An evaluation of the behavioural inhibition system and behavioural activation system (BIS-BAS) model of pain in athletes

ABSTRACT

This study examined coping and pain responses using a behavioural inhibition (BIS) – behavioural activation (BAS) framework in 489 student athletes (M(age) = 20, SD = 4; 69% female). Two samples of athletes (226 pain-free athletes and 232 athletes with current pain) completed surveys assessing BIS- and BAS-related cognitions, emotions, and behaviours. Distinct groupings of BAS-related variables were identified in both samples, evidenced by significant positive correlations within BAS-related variables (positive affect, pain openness, approach thoughts and behaviours). Most BIS-related variables (depression, anxiety, harm beliefs, pain catastrophizing and avoidance behaviours) were also correlated in the sample of athletes with pain; however, this was not observed in pain-free athletes. In athletes with pain, BIS-related variables were significantly associated with pain variables, with this association stronger than that found for BAS-related variables. Regression analyses highlighted the pivotal role of pain catastrophizing as a predictor of pain unpleasantness and intensity. Findings shed light on the factors shaping athletes’ coping, pain perception and decisions as to whether to pause or push through. Future investigations to explore these dynamics in more depth may aid in the development of targeted interventions that enhance athletes’ ability to cope and to manage pain more effectively.

KEYWORDS:

• Athletes
• pain
• catastrophizing
• cognitions
• emotions
• behaviors

1. Introduction

Many athletes experience significant pain while training to reach their goals. Perhaps due to this regular exposure to painful sensations experienced in the context of striving towards goals, athletes are known to have a higher pain tolerance (Assa et al., 2019; Geva & Defrin, 2013; Tesarz et al., 2012) higher pain thresholds (Johnson et al., 2012; Pettersen et al., 2020) and lower pain intensity (Roebuck et al., 2018; Sullivan et al., 2000) than non-athletes when exposed to noxious stimuli. Despite the potential benefits of this, such as allowing athletes to maintain higher levels of intensity in training and competition, there are significant risks. When athletes need to push themselves to their physical limits, persisting through injury-related pain mistaken for muscle soreness or overexertion potentially puts athletes at risk of injury, jeopardizing their health, performance, and career longevity. Athletes’ perceptions and responses to pain are influenced by a wide range of complex biopsychosocial factors. Although past research focuses on environmental and biological factors (Kalkhoven et al., 2020) the contributions of psychological factors remain poorly understood (Gagnon-Dolbec et al., 2021).

While prior research has not examined this model in athletes, the behavioural inhibition system (BIS)- behavioural activation system (BAS) model of pain provides a theoretical framework for understanding the complex factors which inform automatic judgements regarding pain and behavioural responses to pain (Jensen et al., 2016). The BIS-BAS model of pain (Jensen et al., 2016) was adapted from Gray’s Reinforcement Sensitivity Theory (RST) (Gray, 1990) which proposed two distinct neurophysiological systems in the brain – the BIS and the BAS. Each system is theorized to correspond to a convergence of distinct cognitive, behavioural (e.g., reinforcement-related), and emotional responses to external and internal cues. Jensen and colleagues’ adapted this BIS-BAS framework to contextualize it to pain, specifically (Jensen et al., 2016). The BIS-BAS model of pain proposes that the BIS is activated when pain (or the possibility of pain) is perceived as a threat/punishment, facilitating behavioural avoidance, negative cognitions (e.g., pain catastrophizing and hurt = harm beliefs), and negative mood states, ultimately increasing perceived pain. Conversely, the BAS is activated when pain is perceived as temporary or could lead to a reward, facilitating approach behaviours, positive cognitions (e.g., pain approach thoughts) and positive emotions, which may reduce perceived pain. Although the model (consistent with RST) theorizes that the two systems are distinct, they can influence each other, with BIS activation suppressing BAS activation and vice-versa (i.e., they are mutually inhibitory). The degree of activation of each system, and the specific goal-directed behaviours that result from this interaction, depends on the individuals’ learning history and attentional processes, the environmental cues present, and trait-like factors (Jensen et al., 2016).

The BIS-BAS model of pain aligns and extends on other dual-system pain models, such as the Avoidance-Endurance model which posits that pain either elicits fear-avoidance response patterns, akin to BIS responses, or eustress endurance responses, akin to BAS responses (Hasenbring & Verbunt, 2010). In both the BIS-BAS model of pain and Avoidance-Endurance Model, an adaptive response pattern is characterized by one’s ability to flexibly shift between these two systems when responding to pain (Hasenbring & Verbunt, 2010; Jensen et al., 2016). To the best of our knowledge, no prior research has evaluated the full BIS-BAS model of pain in athletes.

In athletic contexts, applying the BIS-BAS model of pain has the potential to provide nuanced insights into how athletes respond to pain and in what circumstances certain responses might be adaptive versus maladaptive long-term. For instance, the BIS would be theorized to activate when pain poses a threat, such as when pain is judged/thought to indicate potential injury. Once activated, the model hypothesizes that the BIS would facilitate behavioural avoidance (e.g., slowing down or stopping during a competitive event), cognitive content related to threat (e.g., a belief that pain is an indication of physical damage), cognitive processes associated with the potential for danger (e.g., focusing on pain), and negative mood states (e.g., anxiety) – all of which would be anticipated to increase the perception of pain. In contrast, the BAS would be theorized to activate when cues are present that signal the possibility of reward, such as achieving first place in an important athletic event. Once activated, the model hypothesizes that BAS would facilitate approach behaviours (e.g., pushing through pain to achieve a goal/reward), positive cognitive content (e.g., visualizing winning an event), positive cognitive processes (e.g., ignoring pain), and positive emotions (e.g., hope and optimism at the prospect of winning) – all of which would be theorized to decrease the perception of pain.

The BIS-BAS model of pain has received empirical support in clinical samples (Day et al., 2019; Sánchez-Rodríguez et al., 2021; Serrano-Ibáñez et al., 2019; Turner et al., 2021); however, as noted above, the full model has not yet been applied or tested in athletes. Understanding the applicability of the model in athletes could enhance knowledge of the complex biopsychosocial factors that inform athletes’ judgements (e.g., perceived threat value) and responses to pain. Specifically, judgements/decisions by athletes about whether to pause or “push through” pain in a given context.

The objective of this research was to evaluate the tenets of the BIS-BAS model of pain (Day et al., 2022; Jensen et al., 2016) in two samples of athletes: those who are not currently experiencing pain, and those reporting current pain. As stated previously, the model proposes that the BIS- and BAS-related factors are bidirectionally facilitative within each system (e.g., heightened BIS-related anxiety would ramp up BIS-related cognitions about pain as a threat and vice versa) and are both mutually inhibitory (i.e., with activation of one system suppressing activation of the other). Accordingly, we hypothesized that in both samples, (1) positive associations would be observed within measures of BIS- and BAS-related domains, respectively, whereas (2) negative associations would be observed between measures of BIS- and BAS-related domains. Further, consistent with the model’s proposition that worse pain outcomes are more strongly associated with BIS-related activation than with BAS-related activation, we also hypothesized that in athletes with current pain, (1) pain intensity and pain unpleasantness ratings would be positively associated with BIS-related domains and negatively associated with BAS-related domains, and (2) the pain variables would be more strongly associated with BIS-related measures than with BAS-related measures. An exploratory objective was to determine which, if any, measures of BIS- and BAS-related domains accounted for unique variance in the prediction of pain intensity and pain unpleasantness in athletes currently experiencing pain.

2. Methods

The cross-sectional web-based survey was approved by the Human Research Ethics Committee at The University of Queensland. Study participants were undergraduates participating for course credit who were ≥18 years of age, proficient in English, had access to a computer or smartphone, and regularly participated in sports and exercise at least once a week on average over the preceding 12 months. A priori power analyses were conducted using the G*Power programme (Faul et al., 2007) to determine the sample size required to achieve adequate power (85%) to detect medium effect sizes (ρ = 0.3 for correlations and f² = 0.15), reflecting guidelines which indicate that a medium effect size is a clinically meaningful effect (Dworkin et al., 2008) at a .05 error probability. Accordingly, a minimum of 93 athletes without current pain and 126 athletes currently experiencing pain (acute or chronic) were required. A total of 748 participants were enrolled, however, the data from 250 participants were excluded. Reasons for exclusion were not meeting eligibility requirements (n = 5), having more than 50% missing data (n = 93), or failing one or more of the attention checks (n = 152). The final analysis included data from 498 participants (M(age) = 20, SD = 4; 69% female), including 232 with current pain and 266 who were pain-free (see Table 1 for the sample demographics).

Table 1. Sample Demographics and Sports Involvement.

Variable		M	SD	N	%
Age (Years)		20.02	4.14
Gender identity
	Female			346	69
	Male			149	30
	Other			3	1
Self-identified race
	Caucasian			313	63
	Asian			147	30
	Other			38	8
Education level (years)		15.22	1.55
Primary Pain Type
	Soft tissue/Muscle			143	29
	Injury			116	23
	Headache			29	6
	Other			62	12
Sport/Physical Activity Type
	Contact Ball Sports			90	18
	Strength Sports			52	10
	Endurance Sports			43	9
	Racquet/Ball Sports			26	5
	Dance			25	5
	Athletics			17	3
	Combat Sports			11	2
	Other			31	6
Level of Competitiveness
	Elite			38	8
	Competitive			25	5
	Recreational			429	86

N = 498.

Participants completed a questionnaire battery hosted on Qualtrics. All measures showed adequate to excellent internal consistency. BIS- and BAS-related measures were selected to map onto the specific pain-related cognitive content, cognitive process, emotional, and behavioural domains proposed in Jensen’s adaptation of the BIS-BAS model of pain (Jensen et al., 2016). These measures have also been used in past research assessing the applicability of the BIS-BAS model of pain (Day et al., 2019, 2022). BIS-related measures were the short-form, four-item Depression, and Anxiety scales from the Patient Reported Outcomes Measurement Information System (PROMIS) (Pilkonis et al., 2011) for the emotional domain, the Harm subscale of the 35-item Survey of Pain Attitudes (SOPA-35) (Jensen et al., 2000) for the cognitive content domain, the Trait Pain Catastrophizing Scale (PCS) (Sullivan et al., 1995) for the cognitive processes and content domains, and the Escape Behavioural Intentions subscale of the Pain Responses Scale (PRS) (Day et al., 2022) for the behavioural domain. BAS-related measures were the 10-item Positive Affect subscale of the Positive and Negative Affect Schedule (PANAS) (Watson et al., 1988) for the emotional domain (which asks about positive emotions experienced in the prior few weeks), the Pain Openness subscale of the Pain-Related Cognitive Processes Questionnaire (PCPQ) (Day et al., 2018) for the cognitive process domain, and the Approach Thoughts subscale and the Behavioural Intentions subscale of the PRS (Day et al., 2022) for the cognitive content and behavioural domains, respectively. Current pain intensity and pain unpleasantness were measured on 11-point numerical rating scales (NRS) ranging from 0 (no pain sensation and not at all unpleasant, respectively) to 10 (the most intense pain sensation imaginable and the most unpleasant pain sensation imaginable, respectively).

Analyses were conducted using IBM SPSS version 28.0. Correlation coefficients were computed between BIS-related domain measures and BAS-related domain measures in athletes without current pain and with current pain. Correlation coefficients were also computed between BIS-BAS-related measures and pain intensity and unpleasantness in athletes currently experiencing pain. Effect sizes were interpreted as small for r = .10, medium for r = .30 and large for r ≥ .50 (Cohen, 2013). To address the exploratory aim, four multiple regression analyses were conducted in athletes with current pain, with pain intensity (model one) and pain unpleasantness (model two) as the criterion variables. For the first pair of regression analyses, BIS-related measures were entered as a block in step one, and BAS-related measures were entered as a block in step two. In the second pair of regression analyses the order of entry of the predictor variables was reversed.

3. Results

Means, standard deviations and correlation coefficients for the self-report BIS-BAS-related measures in healthy athletes are shown in Table 2. In athletes without pain, correlations within BAS-related measures were significant and positive, with small to medium effect sizes (r’s range, .22 to .48, p < 0.01), except for the correlation between approach thoughts and approach behaviours, which was large (r = .73, p < 0.01). For correlations within BIS-related measures, a significant large positive correlation was observed between depressive symptom severity and anxiety (r = .74, p < 0.01) and significant moderate positive correlations were also observed between pain catastrophizing and escape behaviours (r = .46, p < 0.01), however all other correlations between BIS-related variables were small and non-significant. For correlations between BIS- and BAS-related variables, both pain catastrophizing and escape behaviours had small to medium significant negative correlations with all BAS-related variables (r’s range, −.17 to .38, p < 0.01). For depressive symptom severity, all correlations with BAS-related measures were small to medium, negative, and statistically significant (r’s range, −.14 to −.34, p’s range, < 0.01 to < 0.05), except for the correlation with pain openness which was small and non-significant. Correlations between anxiety and BAS-related measures of positive affect and approach thoughts were small to medium, negative, and significant (r = −.34, p < 0.01 and r = −.13, p < 0.05, respectively). No significant correlations were observed between anxiety and pain openness or approach behaviours. Finally, harm beliefs were only significantly correlated with approach behaviours (r = .13, p < 0.01), all other correlations with BAS-related variables were small and non-significant.

Table 2. Correlation coefficients between the BIS- and BAS-related variables for participants without pain.

Variable	N	M	SD	1	2	3	4	5	6	7	8	9
1. Positive Affect^a	263	32.54	8.03
2. Pain Openness^a	253	21.60	8.27	.22**
3. Approach Thoughts^a	261	2.69	0.85	.46**	.26**
4. Approach Behaviors^a	266	2.36	1.00	.48**	.37**	.73**
5. Depressive symptom severity^b	266	53.47	9.13	−.34**	.02	−.18**	−.14*
6. Anxiety^b	266	56.41	10.26	−.34**	−.02	−.13*	−.11	.74**
7. Pain Catastrophizing^b	264	15.84	10.82	−.17**	−.19**	−.37**	−.35**	.08	.12
8. Harm Beliefs^b	265	2.09	0.76	.01	−.04	−.11	−.13*	−.03	−.03	.11
9. Escape Behaviors^b	266	2.23	1.01	−.27**	−.18**	−.38**	−.34**	.12	.10	.46**	.05

^aBehavioral activation system-related (BAS) variable; ^bBehavioral inhibition system-related (BIS) variable. *p < 0.05, **p < 0.01.

The correlation coefficients between pain intensity, pain unpleasantness and the BIS- and BAS-related measures for athletes currently experiencing pain are presented in Table 3. In athletes with current pain, correlations within all BAS-related measures were significant and positive, with a large correlation between approach thoughts and approach behaviours (r = .63, p < 0.01), and medium correlations for all other BAS-related variables (r’s range, .25 to .47, p < 0.01). Additionally, most correlations within BIS-related measures were significant and positive. Correlations between anxiety and depressive symptoms were positive and large (r = .78, p < 0.01), and other significant correlations were small to medium (r’s range, .15 to .48, p’s range, < 0.01 to < 0.05). Conversely, harm beliefs had small, non-significant correlations with depressive symptom severity and anxiety. For the correlations between BIS- and BAS-related measures, anxiety and positive affect, and depression and all BAS-related variables evidenced small and non-significant correlations. All other correlations between BIS- and BAS-related variables were significant, with small to medium negative correlations (r’s range, −.15 to −.41, p’s range, < 0.01 to < 0.05). Pain unpleasantness and pain intensity were significantly positively correlated with all BIS-related measures except for harm beliefs and escape behaviours. Significant correlations were small, with r’s ranging from .15 to .20 (p’s range, < 0.01 to < 0.05). Finally, pain intensity and unpleasantness were significantly positively correlated with each other, with a large correlation (r = .80, p < 0.01).

Table 3. Correlation coefficients between the BIS- and BAS-related variables for participants with current pain.

Variable	N	M	SD	1	2	3	4	5	6	7	8	9	10	11
1. Positive Affect^a	229	32.62	7.62
2. Pain Openness^a	225	21.58	9.10	.25**
3. Approach Thoughts^a	231	2.72	0.78	.47**	.25**
4. Approach Behaviors^a	231	2.43	0.92	.37**	.29**	.63**
5. Depressive symptom severity^b	232	53.95	9.73	−.18**	.03	−.10	−.09
6. Anxiety^b	232	57.38	9.74	−.12	.04	−.03	−.01	.78**
7. Pain Catastrophizing^b	232	18.39	11.25	−.08	−.19**	−.24**	−.33**	.20**	.15*
8. Harm Beliefs^b	230	2.05	0.72	−.21**	−.21**	−.18**	−.15*	.01	−.03	.17*
9. Escape Behaviors^b	231	2.29	0.95	−.19**	−.16*	−.26**	−.41**	.25**	.23**	.48**	.17**
10. Pain Intensity	232	3.59	1.85	−.05	−.03	−.05	−.07	.19**	.16*	.20**	.03	.09
11. Pain Unpleasantness	232	4.16	2.33	−.11	−.05^a	−.05	−.06	.16*	.15*	.20**	.05	.12	.80**

^aBehavioral activation system-related (BAS) variable; b Behavioral inhibition system-related (BIS) variable. *p < 0.05, **p < 0.01.

The results of the exploratory hierarchical multiple regression analyses with pain intensity (model one) and pain unpleasantness (model two) as the criterion variables, are presented in Tables A.1 to A.4 of the supplementary materials. When the BIS-related variables were entered first, they explained a statistically significant 7% of the variance in pain intensity and 6% of the variance in pain unpleasantness. Pain catastrophizing was a significant positive predictor of both pain intensity (β = .18, p < 0.05) and pain unpleasantness (β = .18, p < 0.05). When the BAS-related variables were entered in step two of both models, they did not significantly increase the explained variance in either criterion variable, but pain catastrophizing remained a significant positive predictor of both pain variables (β’s = .19, p’s < 0.05). When the BAS-related variables were entered in the first step, the models did not significantly explain variance in the pain outcome variables. However, when the BIS-related variables were entered in step two, the model explained 6% of the variance in pain intensity and 5% of the variance in pain unpleasantness. Pain catastrophizing again emerged as a significant positive predictor of both pain intensity (β = .19, p < 0.05) and pain unpleasantness (β = .02, p < 0.05).

4. Discussion

The current study is the first to investigate the utility of the BIS-BAS model of pain for understanding coping and pain responses in athletes. Consistent with the hypotheses in relation to both athletes with and without pain, the BAS-related variables were significantly and positively associated with each other. Similarly, significant positive associations were found among most BIS-related variables in athletes with pain, but not in pain-free athletes. However, mixed results were found in tests of the hypothesized negative associations between measures of BIS- and BAS-related domains. Some, but not all, BIS-related variables were significantly and negatively associated with BAS-related variables in both samples. In athletes with pain, and consistent with what we hypothesized, BIS-related variables were significantly associated with pain variables, with these associations being stronger than those found for BAS-related variables. However, the BAS-related variables tended to have weak and non-significant associations with pain outcomes. Collectively, the findings suggest a complex relationship between the BIS- and BAS-related measures included in this study, which appear to differentially influence coping and pain responses in athletes. Potentially, this may be due to differences in strength of activation of cognitive, emotional and behavioural “nodes” within these systems depending on the presence of pain. Finally, exploratory regression analyses highlighted the role of pain catastrophizing as a predictor of pain unpleasantness and intensity, indicating a potential focal point for future BIS-BAS research in athletes.

4.1. Athletes not currently experiencing pain.

In order to understand the applicability of the BIS-BAS model of pain for understanding athletes’ responses to pain, one objective of this study was to test theoretically-derived hypotheses pertaining to central tenets of the model (Jensen et al., 2016) in a sample of pain-free athletes. As expected, independent grouping of BAS-related variables and most BIS-related variables was observed in pain-free athletes. This was evidenced by the positive associations found among measures of BAS-related variables, and the positive associations found among most BIS-related variables. The exception was for harm beliefs which showed small, negative effect sizes, although given the small magnitude of the observed association, this is likely not clinically meaningful. These findings are consistent with prior research which reports positive correlations between BIS-related and between BAS-related factors in both clinical (Day et al., 2019) and healthy adult (Day et al., 2021; Vetterlein et al., 2024) samples.

The BIS-BAS model of pain also proposes that the BIS and BAS are mutually inhibitory, such that BIS activation inhibits BAS activation and vice-versa (Day et al., 2019; Jensen et al., 2016). Consistent with this hypothesis, in athletes without pain, negative associations were observed between most measures of BIS- and BAS-related domains. The strongest negative associations were found between positive affect and both depression and anxiety, suggesting the possibility that positive affect may play a protective coping function. Further, approach-related cognitions showed the largest negative association with pain catastrophizing, which suggests the possibility that targeting approach-related cognitive content might be effective for reducing catastrophizing. Research to examine this possibility is warranted.

However, not all of the associations found were in line with the BIS-BAS model of pain, particularly in relation to harm beliefs, which were not significantly associated with most of the BAS-related variables in the non-pain sample. Interestingly, in the SOPA development sample of adults with chronic pain, the Harm scale mean was 1.52 (SD = .87) (Jensen et al., 2000) whereas in the non-pain sample in this study, the mean was 2.09 (SD = .76). Taken together, this may indicate that while harm beliefs were common in this sample, they might not operate in the same way among healthy athletes as they might in clinical samples reporting pain. That is, while harm beliefs function to “put the brakes on” activity and other BAS-related domains in individuals with pain, these beliefs may not inhibit BAS-related variables in healthy athletes (i.e., as evidenced by the lack of significant associations). This suggests the possibility that healthy athletes possess a distinct cognitive-emotional-behavioural coping framework, which may allow them to respond uniquely to the perception that pain signifies damage/harm. This nuanced understanding could potentially stem from their extensive experience with various forms of pain within their sport. How BIS- and BAS-related factors impact function and performance in individuals with and without pain deserves further study.

4.2. Athletes currently experiencing pain.

Given that pain and injury are common experiences among athletes, a further objective of this study was to evaluate the tenets of the BIS-BAS model of pain in the sample of athletes experiencing current pain. We hypothesized that in such individuals, positive associations would be observed within measures of BIS- and BAS-related domains, respectively. In line with these hypotheses, as in the pain-free athletes, all of the BAS-related variables and most of the BIS-related variables were significantly positively associated with one another. This indicates that irrespective of the presence or absence of current pain (with the exception for harm beliefs in the non-pain sample, as discussed above), the BIS- and BAS-related measures tend to be consistently associated with one another in athletes as theorized by the model. This was particularly evident among the BAS-related measures. Such consistency in the BAS-related measures amongst athletes might be underpinned by reward-seeking and goal-directed behaviours in this group despite the presence of pain. These behaviours are vital for athletes to meet their objectives and are theoretically key elements of BAS activation.

We were also interested in examining the associations between the BIS- and BAS-related measures in this sample of athletes with current pain and hypothesized that these would be negative in nature. There were some important differences that emerged in contrast to the healthy sample. We found that the aforementioned potential protective role of positive affect and approach-related thoughts in mitigating depression and anxiety was weakened/lessened in this group. However, approach-related cognitive content was still negatively associated with pain catastrophizing. This suggests that in the context of athletes experiencing current pain, how the BIS- and BAS-related factors operate and relate to each other is different from those athletes without pain.

To understand how pain might interact with the other BIS- and BAS-related factors, we also evaluated the theoretical premise (Day et al., 2019; Jensen et al., 2016) that pain intensity and pain unpleasantness ratings would be negatively associated with BAS-related domains and positively associated with BIS-related domains. In addition, we evaluated whether pain variables would be more strongly associated with BIS-related measures than with BAS-related measures. Consistent with these hypotheses, not only were BIS-related measures more strongly related to pain than BAS, the BAS-related measures showed weak, albeit negative, associations with both pain intensity and unpleasantness. The less than small effect sizes found between the BAS-related factors and the pain outcomes are potentially due to the mild- to moderate level of pain intensity reported on average in this sample. It may be that such BAS-related factors moderate pain only at higher levels. However, in one of our other studies of the BIS-BAS model of pain in a clinical sample, results also showed that multiple BAS-related measures also had weak associations with pain intensity, although they were associated with catastrophizing, depression and anxiety (Day et al., 2019). Taken together, the findings suggest the possibility that while BAS-related factors may influence functional coping mechanisms in response to pain, they may have minimal direct effects on the experience of pain itself.

In the case of the BIS-related factors on the other hand, and as hypothesized, there were significant positive associations between the severity of depressive symptoms, anxiety, and pain catastrophizing with pain intensity and unpleasantness. In contrast, harm beliefs and avoidance behaviours, despite being elevated, did not evidence a significant relationship with pain intensity or unpleasantness. This suggests that the domains assessed by the BIS-related measures might not interact in the same manner in athletes with current pain than what has been found in past research in clinical pain samples. This lack of association between harm beliefs and avoidance behaviour with pain outcomes might stem from several athlete-specific external factors, such as pressures from coaches (Nixon, 1992; Wiese-Bjornstal, 2010) feeling judged by teammates (Barrette & Harman, 2019; Deroche et al., 2011) insecurity about status on the team (Deroche et al., 2011; Nixon, 1992) or an important upcoming competition (Barrette & Harman, 2019). Such external pressures might contribute to a mindset where although athletes do believe that the hurt they are feeling is an indication of physical damage/harm, and while they may want to avoid the pain, despite this, they are not “allowing” such responses to influence their experience of pain. That is, potentially, due to such external factors, avoidance behaviours (for example) may not be linearly associated with pain variables. This potential interpretation is also consistent with theoretical tenets of the Avoidance-Endurance model (Hasenbring & Verbunt, 2010) which proposes that some individuals respond to pain with endurance responses and use strategies such as thought suppression, distraction or minimalization, in order to persist with a valued task, despite the pain. While this might be beneficial in the short-term, it also may increase the risk for vulnerability to injury longer-term. A longitudinal, repeated measures study that could take such contextual factors, as well as explanations related to endurance responses into account would potentially provide more insight into these dynamics.

Lastly, an exploratory objective of this research was to determine which, if any, measures of BIS- and BAS-related domains accounted for unique variance in the prediction of pain intensity and pain unpleasantness in athletes currently experiencing pain. These exploratory analyses showed that BIS-related measures significantly accounted for variance in pain intensity and pain unpleasantness, while BAS-related measures did not. This is consistent with the nature of the strength of correlations between these variables, as discussed above. Of note, the most robust unique predictor emerging from these models was pain catastrophizing, which significantly predicted both pain intensity and unpleasantness. This finding may be explained by the critical role pain catastrophizing as a cognitive process is conceptualized to play in the BIS-BAS model of pain, where it is proposed to function as a modulator of the emotional, cognitive, and behavioural responses to pain, and directly influence pain perception (Jensen et al., 2016). This result is also consistent with a plethora of existing literature which substantiates the important role of pain catastrophizing as a strong predictor of pain outcomes, including in athletes (Gagnon-Dolbec et al., 2021; Lentini et al., 2021; Quartana et al., 2009; Sullivan et al., 2000).

4.3. Implications

Applying the BIS-BAS model of pain to athletes can enhance our understanding of the psychological factors that influence athletes’ pain responses. Our findings suggest that athletes may utilize a distinct cognitive-emotional-behavioural coping framework when interpreting pain as an indicator of damage/harm. In this context, the effect of external pressures might mould athletes’ perceptions about pain, and this influence warrants consideration. In addition, it is important to consider the potential protective and buffering role of positive affect. Should future research replicate this finding, it could have significant implications for tailoring interventions to optimize coping and well-being. Furthermore, addressing catastrophizing should be a central focus for clinical interventions seeking to improve athletes’ abilities to adjust to pain. Optimized interventions could thus be potentially achieved by developing personalized treatments that utilize profiles based on athletes BIS-BAS traits to align treatment approaches with individual profiles. For example, in taking the overarching pattern of findings obtained into consideration: a BIS-BAS tailored intervention might specifically target pain catastrophizing and (depending on the athlete’s individual profile) this may be best accomplished in athletes by using (1) tailored techniques to either directly target catastrophizing cognitions (e.g., via cognitive restructuring) or (2) possibly indirectly via boosting approach thoughts or pain openness (both of which were found to be negatively correlated with catastrophizing in this study) if levels of these cognitive processes are initially low (e.g., via exposure techniques or mindfulness meditation, depending on the athlete’s preference). Moreover, assessment and potentially tailored intervention to target contextually-driven endurance responses despite the pain (and related elevated harm beliefs and enhanced desire to avoid the pain) might inform potential injury prevention strategies. Thus, the application of the BIS-BAS model of pain, as was undertaken in this research, affords the capacity to not only replicate known effects but also extends and builds on this research base to inform potential targeted, tailored, and theoretically grounded interventions for both prevention and treatment.

4.4. Limitations and future directions

One limitation of this research was the lack of assessment of the characteristics of pain experienced by athletes, and whether it was associated with an injury. Future research should consider a more extensive evaluation of the specific types of pain experienced by the athletes as the nature and potential for harm would have implications for athletes’ BIS or BAS responses. In addition, the cross-sectional nature of this study limits our ability to evaluate causal relationships between BIS-BAS related factors and pain outcomes. A longitudinal study design with repeated measures would offer deeper insights into these dynamics. We do also acknowledge that we did not directly measure the BIS and BAS neurobiological brain systems as this would require the use of brain imaging. However, the self-reported measures used are psychometrically valid tools for assessing the “nodes” in the BIS- and BAS-related networks as proposed in the model by Jensen and colleagues. Additionally, the generalizability of these findings could be a concern. The sample consisted primarily of young, WEIRD (Western, Educated, Industrialized, Rich, and Democratic) individuals from an Australian University. Moreover, the participants were predominantly recreational athletes, suggesting that the results may not extend to higher-level athletes. Future studies should aim to include more diverse and representative samples to enhance generalizability. Finally, the role of external contextual factors such as coaching pressures and performance expectations warrants further exploration in relation to BIS and BAS activation.

5. Conclusions

The present study is the first to provide support for the utility of the BIS-BAS model of pain in athletes, presenting a novel lens through which to view the complex factors influencing athletes’ coping and decisions to pause or push through pain. The results showed support for a potential protective role of positive affect and approach-related thoughts in coping, and in mitigating symptoms of depression and anxiety. Further, pain catastrophizing appeared to be an important predictor of pain outcomes, underscoring its influence on athletes’ pain perception. Future investigations to explore these dynamics in more depth have the potential to inform the development of more precisely targeted interventions that enhance athletes’ ability to cope and to manage pain more effectively.

6. Implications

• Athletes have a unique way of processing and coping with pain, especially when they interpret it as an indicator of potential harm.

• Positive affect and approach-related thoughts may play a protective role in coping, and in mitigating symptoms of depression and anxiety in athletes.

• To better support athletes in making appropriate responses to pain, a key strategy should be addressing tendencies to catastrophize about pain. This may involve helping them adjust their thinking around confronting or approaching pain.

• For athletes currently experiencing pain, it may also be beneficial to encourage a more open and accepting attitude towards their pain in order to address catastrophic thinking around pain.

Availability of data and materials

Please contact the corresponding author with any requests for access to limited, fully deidentified data; all requests will be considered on a case-by-case basis. Because open access to data was not included as part of informed consent, access is limited.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online https://doi.org/10.1080/02640414.2024.2370154.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.