Self-efficacy is a term banded around in therapy quite regularly at the moment especially as more active approaches to rehabilitation are being embraced.

So we have to ask exactly what does it mean, why does it matter and how do we improve it?

In fact, my twitter friend/colleague Jerry Durham asked me this question whilst I was in the process of writing this blog, talk about great timing! It also shows that we often don’t have a well-defined definition for a well-used term.

Let’s Start With What Does It Mean?

It was a term first coined by Bandura in the 70’s, he described it is the ‘belief of an individual on whether they have the ability to perform behaviours relative to a specific activity’. Self-efficacy has also been described as a ‘resilient self-belief system’.

I like to describe it as a sense that ‘I have got this’ or ‘I can do this”.

This could be self-efficacy in relation to pain, such as the perception of the ability to remain functional and perform activities of daily living whilst you have pain, or it could be treatment-related activities such as a specific activity or exercise.

So let’s say that your kind therapist has suggested that you go to for a walk to help out with your back pain, do you think that you will be capable of doing this?

Maybe you don’t feel motivated?

Perhaps you don’t feel confident that you physically can?

Could be that you feel you can’t fit it into your busy life?

Low self-efficacy may result in challenges, such as changes in behaviour, being seen as threats to be avoided rather than things that can be overcome. Bandura identified a number of psychological processes involved with self-efficacy, these being cognitive, motivational and affective (emotional). Having valued goals and activities appears to be associated with these factors as well and self-efficacy and resilience literature points towards valued activities being an important part of this process HERE.

Bandura also identified four main sources of self-efficacy.

Mastery

Previous mastery of an activity or action influences our future perception of capabilities. We are starting to learn that human beings use prediction based on past experiences to navigate the uncertain nature of the world around them. If we have been successful at something in the past then it is likely we will perceive that we can overcome it again. This is also related to the ease of successes.

If our successes have been easy then we may be quickly dissuaded by obstacles. If the successes have been tough then we may also be used to overcoming any obstacles that come our way.

In line with this view, we see that previous adherence and participation in exercise has been shown to be important in future exercise adherence HERE.

Experiences

The world around us also influences our perception of capabilities. If people surround you that you perceive as similar, who are achieving similar things that you are being required to achieve, then you will also be more likely to see these things as attainable. This could be from the media that we consume to the involvement in social activities or our family circle, this underlines the social aspects of pain that appear to be pretty important.

This is a great recent paper on social factors in pain HERE

Persuasion

Now, this can be both positive and negative, and of course, it is easier to be influenced negatively than positively! But those that are persuaded, both verbally and experientially, that they are capable of achieving a task are more likely to be able to do so especially if we see previous success as a key factor.

Negative Emotions

Strong negative feelings towards an activity or the negative perception around an activity also will influence the level of self-efficacy someone has. Self-doubt is often an emotion that influences behavior negatively.

So We Have To Also Ask, Why Is It Important?

It appears that self-efficacy has been linked in multiple papers to worse outcomes across various measures of pain and disability. Now we cannot suggest it is causative or even that improving it will simply improve outcomes at this moment in time. But if I were to go out on a limb I think it probably would : ), especially if we are promoting more active approaches to therapy.

Certainly exercise as a treatment relies on it being performed and evidence-based medicine falls flat on its face if we cannot apply the treatment to the patient.

Foster, in 2010, found that for people with low back pain, low confidence in their ability to perform normal activities, or low self-efficacy, was predictive of a worse outcome in terms of disability at 6 months, in fact, better than fear avoidance, catastrophizing or depression HERE.

Keedy, 2014, found that those without the ability to engage in pain management related behaviours, pain self-efficacy, is related to the outcomes for back pain rehabilitation HERE.

Greater passive behaviour scores were also found to be associated with worse outcomes at a five year follow up for lower back pain by Chen, 2018 HERE. Passive coping strategies rely on external resources for pain control rather than internal resources such as our belief systems HERE that also influence self-efficacy.

Self-efficacy has also shown to be fundamental to the adherence of exercise interventions. These studies found that low self-efficacy was a predictive factor for poor adherence to a home exercise program HERE & HERE. For all the focus on the nuts and bolts of exercise, it is a pretty redundant process if the person does not feel capable of doing it. Time spent in this area rather than a focus on sets and reps may drastically improve adherence and therefore outcomes.

I call this focusing on the hole rather than the donut (the whole!)

What Can We Do To Alter It?

Success

The first steps may simply be to create a successful experience!

Previous successful adherence and progress have been associated with increased self-efficacy and this ties in with a Bayesian perspective of human function. So perhaps our aim for those that display low self-efficacy should be to set a low threshold for activity that can lead to easy adoption and fast progress. We often aim for a dosage of activity that leads to some kind of physical overload and adaptation. This could potentially lead to a negative experience for some and limit increased participation, without a positive initial experience they may not achieve longer-term sustainable success. So essentially good for psychology but not so much for physiology in the short term but hopefully leading to greater longer-term physiological impact through sustained participation.

It could be that just making an exercise session fun and not boring could be a very beneficial outcome. We often don’t place much importance on these things within medicine though. Why do people play sports? Maybe because they enjoy other aspects beyond just the physical exertion component.

People are often driven by challenge, fun & competition, how often do you incorporate these aspects into your training?

Some questions I often ask to gauge self-efficacy around exercise & activity are:

“Would you describe your self as confident around moving and exercising?”

“Do you feel you are currently capable of increasing your activity levels if required?”

“Would you describe yourself as motivated with regards to activity and exercise?”

Motivation

Motivation also appears to be a key aspect of self-efficacy. Helping people find something that actually motivates them could also be important and this could be through a goal-setting process that identifies valued activities.  We could then break it down into more perceived manageable chunks that create little wins to help motivate the person.

I call this helping them find their ‘why’.

Lots of exercise programs don’t resonate with people, especially if they have not really participated in one before so exercise in itself is not enough of a ‘why’ for them.

We might ask “what would your perfect day look like with regards to activity?” or “what are some things you love to do that you don’t or can’t?”.

Autonomy is another factor associated with successful exercise, HERE, so also giving choices and options rather than a ‘this is the exercise you have to do’ approach.

Planning

Sitting down and planning with people when they might do things and how much might also have an impact on self-efficacy. Being able to do this for themselves might be a limiting factor and the participation in activity may feel like too great a challenge without some guidance.

What days might be best?

What time of day?

What type?

For how long?

What kind of effort level?

Set a reminder on the smartphone?

How to progress?

Alternative options if you do not succeed?

Takeaways

• Previous experiences with behaviours are involved with future self-efficacy
• Social environment and support is important
• Self-efficacy can make or break an active approach to treatment
• Self-efficacy is involved in outcomes for pain and disability
• Self-efficacy is important for exercise adherence
• Create behavioural wins and good experiences
• Your input in terms of planning and motivation is vital if self-efficacy is low

Last week we posted an article discussing some of the research around the clinical guidelines of low back pain.

There are several modalities commonly used that aren’t recommended like Tens, laser therapy, imaging, and corticosteroids,  but when we look at what is recommended we have an opportunity to make a real difference for those suffering from back pain.

One of the big things recommended is a biopsychosocial approach along with education. In order to start this kind of approach, patient reassurance is critical in order to help the patient feel safe (as we talked about last week).

In addition to reassurance, supervised exercise is also a crucial part of helping patients deal with their back pain. However, these two go hand in hand as it will quite often take a considerable amount of reassurance to convince a patient that it is okay to move.

One way to help is by looking at what the research says for exercise and low back pain, which you can use as a tool to convince (and reassure) patients this is the best course of action.

Exercise For Low Back Pain

Remember the old days when bed rest was the main prescription for low back pain?

Well, now bed rest is actually discouraged unless the pain is too severe, then only two days of bed rest are chosen. In contrast to this, we now understand that staying active has far better outcomes than the way we used to manage this.

And I know many of you might be saying “exercise is out of my scope of practice” and while this may be true, active and passive range of motion probably is within your scope, so there is no reason you can’t incorporate some of this into your treatments. 

I know there is probably some concern over being able to recommend “specific” exercises (or movements) but don’t worry it doesn’t have to be all that complicated…in fact, it shouldn’t be! Supervised movement without the use of expensive equipment is one of the specific recommendations, so you can do this right in your treatment room.

This is especially true in the acute stage, where strengthening, extension, and specific exercises are not recommended. Rather, in this case, we want to use graded exposure to physical activity. Graded exposure is essentially getting a patient to move (gradually) into a feared or painful movement (we’ve had articles about this before which you can read HERE for a more detailed description).

For example, when it comes to acute low back pain, if your patient is scared, or experiencing pain with a certain movement like standing forward flexion, have them change the plane of movement and try flexion again. Try having them sit comfortably in a chair, then lean forward. This is still spinal flexion, it’s just in a more supportive position. When they can move in this position comfortably, point out how capable they are of the movement and reassure them that flexion is safe. You can then gradually work up to standing flexion until this feels safe again.

There are many ways to do this, it just takes a little experimentation on your part.

When it comes to chronic low back pain there is no evidence that one exercise is superior to another.

However, recommendations show that remaining as physically active as possible along with an early return to work is well supported by evidence (probably why some workplaces have a gradual return to work program). While there are no specific exercises highlighted as more effective than others, the exercises that work are simply the ones your patient will do. Find out what’s important to them and encourage them to do it. Whether it is strength training, going for a walk, playing with their kids, or playing hockey, the intent is to build confidence in their bodies as opposed to fixing a problem.

Inevitably the question of dosage comes up and the research shows that too much, or too little exercise with some patients can run the risk of developing persistent pain. This is where it’s important to experiment a little to see what works best for the patient, we don’t want them to overdo it, but also want to avoid not doing enough (one of the reasons bed rest has been eliminated).

Overall since we know a biopsychosocial approach is most effective, encourage things like movement in general, getting back to work, staying connected with the things and the people they enjoy. Just make sure these things are done gradually. If we can address peoples fear of movement by using graded exposure early on, we have a better chance of avoiding prolonged pain and disability. So, don’t stress about ‘specific’ exercises, the overall goal is to get our patients moving and keep them moving. Movement along with some education and reassurance can go a long way in not only improving low back pain but also the patients quality of life.