identify beliefs and behaviours used by patients who experience stressors and need to engage in coping in order to adjust to a musculoskeletal disorder. Two primary stressors have often been identified in the previous musculoskeletal literature: pain and disability. Differing experiences with a musculoskeletal disorder can result in different appraisals of the stressors of pain and disability by patients. Often individuals with similar musculoskeletal disorders have different outcomes related to the experience of pain and disability even with similar treatment approaches. We have many examples in practice of patients who may have similar musculoskeletal conditions and even may have similar testing results or scores on outcome measures, such as the Oswestry Disability Index or the Lower Extremity Functional Scale, yet one will do well with coping with the condition, and the other will be significantly limited in many life activities and participation. Prognostic factors may provide a predictive indication of which patients we may observe a positive outcome (regardless of treatment), whereas treatment effect moderators provide an indication of which patients will beneficially respond to specific treatments. Understanding psychosocial factors and coping behaviours may add additional insights into patient responses to treatments and potential for improved outcomes. In order to understand the overall experiences of pain and disability, we examine two frameworks important to musculoskeletal clinicians’ assessment, reasoning and management: the stress-diathesis model (Shanahan and Macmillan, 2008; Elder, 1994) and the International Classification of Functioning, Disability and Health (ICF) model (World Health Organization [WHO], 2001) framework of health and disablement (Shanahan and Macmillan, 2008; Rowland, 1989). Both models include identifying contributing factors and modifying resources that are available to patients that also influence outcomes.
The stress and coping model (Lazarus and Folkman, 1984b) is used to identify what coping behaviours preserve well-being in patients with musculoskeletal disorders while facing stressful experiences with acute or chronic conditions. Integrating the new lens of health as described by the ICF framework introduced in Chapter 1 requires consideration of the larger personal and environmental influences around the individual. Finally, this chapter explores self-rated health and self-efficacy from the perspective of social cognitive theory (Bandura, 1977b; Bandura, 1977a) and social support as a social resource for health in the stress and coping model (Lazarus and Folkman, 1984a, 1984b). Understanding both individual-level and social-level concepts will serve to broaden the understanding of health behaviours that influence patients with musculoskeletal disorders and ultimately influence treatment and related outcomes in caring for individuals with musculoskeletal disorders.
Behavioural Factors in Musculoskeletal Disorders
Individuals with musculoskeletal disorders often report decreases in physical health (Weinstein et al., 2008; Fritz et al., 1998; Whitman et al., 2003). Decreased physical health, either real or perceived, can impact an individual in many ways. Overall, it is known that those who have decreased physical health reduce or eliminate participation in daily living, physical, social and recreational activities. A lack of activity has been shown to lead to other stressors such as obesity and general physical deterioration that may eventually result in further disability with the onset of cardiovascular and other serious health problems (Pinsky et al., 1990). Activity restrictions may also lead to low self-confidence, fear-avoidance behaviours, depression and other psychological problems that further restrict the person with a musculoskeletal disorder from participation in activities of daily living (ADLs), physical activities, recreational activities, social activities and community functions (Shakil et al., 1999; Kirkaldy-Willis and Bernard, 1999; Hirsch and Liebert, 1998). Chapter 4 further explains how psychological factors such as maladaptive cognitions (e.g. pain and ‘illness’ representations or beliefs, catastrophizing), distress, fear based beliefs and related avoidance behaviours are negative influences on the stressors of pain and disability and result in declines in treatment success in musculoskeletal disorders in general (Waddell et al., 1993; Flynn et al., 2002; Buer and Linton, 2002). Psychological distress, from frustrations to anxiety and depression, and fear-avoidance behaviours correlate with reduced participation in functional daily tasks, indicating a higher risk for disability. Although diagnosis of depression is beyond the scope of practice of musculoskeletal clinicians, some studies have shown that depressive symptoms and high fear-avoidance scores can improve during some areas of musculoskeletal management and result in positive changes in patient outcomes of pain and disability (Fritz and George, 2002; Brox et al., 2003; Whitman et al., 2006). In addition, research has demonstrated that using an enhanced or multimodal team approach to treatment results in improved patient outcomes for musculoskeletal conditions such as low back pain (Sunderland et al., 1992; Whitman et al., 2006). Even though some physical, cognitive and psychological factors contributing to higher pre-treatment pain and disability and post-treatment outcomes have been identified in many musculoskeletal conditions, identifying all the behavioural factors that influence individuals with musculoskeletal disorders continues to be incomplete.
Similar to other health conditions, the daily lives of individuals with musculoskeletal disorders likely involve unanticipated challenges. Patients with musculoskeletal disorders must learn to navigate life with the stress of either acute or chronic pain, cope with reduced functioning, experience limitations to their physical and social abilities, manage through decreased activities, and face fears about recurrence or worsening of their condition. Previous research on arthritis and other health conditions has identified that persistent psychosocial needs can decrease the effectiveness of medical treatment, general health status and quality of life while increasing healthcare costs (Sullivan et al., 2005; Brooks, 2002; Steiner et al., 2002). Although unidentified in many areas of musculoskeletal literature, unaddressed personal and social needs may contribute to reduced participation with treatment and follow-up recommendations, diminished self-care and reduced overall health management (Marinelli and Orto, 1999). Therefore, we recommend that clinicians have a good understanding of the patient’s experience of stressors, understand coping behaviours and identify patient resources that may contribute to an improved outcome.
Stress and Coping Model
Pain and disability have been identified as primary stressors in previous musculoskeletal literature. Differing experiences with musculoskeletal disorders result in different appraisals of the stressors of pain and disability. Moreover, individuals with musculoskeletal disorders can have different outcomes related to the experience of pain and disability even with the same treatment approaches. To better understand these main stressors, this chapter uses the underlying theoretical concepts in the stress and coping model (Lazarus and Folkman, 1984b) to define both stress and coping as well as identify the relationship of these concepts in musculoskeletal disorders. Within the stress and coping model (Lazarus and Folkman, 1984b), stress involves the relationship between an individual and his or her environment. This relationship or transaction between individuals and their environment indicates that stress is more than an internal stimulation or specific pattern of physiological, behavioural or subjective reactions (see Fig. 3.1). Two key mediators within the person–environment transaction are cognitive appraisal and coping effort. Cognitive appraisals and coping efforts are influenced by moderators such as personal and situational factors that result in individual adaptations that impact health on many levels. An understanding of stress and coping constructs underpins musculoskeletal clinicians’ assessment of individual patients’ stressors and coping behaviours that then informs how these may be addressed within clinical management.
Cognitive Appraisal
The cognitive appraisal or evaluation by the individual is paramount to determining if the stress is threatening to his or her well-being or surpassing his or her resources. Upon appraising a stressor, the theory asserts that people engage in coping, defined as fluctuating behavioural exertions, in an effort to manage that stressor. The cognitive appraisal process helps an individual determine both the controllability and availability of coping resources identified as necessary to manage the stressor(s) (Lazarus and Folkman, 1984b).
Cognitive appraisal is a necessary component of dealing with a stressor. It accounts for the different ways in which individuals react to similar events. Health conditions such as those resulting in pain provocation and disability, as in many musculoskeletal disorders, can cause stress in nearly every person, yet people vary in their reactions and interpretations of the same event and condition (Lazarus and Folkman, 1984b). This variability in cognitive appraisals can change a person’s level of vulnerability during a stressful health condition. Vulnerability is closely related to appraisal because vulnerability increases as a person appraises that he or she has reduced coping resources available. Vulnerability reflects the inability of individuals to withstand adverse impacts from a single stressor or multiple stressors to which they are exposed. It can be associated with a pattern of thought that is believed to predispose the individual to psychological problems and feelings of hopelessness. In addition, the variability of individual appraisals, as well as the individual’s responses, helps to explain why some individuals experience similar health conditions but have differing quality, intensity and duration of physical, social and emotional outcomes.
Personal and Situational Factors
Two types of factors influence the cognitive appraisal process: personal factors and situational factors (Lazarus and Folkman, 1984a, 1984b). Personal factors consist of the personal values that motivate individuals to make certain decisions and beliefs that give the individual a personal sense of control. Therefore, at the individual level, commitments and beliefs are part of an individual’s process of appraisal. Commitments are expressions of what is important to a person and can be related to vulnerability. For example, where a participation restriction may be an inconvenience to one patient that does not unduly add to the patient’s stress, for another patient, the value and even self-identity he or she attaches to reduced or lost participation (e.g. work, sport) can represent a significant personal loss associated with increased vulnerability. The deeper a person’s commitment, the greater potential for threat, but also the greater the push toward ameliorative action and hope. Beliefs are also important in determining how a person evaluates a stressful event or health condition. Beliefs of personal control over situations can relate to how an individual believes internal self-responses to situations (e.g. emotions) can be controlled. General control beliefs relate to the extent that the person believes the health-related outcomes can be controlled. For example, two patients may experience the same musculoskeletal injury, such as an anterior cruciate ligament rupture of the knee. One patient has had previous experience with an acute injury and rehabilitation and is confident he can emotionally manage this situation. The other patient is going through a difficult divorce and just went through the death of her mother. Her internal self-responses are exaggerated compared with normal and are highly emotional, so she does not believe that she can handle this additional life event. These beliefs will greatly impact each patient’s evaluation of the stressful health condition and will ultimately affect the coping responses and strategies that they use to manage their knee rehabilitation. When working with the second patient who has negative health beliefs and a reduced sense of control, the clinician must work to address these beliefs and help improve her sense of control in order to help augment positive coping behaviours.
Another influence to the appraisal process is situational factors, which play a critical role in determining the external controllability of the stressor and what ameliorative action can be taken (Lazarus and Folkman, 1984a, 1984b). Situational factors can include predictability and uncertainty, temporal and life course factors and ambiguity. The modifiability of situational factors will vary, and as such, the potential to influence how and to what extent the stressor can be managed also varies. Although factors such as socio-economic status (SES) – recognized as a strong predictor of poor outcomes across a variety of health conditions – are less modifiable (although resources for financial assistance can still be explored), adverse workplace relations may be a situational factor amenable to change. For example, adverse workplace relations are a common situational factor and can be a source of stress for patients. Musculoskeletal clinicians can contribute to addressing workplace factors such as alternative work tasks and performance modifications that may improve workplace relations as a management strategy. In addition, patients with musculoskeletal disorders often vary in their stages of life and have aging-related concerns related to their potential for healing, recovery and future work or recreation opportunities. These age-related concerns are another example of a situational factor that could be a component of what a patient experiences, and they should be addressed by a clinician.
Maximum uncertainty is often extremely stressful for an individual experiencing a health condition such as an acute musculoskeletal injury or a chronic musculoskeletal disorder. Uncertainty is particularly common with persistent pain conditions that cannot be explained within the traditional biomedical framework or when patients encounter conflicting explanations and advice from different health professionals. The uncertainty can have immobilizing effects on anticipatory and actual coping processes and can cause mental confusion in the individual. Helping patients recognize the many personal and situational factors that may contribute to the stressors or improve coping behaviours can assist in reducing some of the uncertainty that comes with musculoskeletal disorders. Overall, it is important to assess both situational factors and personal factors in order for clinicians and patients to understand and recognize factors that ultimately influence the level of stress related to pain and disability in musculoskeletal disorders.
Different Appraisals
Although differences between individuals under similar circumstances are inevitable due to various personal and situational factors, the stress and coping model emphasizes that all individuals evaluating a stressor undergo a cognitive appraisal process involving primary appraisal, secondary appraisal and/or reappraisal (Lazarus and Folkman, 1984a). Primary appraisals involve assessment of the magnitude and significance of a stressor or traumatic event. During primary appraisal, the individual will assess the actual harm, loss, threat or challenge that must be encountered with a stressful health condition. When an individual first experiences a musculoskeletal condition or a reoccurrence of a musculoskeletal condition, primary appraisal takes place. Individuals with musculoskeletal conditions are often in the process of primary appraisal when they seek out medical care and treatment.
Secondary appraisal refers to an individual’s assessment of the degree to which the stressor or traumatic event can be controlled and the available coping resources (Lazarus and Folkman, 1984a, 1984b). Secondary appraisals are a judgment about what might and can be done in the situation (Lazarus and Folkman, 1984b). Secondary appraisals include an evaluation about whether a coping option (e.g. rest, medication, therapy) will accomplish what it is supposed to do as well as the consequences in the context of other internal and/or external demands and constraints. Appraisals of controllability of a health condition can be stress-reducing if one believes that the outcome is controllable or that one has the coping resources to manage the outcomes. However, appraisals of controllability can also heighten threat and give rise to negative emotions and beliefs about coping if perceptions of control and resources are diminished. For example, individuals with low back pain (LBP) will use secondary appraisals when their chronic LBP has reoccurred and their activities have been limited. This in turn motivates some to seek treatment to control their pain and disability as part of the coping process if they have the necessary access and resources. For others, their LBP reoccurrence may heighten negative emotions and beliefs about the seriousness of their condition and its underlying cause and diminish their ability to manage the condition.
Reappraisal is the final feature of the appraisal process and entails an altered or revised version of a previous appraisal. Reappraisals can occur multiple times for reasons such as changes in the environment or the health condition (Lazarus and Folkman, 1984a, 1984b). Reappraisals can also occur when an individual has gone through the cognitive coping process and has altered his or her assessment of the available coping resources. Because the complete process of appraisal is dynamic, a patient with a chronic disease or persistent pain state, such as with many musculoskeletal conditions, is likely to appraise and reappraise the stressors of pain and disability and respective coping resources before, during and after treatment multiple times and with each successive episode. Ultimately, reappraisal of previous unhelpful appraisals is the aim of educative, behavioural and activity/exercise management for patients with persistent musculoskeletal pain and disability associated with a nociplastic dominant pain type and unhelpful cognitions and coping behaviours.
Coping
Coping is intimately related to the concept of cognitive appraisal and the person–environment relationship. Coping involves the cognitive and behavioural efforts to address external and internal demands on the person experiencing a stressful encounter. Coping can either be focused on changing the person–environment problem behind the stress or be directed toward changing the appraisal of the situation. Moreover, coping can be focused toward trying to reduce a negative emotional state of the situation. Early identification of patients who have reduced coping behaviours could help target certain factors and resources needed to improve coping behaviours. For example, in patients with a musculoskeletal disorder, early identification of individuals who have negative appraisals and reduced coping resources can help direct clinicians to increase cognitive-behavioural management to improve patient beliefs, motivation and participation in treatment. Ultimately, understanding coping behaviours in relationship to health outcomes can be important in the big picture to identify and prioritize healthcare resources for individuals with a musculoskeletal condition.
Managing Stressors: Coping With the Stressor of Pain
The experience of pain is often described as stressful by an individual and identified as a source of stress for individuals (Jensen and Karoly, 1991). In recognizing the role of pain as a stressor, it is necessary to explore and expand upon an understanding of the factors contributing to an individual’s experience of pain. The traditional biomedical model of pain dates back hundreds of years to an era when pain was understood to be a primarily sensory experience resulting from the stimulation of noxious sensory receptors, usually from physical damage or injury (Descartes, 1985). This theory of pain describes primarily nociceptive pain, defined as pain elicited when sensory receptors specialized to sense mechanical, thermal or chemical pain react when stimulated past a sensory threshold. This simplistic view suggests that pain only comes from specific physical pathology and is often called the biomedical model of pain. It does not take into account how pain is experienced by the individual, involving additional psychological, social and behavioural mechanisms of injury and illness. Chapter 2 goes into further depth about our current understanding of pain and its effects on the individual. In this chapter, a broader understanding of pain and its influences beyond the individual level that ultimately impact the individual’s pain experience during a health condition will be explored. There are many potential avenues that can heighten or alter the pain experience. In the musculoskeletal condition of LBP, for example, patients with LBP often experience pain that is unrelated or only partly related to their radiographic severity or lumbar pathology (Boden, 1996; Pahl et al., 2006), illustrating that their pain experience is greater than the pure pathophysiological processes involved. Due to the narrow scope of the biomedical model of pain, it is often criticized for being reductionist and exclusionary, and broader concepts need to be explored (Turk and Flor, 1999).
Biopsychosocial Models of Pain
To encompass a broader view of pain, Turk and Flor (1999) described a biopsychosocial approach to pain which addresses many of the shortfalls found in traditional biomedical models. In this approach, it is recognized that the experience of pain is the reciprocal and dynamic interaction of biological, psychological and social factors. It is based on the concept that the experience of pain arises from illness behaviour, although it is typically initiated by and/or has contributions from nociceptive and/or neuropathic pain. Illness behaviour is a term used to describe the ways in which given symptoms may be differently perceived, evaluated and acted or not acted upon by different individuals (Mechanic, 1962). Illness behaviour is believed to be a dynamic process that allows for the role of the biological, psychological and social factors to change in health conditions and as the condition evolves (Engel, 1980).
In the 1980s, Waddell (1987) applied the construct of illness behaviour to LBP (see Fig. 3.2). Their view was that persons with chronic LBP experienced illness behaviours and not just nociceptive pain. This view represented a broader biopsychosocial model of pain stemming from physiological impairment but with broader cognition, affective and social factors resulting in the experience of pain perceived and reported by individuals with chronic LBP (Waddell, 1987). Since this work, the construct of illness behaviour has been recognized as an important construct in many health conditions but continues to be absent in evaluative and management strategies for most musculoskeletal conditions other than LBP.
Stress-Diathesis Model of Pain
Asmundson and Wright (2004) expanded on the biopsychosocial framework by describing pain behaviours and the additional factors that contribute to disability in patients with chronic pain. In their stress-diathesis model (see Fig. 3.3), the impact (stress) of a painful condition is described in terms of the effects on the person and his or her social activities, and the model considers if the individual is vulnerable (diathesis) to additional comorbidities. A key part of the stress-diathesis model is the issue of pain appraisal. Pain appraisal refers to the meaning ascribed to pain by an individual (Sharp and Harvey, 2001). As already discussed with the stress and coping model (Lazarus and Folkman, 1984c), a distinction can be made between primary appraisal of pain in terms of it being threatening, benign or irrelevant and secondary appraisal, which evaluates the controllability of pain and one’s coping resources. Primary appraisal of a threat or harm/loss is an indication of a stressor. Therefore, pain described as threatening by the stress-diathesis model is inherently stressful. The degree of the stress depends on the other factors of vulnerability, social and cultural influence and assessment of coping resources.
Let’s use an example of a middle-aged male patient with sciatica. He rates his pain as 8/10 when sitting and 4/10 when walking or standing. He has tried multiple interventions, including physical therapy and injections, following surgery several years ago, with modest results. Although this is distressing to him, he has found ways to manage his pain and continue in activities that are important to him, including his spending time with his grandchildren and working. His work environment is flexible in that he is able to choose when he needs to move around and can control his schedule and activities. He has cut back on his activities with the grandchildren but enjoys his family time. By all accounts, this gentleman has low fear and avoidance behaviours and a good narrative in the aspects of the biopsychosocial model described by Waddell.
In the stress-diathesis framework, this gentleman does not perceive (appraise) his pain as a significant distress and has a social-cultural context which accommodates his level of pain, thus contributing to a low level of disability. But the stress-diathesis framework can help explain situations that are more complex. Let’s take another patient, also male and middle-aged, with low back pain of the same intensity. This patient, too, has tried many interventions, including physiotherapy, injections and surgery. This patient works in an office which requires him to spend most of the time at the computer or phone, with few breaks. His home/active life is focused on his wife’s recovery from breast cancer surgery and his son, who wants to hike and bike in the mountainous environment. He perceives his pain to interfere with his ability to focus at work, his relationship with his wife and the activities with his son. He feels limited and frustrated that he cannot be the person he wants to be. These are examples of how the social and cultural contexts influence the patient’s perception of pain and contribute to disability. In addition, this patient has experienced feelings of helplessness before – after his first back surgery 15 years ago, after his discharge from the military and after his father had a heart attack. These experiences make him vulnerable to perceiving his LBP as very disabling and likely contribute to maintaining his persistent pain condition. This vulnerability is the ‘diathesis’ portion of the model.
In the stress-diathesis model, we can expect that patients with high vulnerability, psychological distress, low self-efficacy and/or complex social/cultural situations will have increased pain and higher levels of disability. In order to minimize disability (and pain), it is important for clinicians to understand and recognize the influences of social/cultural experiences and vulnerability as they impact outcomes.
Managing Stressors: Coping With the Stressor of Disability
As we see in the stress-diathesis model, pain is only one factor in a more complex set of factors contributing to disability. Coping behaviours can therefore ultimately differ when addressing the stressor of pain as compared with the stressor of disability. Understanding disability has been an evolving process in health and the healthcare literature. It is the role of musculoskeletal clinicians to reduce or limit the level of disability and improve function in patients, which requires the complex understanding we have today about disability and the factors that contribute to function.
Disability and Functioning
Over the years, multiple frameworks have been developed to explain a broader concept of disability. One of the earliest frameworks for disability, proposed in the 1960s by sociologist Saad Nagi, is the ‘disablement model’ that illustrates a disease pathway that is still used by healthcare professionals. The disablement model describes a pathway comprised of four inter-related but separate constructs that contribute in a linear fashion to disability (Nagi, 1965). The model starts with pathology as the underlying disease condition that eventually leads to impairments, functional limitations and disability. Much of current practice continues to describe the links between these constructs with the underlying implication that treating impairments will improve function and limit disability.
ICF Framework
In many ways, the disablement model describes a simplistic approach to treatment that does not address factors seen in other biopsychosocial models. Chapter 1 introduced the ICF model developed by the World Health Organization (WHO) and the Committee on a US National Agenda for the Prevention of Disabilities that combines previous research contributions to the concept of disability into a universal classification system to define and measure health and function by means of two domains: functioning and contextual factors. The domains characterize different factors that interact with the individual to facilitate or hinder functioning and/or disability (Bichkenbach et al., 1999). Changes to different factors often result in a decrement of health and thereby can be used to describe disability in the individual.
Functioning
Similar to the original disablement model, the ICF has components that encompass pathology, impairment and functioning. Problems in both body function and structure are together usually termed impairments by health professionals and defined as deviations or loss of structure or function. The other two components of activity and participation encompass a larger concept of functioning. Activity and participation are similar concepts, although each has a slightly different definition. Activity is defined as the action or task performance by an individual. Participation represents the involvement in life activities. Problems in an individual’s ability to participate in activities will result in participation restrictions and limit actual activity. For example, individuals with LBP or knee pain may be limited in activities such as walking, climbing steps, or lifting objects. When a person with knee pain cannot perform activities such as walking or climbing stairs, it often precludes his or her participation in many social, recreational and daily chores that require both the functional ability and the psychological confidence to execute these activities, as well as the social supports to navigate these activities in a modified or assisted manner.
Contextual Factors
Contextual factors in the ICF are classified as either personal or environmental factors that influence disability. Contextual factors are similar to the two types of factors that influence the cognitive appraisal process during stress and coping: personal factors and situational factors (Lazarus and Folkman, 1984b). Environmental factors, similar to situational factors, refer to all aspects of the external or extrinsic world that form the context of an individual’s personal life that have an impact on a person’s functioning. Environmental factors can be both facilitators that can assist a person’s functioning or barriers that hinder or limit a person’s functioning. Our understanding of disability as a function of the interaction of individuals with the influence of social and physical environments has grown over the years. As a result, the environment has been seen to influence disability via the natural environment, the built environment, culture, the economic system, the political system and social systems. Previous literature has added increased emphasis that persons with disabilities have reduced access in the environment that restricts full participation in life and society (Oliver, 1996). Ultimately, the less supportive the environment is to an individual from both a physical and social perspective, the greater the resulting disability.
The other type of contextual factor, personal factors, can include anything that is an internal influence on a person’s functioning and disability. Personal factors include individual markers such as age, sex and social status (Stucki and Ewert, 2005) and personal characteristics such as coping styles, lifestyle, habits, social background, past experiences, self-efficacy, self-advocacy and other psychosocial assets that, at least initially, are not directly related to the health condition. This overlaps with the concepts in the stress and coping model where personal factors consist of the personal values that motivate individuals to make certain decisions and beliefs that give the individual a personal sense of control (Lazarus and Folkman, 1984a, 1984b). These personality traits can influence how a person responds to possible limitations secondary to disability. Some individuals may have difficulty with assertiveness or have a negative outlook, regardless of the health condition and corresponding disability. Others may have a sense of positive optimism or self-determination that persists regardless of the disability. The individual’s outlook or sense of self can be directly influenced by his or her larger social context. Overall, personal factors are attributes within the person that influence an individual’s level of disability and in turn can be positively or negatively influenced by the pain or disability experienced. The recognition of personal factors in the ICF framework illustrates that a person is more than simply the sum of his or her physical functioning. The ICF framework and its components are displayed in Fig. 3.4.
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