Elsevier

Joint Bone Spine

Volume 78, Issue 4, July 2011, Pages 364-367
Joint Bone Spine

Review
Is volition the missing link in the management of low back pain?

https://doi.org/10.1016/j.jbspin.2010.10.009Get rights and content

Abstract

Patients with nonspecific chronic low back pain are typically prescribed a regimen of regular physical exercises to improve pain and function, increase workability, and prevent pain recurrence. However, adherence to home exercise programs is often partial at best. Patients often fail to translate their intention to exercise (motivation) into action (implementation). Volition is the mental activity by which intentions are implemented. In this review, we argue that volition may be crucial to the successful rehabilitation of patients with low back pain. Obstacles to the implementation of intentions are described, as well as factors that promote implementation, most notably the conscious formation of implementation intentions.

Introduction

Low back pain is defined as pain or functional discomfort between the 12th rib and the gluteal cleft, with or without radiation to the legs. Patients with negative investigations for a specific cause (e.g., inflammatory or infectious disease, tumor, or metabolic disease) are said to have nonspecific low back pain. Based on pain duration, nonspecific low back pain may be acute (less than 6 weeks), subacute (6-12 weeks), or chronic (more than 12 weeks). The lifetime prevalence of nonspecific low back pain has been estimated at 70%. Progression to chronic pain occurs in fewer than 10% of patients [1] but accounts for 70 to 80% of the direct and indirect costs associated with nonspecific low back pain. Therefore, preventing or overcoming chronic pain is a crucial treatment objective. To achieve this objective, normal function must be gradually restored despite persistent or transiently exacerbated pain.

Exercise programs are strongly recommended to improve chronic nonspecific low back pain, preserve workability, and prevent pain recurrence [2], [3], [4]. However, exercise programs raise a number of challenges. Among patients treated for nonspecific low back pain, 60 to 80% report little or no adherence to home exercise programs [5]. Adherence rates are typically low with treatments that require long-term self-management on an outpatient basis and changes in the usual lifestyle. Treatments whose effects take time to develop are also at risk for low adherence. All these features are often found in exercise programs for chronic nonspecific low back pain.

Adherence to home exercise programs faces several additional obstacles. Many patients have misconceptions about their pain, such as a belief that exercising is a causative or exacerbating factor. Coping strategies may include avoidance of movement due to fear of pain or re-injury (kinesiophobia). These factors contribute to generate and to perpetuate chronic pain [5]. Finally, a limited ability to translate intentions into actions may constitute an obstacle to the resumption of physical activity and to the execution of prescribed exercises.

Motivation is crucial if patients are to perform their exercises regularly. Motivation can be defined as a hypothetical construct describing the inner and/or outer forces responsible for the triggering, guiding, intensity, and sustaining of behaviors. Motivation was long considered sufficient to ensure action [6], [7]. However, a highly motivated person may nevertheless be unable to translate the motivation into action. Moving from motivation from action requires a mental process known as volition [8].

Section snippets

Volition

Several motivational constructs have been suggested to predict adherence to rehabilitation programs. One such construct is the feeling of self-efficacy, which is the set of beliefs about one's ability to organize and to execute the actions needed to attain a required level of performance [9]. Another is goal-setting in the context of rehabilitation (e.g., “My goal is to walk without help”). However, none of these constructs explains how motivation translates into action. The level of motivation

The Rubicon model of action phases

Analyses of the “activities” in the above-mentioned definition [16], [17], [18], [19] led to the development of the model of action phases. According to this model, attaining a desired goal requires moving through a sequence of four mental states, or phases, separated by transition points (Fig. 1). Two of the states involve motivation and two involve volition.

Conclusions and perspectives

The efficacy of developing implemental intentions has been demonstrated in studies of physical activity after myocardial infarction [20] or spinal cord injury [21]. To date, no published studies have evaluated the impact of forming implementation intentions on adherence to exercise programs among low-back-pain patients. Obstacles to such studies include difficulties in grasping the concept of volition and absence of a validated tool for assessing volition. Ziegelmann et al. [22] studied the

Conflict of interest statement

The authors declare no conflicts of interest.

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