Pain Expectations Before Surgery Can Be a Self-fulfilling Prophecy

Anna Goshua

June 17, 2021

Patients who expect their pain to worsen after surgery may be at higher risk of lingering postsurgical pain, according to a study published in Anesthesiology. Factors associated with lingering postsurgical pain remain poorly understood.

Researchers retrospectively analyzed a single-center cohort of 3628 postsurgical patients who underwent operations between February 2015 and October 2016 at a US tertiary-care hospital. These patients participated in an observational study called the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS).

During their preoperative assessments, patients completed the Veterans RAND 12-item health questionnaire and a survey about their baseline pain, the reason for surgery, and their expectations about pain 1 month after the operation.

One to 3 months after surgery, patients were asked to fill out a follow-up survey that included questions about whether they were still experiencing pain and, if so, to rank its intensity on a scale of 0 to 10. The investigators defined "lingering postsurgical pain" as an affirmative response to the question, "Currently, do you have any pain in your surgical incision or area related to your surgery?"

Preoperatively, 67% of patients (n = 2414) had positive expectations that they would have no postsurgical pain if they did not have baseline pain or that they would experience an improvement in pain if they did have baseline pain 1 month after surgery. Nineteen percent of patients (n = 686) expected new pain if they reported no pain at baseline or expected their pain to stay the same or worsen if they did have baseline pain.

The remaining 24% said they did not know whether they'd have postoperative pain.

Although 44% of patients with positive expectations had surgeries that are usually done to relieve pain, only 26% of patients with negative expectations had those types of surgeries.

About 36% of patients (n = 1308) reported lingering postoperative pain. The mean severity was ranked 3.8 on a scale of 0 to 10 (standard deviation, 2.1). Patients who expressed negative expectations were more likely to report lingering postsurgical pain (odds ratio [OR] = 1.56; 95% CI, 1.23 – 1.98; P < .001).

Compared to patients with positive expectations, patients with negative expectations were twice as likely to report new or more severe pain (23% vs 11%; P < .001). Other significant risk factors included recollection of severe acute postoperative pain (OR = 3.13; 95% CI, 2.58 – 3.78; P < .001), undergoing a procedure typically meant to alleviate pain (OR = 2.18; 95% CI, 1.73 – 2.75; P < .001), and preoperative pain related to surgery (OR = 1.91; 95% CI, 1.52 – 2.40; P < .001).

Dr Simon Haroutounian

"There are risk factors that are better known, like age and perhaps preexisting chronic pain issues," said Simon Haroutounian, PhD, the senior author of the study and the chief of clinical pain research at the Washington University Pain Center, in St. Louis, Missouri, in an interview with Medscape Medical News. "We found that patient expectations, particularly if they have negative expectations, may be independent predictors of patients who are doing worse and still having pain somewhere between 1 and 3 months after surgery," he said.

Lingering postoperative pain can lead to chronic pain, said W. Michael Hooten, MD, a pain specialist at the Mayo Clinic, in Rochester, Minnesota, in an interview with Medscape. "It's important to differentiate between lingering pain and chronic pain. This is a critical time point during which there might be interventions to mitigate the risk of developing chronic pain," said Hooten, who was not involved in the study.

Patient expectations did not always align with their pain outcomes; 26% of patients with positive expectations reported new, unabated, or worsening pain, and 61% of patients with negative expectations experienced no lingering pain or an improvement in their preexisting pain.

Dr Beth Darnall

It's important to note that the study included "a high degree of heterogeneity in the surgical types and patient populations," said Beth Darnall, PhD, the director of the Pain Relief Innovations Lab at Stanford University, Stanford, California, in an interview with Medscape. For some patients who undergo major surgeries such as total knee replacements, expecting to still be in pain a month after the procedure is perfectly reasonable, she explained. Patient expectations may be influenced by the type of surgery and the preoperative counseling they receive.

More research is needed to understand how patient expectations affect pain outcomes. The effects of negative expectations may range from altering a patient's willingness to participate in rehabilitation to changing pain processing on a physiologic level, Hooten pointed out.

For their next steps, the researchers aim to create a prediction model that could be used to evaluate an individual patient's risk of having chronic pain after surgery, Haroutounian said.

The parent study was funded through institutional and departmental support, including a grant from the Barnes-Jewish Hospital in St. Louis. Haroutounian and Hooten have disclosed no relevant financial relationships. Darnall is the chief science advisor at AppliedVR.

Anesthesiology. 2021;134:915-924. Abstract

Anna Goshua is a reporting intern with Medscape. She is a dual medical and journalism student who has previously written for STAT, Scientific American, Slate, and other outlets. She can be reached at or @AnnaGoshua.

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