**1. Introduction**

Chronic pain affects more than 30% of people worldwide and has a large impact on both patients and society [1]. Due to the complex interactions between biological, psychological and social factors [1,2], it is difficult to manage chronic pain. One of these factors is fear-avoidance, which refers to the avoidance of movements or activities resulting from fear of pain [3]. According to the fear-avoidance model, pain may be interpreted as threatening (i.e., pain catastrophizing), which can lead to avoidant behaviors and hypervigilance to

**Citation:** Waardenburg, S.; Visseren, L.; van Daal, E.; Brouwer, B.; van Zundert, J.; van Kuijk, S.M.J.; Lousberg, R.; Jongen, E.M.M.; Leue, C.; de Meij, N. Do Men and Women Have a Different Association between Fear-Avoidance and Pain Intensity in Chronic Pain? An Experience Sampling Method Cohort-Study. *J. Clin. Med.* **2022**, *11*, 5515. https:// doi.org/10.3390/jcm11195515

Academic Editor: Carmen María Galvez Sánchez

Received: 18 August 2022 Accepted: 16 September 2022 Published: 20 September 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

bodily sensations. Conversely, fear-avoidance and hypervigilance may induce physical disuse and disability, contributing to long-term consequences, including maintenance of chronic pain disability or an increase in the pain experience [3]. Although the association between fear-avoidance and chronic pain has been well-established, only sparse research has been conducted on potential sex differences regarding this association. As a growing number of articles suggests the importance of sex differences in relation to pain, and specifically in pain catastrophizing [4–6], it is important to further investigate whether the association between fear-avoidance and pain also depends on sex.

Furthermore, the biopsychosocial model of pain shows that emotional distress or affective states may influence pain intensity [1] and may, therefore, also confound the association between sex and fear-avoidance. It is known that dynamic fluctuations regarding positive and negative affect are observed in various mental disorders [7], such as depression. Given that depression and pain share pathways [8], fluctuations in emotion regulation as observed in depression and other mental disorders may also be found in chronic pain patients. However, the effect of affective states, such as happiness, anxiety and irritation on the association between fear-avoidance and pain has not been adequately studied. The cross-sectional design of studies that have investigated the association between affective states and chronic pain could not capture the fluctuations of emotional distress over time.

Hence, the present study aimed to investigate whether the association between fearavoidance and pain intensity in chronic pain patients differs between men and women. Additionally, the potential confounding effect of specific affective experiences on the association between fear-avoidance and pain intensity was analyzed by using the experience sampling method (ESM).
