Table 4.

Cognitive–emotional drivers

	Categories	Operational definition and elements
A	Maladaptive cognition	Cognitive–emotional drivers include maladaptive cognitive strategies toward pain (ie, pain coping, pain catastrophizing), pain-related fears (ie, pain-related anxiety and fear, fear of movement), negative perception of pain/disability and expectations toward pain (ie, illness perception, pain self-efficacy), as well as negative mood (which is distinct from clinical depression). According to the fear-avoidance model,71 when maladaptive cognitive drivers are not addressed and if pain/disability persists, factors such catastrophizing, illness perceptions, negative emotions, and pain-related fears may lead to the development of maladaptive behaviors (eg, activity avoidance), which, in turn, may contribute to the maintenance of pain-related disability.72
B	Maladaptive behaviors	Maladaptive behaviors can be manifested in various ways. For example, they may include “communicative” pain behaviors such as facial expressions (eg, grimacing or wincing) or verbal/paraverbal pain expressions (eg, pain words, grunts, sighs, and moans). They may also include “protective” or “safety” behaviors such as guarding of the back straight while lifting or bending/rubbing the back after performing an activity, strongly bracing before doing a functional task, or even completely avoiding performing a task.73 In addition to avoidance, displays of “protective/safety” behaviors (eg, guarding, holding, or rubbing the back) or communicative pain behaviors (eg, grimaces) have also been associated with heightened levels of perceived functional disability.74,75 Maladaptive behaviors are known to be strongly influenced by cognitive–emotional factors;75–77 their presence suggests that cognitive–emotional drivers of pain must be assessed and addressed78 through behavioral or cognitive-behavioral treatment interventions.79