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Issue 14

Table of Contents

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How Do the Activity Patterns of People with Chronic Pain Influence the Empathic Response of Future Health Professionals: An Experimental Study

Dr. Cody Misuraca PT, DPT

Key takeaways:
  • For people with chronic pain, perceived empathy and understanding from others is associated with fewer symptoms
  • As healthcare providers and students, empathy may be impacted by personal beliefs surrounding pain management strategies
  • Empathic responses may be affected by the chosen activity patterns of our patients with chronic pain
  • Ideally healthcare providers would strive to embody high levels of empathy regardless of patient presentation
  • Perspective-taking activities are one potential strategy for increasing empathic responses


As rehabilitation professionals, our work necessarily involves interacting directly with other people, and we’re often working with people who are experiencing pain. It is my belief that working to develop empathy, or the ability to understand and relate to the feelings of others, is an integral piece of being better clinicians. Research on people with chronic pain indicates a strong relationship between improvements in reported pain and the amount of empathy that they perceive from their physicians¹, and that people report greater life satisfaction and fewer physical symptoms such as headaches, dizziness, and stomachaches on days where they felt more listened to and understood by those around them².

It’s clear that experiencing and projecting empathy can have a positive impact on others, and it stands to reason that this carries over to the experiences of people seeking care from rehabilitation professionals. That said, our empathy for others can be influenced by our own experiences and beliefs, and may result in varying degrees of empathy being conveyed by clinicians based on the unique characteristics of the patients they are working with.

Enter the primary article of this month’s research review by Esteve et al³, which investigated how activity patterns displayed by people with chronic pain elicited varying empathic responses from health sciences students. For this study, the authors recruited 228 health science students studying to become doctors, nurses, occupational and physical therapists, among other professions. These students were presented with short texts, or vignettes, describing how a person with chronic pain went about their daily lives.

The authors created 4 different vignettes that were identical with the exception of a description of the subject’s activity pattern related to their chronic pain. The 4 different activity patterns were:

  • Avoiders – generally avoiding most activities, especially those that they think will result in more pain
  • Doers – generally participating in most activities regardless of pain experienced, especially motivating and valued tasks
  • Extreme Cyclers – generally doing “too much” until pain is too high, and then avoiding activity after that
  • Medium Cyclers – dividing activities into smaller tasks, taking frequent breaks, slowing down to conserve energy and minimize pain

Following reading their assigned vignette, the students completed a situational empathy scale which assessed the student’s empathic distress (the degree to which suffering of others elicited a negative experience for the student) and compassion/sympathy for the person described in the vignette. The students also completed an Interpersonal Reactivity Index, which measures baseline qualities related to empathy for others.

The authors hypothesized that the vignette describing Avoiders would elicit more empathy from the students, while the Doer vignette would elicit less empathy. General practitioners and physical therapists largely consider avoidance of painful activities to be the most suitable course of action for people with back pain⁴ (“if it hurts, don’t do it,” anyone?). Research demonstrates poorer assessment of pain interference by caregivers when people with chronic pain participate in painful activities⁵ (“their pain must not be that bad/they must be faking it if they’re able to be active”). Overall, there seems to be a cultural bias against choosing to be active in the face of chronic pain, which informed the authors’ hypothesis.

The results of the study demonstrated no significant differences in the amount of empathic distress elicited by the 4 different vignettes, and varying but small differences in the amount of compassion/sympathy elicited. Overall, the only significant difference that was found was between compassion/sympathy elicited by the Doer and Medium Cycler Vignettes, with compassion/sympathy being lower for Doers and higher for Medium Cyclers. For compassion/sympathy, the 4 vignettes were ordered from lowest to highest as Doers, Avoiders, Extreme Cyclers, and Medium Cyclers. Of note, the compassion/sympathy scale was scored on a -5 to +5 Likert scale, and the average compassion/sympathy for Doers was 4.66, and was 4.95 for the Medium Cyclers.

Despite a statistically significant difference between compassion/sympathy for these two activity profiles, it’s encouraging to see that all of the vignettes elicited fairly high ratings from the students. These results were contrary to the author’s hypothesis, as they anticipated that activity avoidance in the face of pain would be the preferred activity profile, and thus elicit the highest empathy. The fact that the Doer vignette elicited the lowest compassion/sympathy is somewhat in-line with the authors’ expectations, though it does seem that in general, the students participating in this study placed higher value on remaining active through pacing and chunking of activities.

The authors speculated that these results could be explained by more modern training on the negative effects of physical inactivity, and that this training would lead students to place higher value on strategies that allow people in pain to remain active but within the bounds of their tolerance. That said, I think that it’s important to recognize that all 4 of the activity profiles described in the vignettes elicited fairly high levels of compassion/sympathy, with the lowest average score being 4.66 on a -5 to +5 scale. It seems likely to me that the difference observed between the highest and lowest scoring activity profiles are not clinically significant.

One potential issue with drawing conclusions about clinical practice from a vignette-based study design is that the students in this study may have provided answers differently from how they would have reacted to these scenarios in real life. It may be that the overall small differences observed in this study were due to the students changing their choices in response to knowing that their choices were being observed, otherwise known as the Hawthorne effect. I would really like to think that the results of this study are representative of the real-life attitudes and beliefs of modernly-trained health science students, because relatively high and unchanging compassion/sympathy regardless of the patient’s presentation is ideal.

Wanting to avoid increased pain does not necessarily mean that somebody is lazy, just as pushing through pain to participate in life activities does not mean that somebody is lying about the amount of pain that they report. Regardless of the external validity of this study’s results, I think that it provides a good opportunity for students and practicing clinicians to reflect on their own personal beliefs and biases around pain and activity, and honestly consider if/how their preferred management strategies might impact the level of empathy that they project towards patients that use a different approach.

Keeping in mind that the amount of understanding and empathy that a person perceives from the clinicians and people they interact with can have a positive effect on their symptoms¹⁻², making a conscious effort to shift our attitudes around varying pain management strategies can have significant benefit for our patients. One interesting finding from the present study was that the “perspective-taking” subscale of the Interpersonal Reactivity index had a consistent association with compassion/sympathy subscale of the situational empathy scale³. That is, students who rated higher at the ability to adopt another person’s point of view tended to provide higher compassion/sympathy scores for their selected vignette.

This provides a potential exercise for improving one’s empathic responses: when faced with a patient whose self-selected activity patterns conflict with your preferred strategies for managing pain, try to imagine yourself in their situation; ask yourself “what aspects of this person’s experiences and environment make their current activity pattern seem like the most reasonable choice?” This may help to create a more conducive environment for rehabilitation going forward. Even if a clinician doesn’t agree with the Avoider strategy of not engaging in life activities out of fear of increased pain, these people deserve the same amount of empathy from healthcare providers as any other patient.



Cody Misuraca is a physical therapist and strength coach in Seattle, WA. He works as a sports physical therapist for a community hospital system and also owns Waypoint Strength and Performance LLC, which offers strength coaching services. The views and opinions expressed in this review are those of the writer and do not necessarily reflect the views or positions of any institutions he is associated with.