Negative expectations and related nocebo effects in shoulder pain: a perspective for clinicians and researchers

The nocebo effect, a phenomenon wherein negative expectations can worsen symptoms, is increasingly acknowledged within the context of musculoskeletal conditions. While experimental evidence has, to some extent, examined negative expectations in shoulder pain, their specific relationship with nocebo effects and their manifestation in clinical practice remains unexplored. In this perspective, clinicians and researchers are guided by first examining the psychobiology and neurophysiology underlying nocebo effects from a basic science standpoint, thereby equipping clinicians with a robust understanding of the phenomenon. What are considered the primary potential sources of nocebo effects in individuals with shoulder pain are then outlined - namely, diagnostic labels, diagnostic imaging and special tests, the medicalization of normality, and overtreatment. Practical clinical strategies are subsequently proposed to mitigate nocebo effects arising from these sources. Finally, the research implications for advancing the study of nocebo effects in people with shoulder pain are discussed. Overall, this perspective provides a comprehensive overview of the impact of negative expectations and associated nocebo effects on shoulder pain outcomes. By identifying potential sources of nocebo effects that may emerge in everyday clinical practice, guidance on mitigating related negative expectations in patients with shoulder pain is offered.