Expectancy, fear and pain in the prediction of chronic pain and disability: a prospective analysis
Abstract
Studies with (sub) acute back pain patients show that negative expectancies predict pain and disability at a one-year follow up. Yet, it is not clear how expectations relate to other factors in the development of chronic disability such as pain and fear. This study investigates the relationship between expectations, pain-related fear and pain and studies how these variables are related to the development of chronic pain and disability. Subjects (N = 141) with back and/or neck pain (duration <1 year) were recruited via primary care. They completed measures on pain, expectancy, pain-related fear (pain-related negative affect and fear avoidance beliefs) and function. A one-year follow up was conducted with regard to pain and function. It was found that pain, expectancy, pain-related fear and function were strongly interrelated. In the cross-sectional analyses negative expectancies were best explained by frequent pain and a belief in an underlying and serious medical problem. Prospectively, negative expectancy, negative affect and a belief that activity may result in (re) injury or increased pain, explained unique variance in both pain and function at one-year follow up. In conclusion, expectancy, negative affect and fear avoidance beliefs are interrelated constructs that have predictive value for future pain and disability. Clinically, it can be helpful to inquire about beliefs, expectancy and distress as an indication of risk as well as to guide intervention. However, the strong interrelations between the variables call for precaution in treating them as if they were separate entities existing in reality.
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Higher pain expectancy is associated with increases in subsequent pain experiences.
“Experimental and diary studies have shown that higher pain expec tancy is associated with increases in (subsequent) pain experiences [4,7 -10].”
From Nocebo hyperalgesia and other expectancy-related factors in daily fibromyalgia pain: Combining experimental and electronic diary methods (2024) · cites this paper as [8]
Greater pain expectancy is an indicator of future pain trajectory and quality of life.
“and also an indicator of future pain trajectory and quality of life [8,11].”
From Nocebo hyperalgesia and other expectancy-related factors in daily fibromyalgia pain: Combining experimental and electronic diary methods (2024) · cites this paper as [8]
Our results for pain expectancy are in line with previous studies indicating that pain-related expectancies modify pain intensity, similar to self-fulfilling prophecies [4,8,9,30].
“Our results for pain expectancy are in line with previous studies indicating that pain-related expectancies modify pain intensity, similar to self-fulfilling prophecies [4,8,9,30].”
From Nocebo hyperalgesia and other expectancy-related factors in daily fibromyalgia pain: Combining experimental and electronic diary methods (2024) · cites this paper as [8]
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“Expectations about pain have not yet been directly investigated in the case of dyspareunia, but they have proven to be important in the experience of both chronic and acute pain (eg, Boersma & Linton, 2006 ; Boston & Sharpe, 2005 ).”
BackgroundConsequences of Chronic Non-Cancer Pain in adulthood. Scoping Review
Cáceres‐Matos, R., Gil‐García, E., Barrientos‐Trigo, S., Pórcel‐Gálvez, A. M., & Cabrera‐León, A. (2020) · Revista de Saúde Pública · doi:10.11606/s1518-8787.2020054001675 · Cited by 50 · see citing works
Walking the Tightrope: A Proposed Model of Chronic Pain and Stress
Lunde, C. E., & Sieberg, C. B. (2020) · Frontiers in Neuroscience · doi:10.3389/fnins.2020.00270 · Cited by 47 · see citing works
“Focusing on the long-term consequences, unforeseeable stress induces pain and a cycle of “feeding-forward” inadequate adjustments to the situations, thus resulting in physiological responses and susceptibility to pain persistence (Borsook et al., 2012).”
BackgroundZale, E. L., LaRowe, L. R., Boissoneault, J., Maisto, S. A., & Ditre, J. W. (2019) · The American Journal of Drug and Alcohol Abuse · doi:10.1080/00952990.2019.1578968 · Cited by 43 · see citing works
Ihara, N., Wakaizumi, K., Nishimura, D., Kato, J., Yamada, T., Suzuki, T., Hashiguchi, S., Terasawa, Y., Kosugi, S., & Morisaki, H. (2019) · PLoS ONE · doi:10.1371/journal.pone.0221023 · Cited by 43 · see citing works
Motivating disability pensioners with back pain to return to work - a randomized controlled trial
Magnussen, L., Strand, L., Skouen, J. S., & Eriksen, H. (2007) · Acta Dermato Venereologica · doi:10.2340/16501977-0004 · Cited by 43 · see citing works
“Positive patient expectation is demonstrated to be of great importance in vocational-oriented interventions (33).”
BackgroundDubois, J.-D., Abboud, J., St-Pierre, C., Piché, M., & Descarreaux, M. (2014) · Journal of Electromyography and Kinesiology · doi:10.1016/j.jelekin.2014.04.012 · Cited by 43 · see citing works
“The severity of functional disability in patients with chronic non-specific LBP is also related to psychological factors, such as pain catastrophizing, pain-related fear and avoidance beliefs (Boersma and Linton, 2006; Lundberg et al., 2011; Peters et al., 2005).”
BackgroundLaRowe, L. R., Zvolensky, M. J., & Ditre, J. W. (2018) · Cognitive Therapy and Research · doi:10.1007/s10608-018-9957-y · Cited by 41 · see citing works
Carrière, J. S., Thibault, P., Milioto, M., & Sullivan, M. J. L. (2015) · Journal of Pain · doi:10.1016/j.jpain.2015.09.001 · Cited by 40 · see citing works
“Despite these limitations, the current study advances knowledge regarding themediating role of expectancies on RTW outcomes after WADs.”
ResultInfluentialChronic pain: A non-use disease
Pruimboom, L., & van Dam, A. C. (2006) · Medical Hypotheses · doi:10.1016/j.mehy.2006.08.036 · Cited by 40 · see citing works
“Fear for pain and more damage seems to be the mayor reason for this part of the typical pain-behaviour [17–20].”
BackgroundBishop, F. L., & Lewith, G. T. (2008) · Journal of Acupuncture and Meridian Studies · doi:10.1016/s2005-2901(09)60001-7 · Cited by 39 · see citing works
Pain-related anxiety as a predictor of early lapse and relapse to cigarette smoking.
LaRowe, L. R., Langdon, K. J., Zvolensky, M. J., Zale, E. L., & Ditre, J. W. (2017) · Experimental and Clinical Psychopharmacology · doi:10.1037/pha0000127 · Cited by 39 · see citing works
“Pain-related anxiety has been identified as a risk factor in the transition from acute to chronic pain (Boersma & Linton, 2006; Vlaeyen & Linton, 2000), and greater pain-related anxiety has been related to greater pain intensity, 3 maladaptive approaches to pain coping, and increased somatic…”
An Everyday Phrase May Harm Your Patients
Ott, J., Aust, S., Nouri, K., & Promberger, R. (2011) · Clinical Journal of Pain · doi:10.1097/ajp.0b013e3182321cc3 · Cited by 38 · see citing works
“Individuals who reported extreme fear of pain or blood sampling were excluded from the study because negative expectancy and fear have been proven to correlate with pain.(25) Extreme fear has also been described as a “bias,” as high-fear individuals tend to overestimate certain fear-relevant stimuli.”
BackgroundSadeghian, F., Hosseinzadeh, S., & Aliyari, R. (2014) · Safety and Health at Work · doi:10.1016/j.shaw.2013.11.004 · Cited by 37 · see citing works
“Boersma and Linton [9], in a study among (sub) acute LBP patients showed negative expectations related to pain and its disability at 1-year follow-up.”
BackgroundChronic low back pain patient groups in primary care – A cross sectional cluster analysis
Viniol, A., Jegan, N. R. A., Hirsch, O., Leonhardt, C., Brugger, M., Strauch, K., Barth, J., Baum, E., & Becker, A. (2013) · BMC Musculoskeletal Disorders · doi:10.1186/1471-2474-14-294 · Cited by 36 · see citing works
“Multifactorial analyses usually study the impact of psychosocial characteristics in conjunction with pain-related fear [12,13], emotional distress [14,15], behavioral response [16,17], or other psychosocial and behavioral characteristics [18].”
BackgroundChronic Pain, Insomnia and their Mutual Maintenance: A Call for Cognitive Bias Research
Todd, J., Austin, H., Clarke, P., & Notebaert, L. (2022) · Journal of Pain · doi:10.1016/j.jpain.2022.03.241 · Cited by 36 · see citing works
Predictors and social consequences of daily pain expectancy among adults with chronic pain
Mun, C. J., Thummala, K., Davis, M. C., Karoly, P., Tennen, H., & Zautra, A. J. (2017) · Pain · doi:10.1097/j.pain.0000000000000903 · Cited by 34 · see citing works
“Likewise, evidence from longitudinal(10) and daily diary studies(1) shows that higher pain expectancy predicts greater pain and disability, even when controlling for negative affect, fear avoidance, and baseline pain level.(9) In sum, pain expectancy appears to be an important determinant of future pain experience and…”
BackgroundBüchel, C. (2023) · eLife · doi:10.7554/elife.81795 · Cited by 35 · see citing works
Psychologische Mechanismen der Chronifizierung – Konsequenzen für die Prävention
Pfingsten, M., Korb, J., & Hasenbring, M. I. (2010) · Springer eBooks · doi:10.1007/978-3-642-12783-0_7 · Cited by 34 · see citing works
Schultz, I. Z., Crook, J., Berkowitz, J., MILNER, R. A., Meloche, G. R., & Lewis, M. L. (2008) · Journal of Occupational Rehabilitation · doi:10.1007/s10926-008-9130-7 · Cited by 34 · see citing works
“In previous research, it has been found that workers with elevated Waddell scores are the least responsive to a medically modeled recovery and RTW, but are more likely to benefit from an EI incorporating psychosocial and medical components [4, 6, 8, 9, 12, 61, 78, 79].”
MethodGroeneweg, R., Haanstra, T. M., Bolman, C. A. W., Oostendorp, R. A. B., van Tulder, M. W., & Ostelo, R. (2016) · Scandinavian Journal of Pain · doi:10.1016/j.sjpain.2016.10.003 · Cited by 34 · see citing works
When the wind goes out of the sail – declining recovery expectations in the first weeks of back pain
Carstens, J. K. P., Shaw, W. S., Boersma, K., Reme, S. E., Pransky, G., & Linton, S. J. (2013) · European Journal of Pain · doi:10.1002/j.1532-2149.2013.00357.x · Cited by 33 · see citing works
“Such a mismatch may well trigger patterns of fear-avoidance and catastrophizing (Boersma and Linton, 2006; Iles et al., 2012).”
BackgroundSelf-citationPerrot, S., Allaert, F., Concas, V., & Laroche, F. (2009) · European Spine Journal · doi:10.1007/s00586-008-0868-6 · Cited by 33 · see citing works
“Expected recovery time is influenced by several demographic and clinical data, but is also determined by fear, pain, beliefs, and expectations [1].”
BackgroundMehling, W. E., Ebell, M. H., Avins, A. L., & Hecht, F. M. (2015) · The Spine Journal · doi:10.1016/j.spinee.2015.03.003 · Cited by 32 · see citing works
“The expectancy of pain to persist was maladaptive at 6 months [45,46], whereas a low willingness to tolerate pain [14] and perceived stress [41,42] increased risk at 2 years.”
Carrière, J. S., Martel, M. O., Meints, S. M., Cornelius, M. C., & Edwards, R. R. (2018) · European Journal of Pain · doi:10.1002/ejp.1348 · Cited by 32 · see citing works
“…consistent associations between pain expectancies and numerous adverse pain‐related outcomes, including self‐reported pain intensity and disability (Boersma & Linton, 2006; Gandhi, Davey, & Mahomed, 2009; Mun et al., 2017; Sullivan, Rodgers, et al., 2001), emotional distress (Carriere, Thibault,…”
BackgroundGupta, M., Malik, T., & Sinha, C. (2022) · JMIR Research Protocols · doi:10.2196/36910 · Cited by 34 · see citing works
“Similarly, research suggests that anxiety and fear arising from chronic pain are likely to interfere with recovery from the pain [15].”
BackgroundCoping when pain is a potential threat: The efficacy of acceptance versus cognitive distraction
Jackson, T., Yang, Z., Li, X., Chen, H., Huang, X., & Meng, J. (2011) · European Journal of Pain · doi:10.1002/j.1532-2149.2011.00019.x · Cited by 32 · see citing works
“…Lazarus, 1999), clinical studies indicate that pain viewed as a potential source of threat or harm is related to passive coping, increased pain severity and physical disability (Crombez et al., 1999; Jones et al., 2003; Boersma and Linton, 2006; Ramírez-Maestre et al., 2008; Truchon et al., 2008).”
BackgroundVelthuis, M. J., Peeters, P. H. M., Gijsen, B., van den Berg, J., Koppejan-Rensenbrink, R. A., Vlaeyen, J. W. S., & May, A. M. (2012) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2011.08.014 · Cited by 32 · see citing works
“5 84 (75) 496 (80) 214 (77) 28 (25) 126 (20) 64 (23) 20 9.”
The Mediating Role of Recovery Expectancies on the Relation Between Depression and Return-to-Work
Carrière, J. S., Thibault, P., & Sullivan, M. J. L. (2014) · Journal of Occupational Rehabilitation · doi:10.1007/s10926-014-9543-4 · Cited by 32 · see citing works
“Boersma and Linton [47] reported that after controlling for age, gender, pain and negative affect, expectancies accounted for an additional 15 % of the variance in functional disability at 1-year follow-up.”
BackgroundAn amygdala-to-cingulate cortex circuit for conflicting choices in chronic pain
Valentinova, K., Acuña, M. A., Ntamati, N. R., Nevian, N. E., & Nevian, T. (2023) · Cell Reports · doi:10.1016/j.celrep.2023.113125 · Cited by 32 · see citing works
“6 12 Therefore an in-depth understanding of the brain mechanisms leading to such maladaptive responses is urgently needed.”
Anselmo, A., Pagano, M. C., Cappadona, I., Cardile, D., Russo, F., Laudisio, A., Papalia, G. F., Quartarone, A., Calabrò, R. S., & Corallo, F. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13206149 · Cited by 30 · see citing works
“Moreover, in line with our results, numerous cognitive, emotional, behavioral, and environmental factors were involved in the negative perception of chronic pain in patients with LBP [41–48].”
ResultEffectiveness of a community based nurse-pharmacist managed pain clinic: A mixed-methods study
Hadi, M. A., Alldred, D. P., Briggs, M., Marczewski, K., & Closs, S. J. (2015) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2015.09.003 · Cited by 29 · see citing works
Rumination and interoceptive accuracy predict the occurrence of the thermal grill illusion of pain
Scheuren, R., Sütterlin, S., & Anton, F. (2014) · BMC Psychology · doi:10.1186/2050-7283-2-22 · Cited by 29 · see citing works
“Pain magnitude and pain unpleasantness have been reported to depend on the intensity of expected pain (Atlas and Wagner 2012; Boersma and Linton 2006; Tracey 2010).”
BackgroundIakova, M., Ballabeni, P., Erhart, P., Seichert, N., Lüthi, F., & Dériaz, O. (2012) · Journal of Occupational Rehabilitation · doi:10.1007/s10926-012-9369-x · Cited by 30 · see citing works
“A 1-year follow-up study performed on patients with back and/or neck pain, found strong associations between pain, expectancy, pain-related fear and a belief in an underlying and serious medical problem [29].”
BackgroundLundgren, G. P., Vestlund, G.-I. M., & Dahllöf, G. (2018) · Journal of Dentistry · doi:10.1016/j.jdent.2018.06.020 · Cited by 37 · see citing works
The Four-Cluster Spectrum of Mind-Body Interrelationships: An Integrative Model
Ezra, Y., Hammerman, O., & Shahar, G. (2019) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2019.00039 · Cited by 29 · see citing works
Groeneweg, R., van Assen, L., Kropman, H., Leopold, H., Mulder, J., Smits-Engelsman, B. C. M., Ostelo, R., Oostendorp, R. A. B., & van Tulder, M. W. (2017) · Chiropractic & Manual Therapies · doi:10.1186/s12998-017-0141-3 · Cited by 28 · see citing works
“Fear avoidance, measured with the Fear Avoidance Belief Questionnaire (FABQ) [32], is a risk factor for chronic pain and disability [31, 33, 34] and can predict outcomes [35, 36].”
MethodIllusion-enhanced Virtual Reality Exercise for Neck Pain
Harvie, D. S., Smith, R., Moseley, G. L., Meulders, A., Michiels, B., & Sterling, M. M. (2019) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000000780 · Cited by 27 · see citing works
Role of Occupational Therapy in Pain Management
American Occupational Therapy Association (2021) · American Journal of Occupational Therapy · doi:10.5014/ajot.2021.75s3001 · Cited by 27 · see citing works
“…engagement in meaningful activities and measure levels of fear and avoidance of those activities at assessment and to track improvements over time (Boersma & Linton, 2005; Waddell et al., 1993) (cid:129) Sensory Symptoms Checklist to investigate responses to daily sensory experiences affecting…”
Taylor, A., Harris, A. D., Varnava, A., Phillips, R., Taylor, J., Hughes, O., Wilkes, A. R., Hall, J. E., & Wise, R. G. (2015) · PLoS ONE · doi:10.1371/journal.pone.0141133 · Cited by 25 · see citing works
Pain psychology in the 21st century: lessons learned and moving forward
Flink, I. K., Rème, S. E., Jacobsen, H. B., Glombiewski, J. A., Vlaeyen, J. W. S., Nicholas, M. K., Main, C. J., Peters, M. L., Williams, A. C. D. C., Schrooten, M. G. S., et al. (2020) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2019-0180 · Cited by 26 · see citing works
“Expectations about future pain outcomes are among the strongest predictors of pain, pain behavior, and treatment outcomes [58, 59].”
BackgroundSelf-citationPain-related fear, catastrophizing and pain in the recovery from a fracture
Steven, J., Buer, N., Samuelsson, L., & Harms‐Ringdahl, K. (2009) · Scandinavian Journal of Pain · doi:10.1016/j.sjpain.2009.09.004 · Cited by 26 · see citing works
Self-Efficacy, Pain-Related Fear, and Disability in a Heterogeneous Pain Sample
Perry, E. V., & Francis, A. J. P. (2012) · Pain Management Nursing · doi:10.1016/j.pmn.2011.09.001 · Cited by 27 · see citing works
Carrière, J. S., Pimentel, S. D., Saba, S. B., Boehme, B. A. E., Berbiche, D., Coutu, M., & Durand, M. (2022) · Pain · doi:10.1097/j.pain.0000000000002789 · Cited by 25 · see citing works
“For example, studies conducted by Ozegovic et al., 79 Magnussen et al., 69 and Boersma et al. 9 were excluded because they measured self-perceived global recovery, work-related function, and functional disability, respectively.”
Anticipation and violated expectation of pain are influenced by trait rumination: An fMRI study
Kökönyei, G., Galambos, A., Édes, A. E., Kocsel, N., Szabó, E., Pap, D., Kozák, L. R., Bagdy, G., & Juhász, G. (2018) · Cognitive Affective & Behavioral Neuroscience · doi:10.3758/s13415-018-0644-y · Cited by 24 · see citing works
Rise, M. B., Gismervik, S. Ø., Johnsen, R., & Fimland, M. S. (2015) · BMC Health Services Research · doi:10.1186/s12913-015-1190-8 · Cited by 23 · see citing works
Applying Centrality of Event to Persistent Pain: A Preliminary View
Perri, L. M., & Keefe, F. J. (2007) · Journal of Pain · doi:10.1016/j.jpain.2007.10.019 · Cited by 23 · see citing works
- Authors
- Boersma, K., & Linton, S. J.
- Affiliations
- Örebro University (SE)
- Corresponding author
- Boersma, Katja
- Venue
- European Journal of Pain
- Publisher
- Wiley
- Published
- 2006-08
- Volume
- 10
- Issue
- 6
- Pages
- 551-551
- ISSN
- 1090-3801 (ISSN-L)
- 1532-2149
- OpenAlex
- W2124097182
- Cited by
- 224
- References
- 30
- Citations by year
- 2026: 1 · 2025: 9 · 2024: 8 · 2023: 8 · 2022: 13 · 2021: 9 · 2020: 11 · 2019: 14 · 2018: 12 · 2017: 9 · 2016: 13 · 2015: 14 · 2014: 10 · 2013: 16 · 2012: 10
- FWCI
- 5.73
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- European Journal of Pain (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Life Sciences › Neuroscience › Cognitive Neuroscience › Pain Management and Placebo Effect
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric Pain Management Techniques
- Keywords
- chronic pain, disability, fear of pain, negative expectations, fear-avoidance beliefs, back pain, neck pain, pain-related disability, prognosis, pain beliefs, risk factors
- MeSH terms
- Adult, Affect, Avoidance Learning, Back Pain, Chronic Disease, Disability Evaluation, Fear, Female, Humans, Male, Middle Aged, Predictive Value of Tests, Prospective Studies, Set, Psychology, Neck Pain
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