No Pain No Gain? A new perspective on avoidance behavior

When you expect an activity to evoke pain, when and why you decide to avoid or persist that activity? Until recently, this question has been mainly looked at from theories emphasizing the role of pain beliefs, with lots of research demonstrating that particularly fear of pain/movement makes people often avoid activity. Ignored in these theories, however, is that in daily life people’s behavior is often driven by multiple – and often competing – goals [1]. A simple example may illustrate this. Imagine a back pain sufferer, who usually avoids pain-evoking activities, but from time to time plays football with his kids… Although he knows that this is likely to increase pain, he persists because being a good father is an important goal for him. Patients with chronic pain are constantly confronted with this kind of motivational conflict. The question how people make sense of this, and how this influences behavior and disability, is currently informing an exciting new area of pain research.

In a recently published paper in Pain [4] we examined if the decision to avoid or persist a pain-evoking activity is actually affected by the level of motivational conflict. Healthy volunteers performed a couple of tasks, one of which sometimes resulted in pain. They were, however, completely free to perform the pain-evoking task or not. Crucially, half of the participants were told that they would be financially rewarded for performing the pain task. In other words,  we created a lab analogue of a motivational conflict: avoiding pain versus earning money! Interestingly, we observed that avoidance behavior was significantly reduced when the conflicting goal of earning money was activated. In addition, we showed that the correlation between avoidance behavior and self-reported fear of the pain (which is usually high), was drastically reduced. Simply put, when a competing goal comes into play, behavior is less driven by fear. So this study is a direct illustration of the “no pain no gain” idiom!

A related study [2] showed that motivational conflict  also affects how our brain processes pain. We measured attentional processing of pain, and found that performing an additional task drastically reduced the amount of attention allocated to pain signals, but only when the motivational value of that task was increased by means of a financial reward. The mechanism that is possibly underlying this intriguing effect may be “goal shielding”: our brain protects ongoing goal pursuit by suppressing distracting information such as pain [3].

In conclusion, our work shows that, in a lab situation, the decision to avoid or persist pain-evoking activity does not fully depend upon fear, but also on the goals that are related to that activity, and that once we decide to persist, our brain helps protecting these goals by suppressing attention to pain. We hope that future studies will be able to demonstrate this also in clinical populations, and that this may help refining therapeutic  approaches of chronic pain, such as exposure…

About Stefaan Van Damme

Stefaan obtained his PhD in Psychology at Ghent University, Belgium (2004). He currently holds a position as Associate Professor at the same university, in the Department of Experimental-Clinical and Health Psychology. His work focuses on the role of cognitive, affective, motivational, and behavioral factors in the experience of (chronic) pain and other somatic symptoms. Specifically, he coordinates experimental and clinical research projects on attention and hypervigilance, self-regulation, and coping.

Follow Stefaan on Research Gate


[1] Crombez G, Eccleston C, Van Damme S, Vlaeyen JW, & Karoly P (2012). Fear-avoidance model of chronic pain: the next generation. Clin J Pain, 28 (6), 475-83 PMID: 22673479

[2] Schrooten MG, Van Damme S, Crombez G, Peters ML, Vogt J, & Vlaeyen JW (2012). Nonpain goal pursuit inhibits attentional bias to pain. Pain, 153 (6), 1180-6 PMID: 22409943

[3] Van Damme S, Legrain V, Vogt J, & Crombez G (2010). Keeping pain in mind: a motivational account of attention to pain. Neurosci Biobehav Rev, 34 (2), 204-13 PMID: 19896002

[4] Van Damme S, Van Ryckeghem DM, Wyffels F, Van Hulle L, & Crombez G (2012). No pain no gain? Pursuing a competing goal inhibits avoidance behavior. Pain, 153 (4), 800-4 PMID: 22301333



  1. Lesley Singer says

    I could see where supplying opiates might not go over too well with all the research on opiods and hyperalgesia but thanks for the info. I will read up on that study. If that works we would just need to handle the opiod phobia It would be worth it in the short term if it prevented PTSD. I just wonderd if any of this type of work with rewards was done with the military population

  2. Just a few points – Lesley – in terms of military populations – to minimize the risk of PTSD, there is a USA study in which they are pre-emptively providing opiates ? at the first sign of injury/ pain response to minimize the stress response and the potential for centralization – it has shown a reduction in PTSD. In terms of chronic PTSD, they are using graded simulation (virtual reality) of experiences with CBT and other psychological support to help military members re-approach a threat in a controlled safer fashion. Paulee, I respect the challenges you face with employment and pacing and graded progression. The concept of working on your own terms is challenging when you may not be sure what the best terms are. Any help from the research crowd, experts out there on work/home balance ? I know Neil Pearson (Canadian PT) works with people on breathing, yoga and working with exploring attention to the pain and stating ‘I hurt and it’s ok’ (obviously with a carefully guided plan) rather than distraction. In terms of meaningful activity, I think that this is a great modulator of the pain experience. Interested in a response. Thanks !

  3. This is very interesting research.

    Just wondering, did you ask the participants their reasons for their decision? I’d be very interested to hear their perspectives in relation to the model.

  4. This is very interesting and as a CRPS patient thought I would give my thoughts, for most parts I can be distracted while doing an activity including my paid work and then pay with pain dearly later for the activity….my wages are a huge motivator to keep going for sure, but my PM doc has suggested now that its too much for me and it could possibly be making my crps worse, (I need more pacing etc in my daily life which I can’t do with my work) I am having a huge battle with my brain and my heart with what to do, I certainly do not want to make my crps worse, but I don’t want to lose my wage! So yes I am very motivated by money and for the love of my job, but is it worth it?

  5. OK. But…isn’t this one of our problems with our chronic pain patients in that they will do an activity such as dance the night away…or shop till they drop and tell us that they did not have pain while they were doing this but then they have a flare up that lasted several days. Oh, I get it … I will share this information to “warn” them or explain to them that pacing and graded exposure needs to be observed because they may not experience or have fear of an activity that usually causes pain when they have a high motivation to participate in it at the time.
    Thank you for the research.

  6. I really enjoyed the topic you have written about and wondered how you would use this in a military population dealing with chronic pain from physical injuries or PTSD?

  7. Know pain – know gain. Its been my tag for years!

    Values change peoples engagement in activity. The grandparent who will bend to comfort the fallen grandchild but not to dust the skirting boards.

  8. Awesome study. It’s tempting to pay our patients. It would seem important to try to correlate meaningful rewards that are not financial to suppressing attention to pain. I guess those rewards are often individual specific. Show me the money… In terms of CRPS, I think Judy’s comment is interesting but ? practical – the challenge seems to be in providing a meaningful explanation to the patient that disconnects the hurt = harm thought process and highly emphasizes the brain’s role (at least as you shift to more chronic CRPS – seems harder to explain neurogenic inflammation away to worried patient in early stages – suggestions ?). If I’m following David’s comments, I think in terms of fear, there is probably a threshold of ‘painful’ activity that you would lose your audience participation even with financial rewards. Yes ? Thanks for the research.

  9. Nice work Stefaan
    I’m reminded of the well known phrase “one man’s meat is another man’s poison”
    One wonders where the threshold is between temporary symptom surpression for positive reward and a sequential tapering of effect. Have you planned to study repeated effects?
    I wonder if there are parallels between stress induced analgesia in the short term relative to sustained adaptations?

  10. The choice to repeatedly inflict pain upon oneself for reward is not entirely limited to those dealing with persistant pain. Think for a moment of the athlete striving for (state/national/world/olympic) glory and the hours/weeks/months/years of pain and suffering they’ll subject themselves to for the mere hope of earning a victory. It may be easier for the professional athlete to be paid to suffer, but there are many more amateurs out there striving and hurting and suffering for their own rewards. The only real difference is: for the athletes, their pain stops when the stimulus does.

  11. I always thought that “no pain no gain” was what physiotherapists told their patients, that they would not repair whatever the problem is unless they do the prescribed exercises even if it hurt. In the case of something like Complex Regional Pain Syndrome, the slogan should be “no pain = gain”.