The role of psychosocial stress in the development of chronic musculoskeletal pain disorders: protocol for a systematic review and meta-analysis
Buscemi et al. Systematic Reviews
The role of psychosocial stress in the development of chronic musculoskeletal pain disorders: protocol for a systematic review and meta-analysis
Valentina Buscemi 0
Wei-Ju Chang 0
Matthew B. Liston 0
James H. McAuley 1
Siobhan Schabrun 0
0 Brain Rehabilitation and Neuroplasticity Unit, School of Science and Health, Western Sydney University , Sydney, NSW , Australia
1 Neuroscience Research Australia (NeuRA) , Sydney, NSW , Australia
Background: Psychosocial factors play an important role in chronic musculoskeletal pain disorders. Although psychosocial stress is likely to contribute to the development of chronic musculoskeletal pain, investigations are limited to work-related stress or examination of specific conditions such as upper limb pain. The purpose of this review is to assess the evidence for an aetiological role of psychological stress in chronic musculoskeletal pain disorders. Methods: A systematic review and meta-analysis will be conducted. Electronic databases will be searched using predefined search terms to identify relevant studies. Data will be extracted by two independent reviewers, and disagreement will be resolved by a third reviewer. Only prospective longitudinal studies that assess psychosocial stress at baseline will be included. The population of interest will be inception cohorts or cohorts of people who have not yet developed chronic musculoskeletal pain disorders. The primary outcome measure will be the onset of chronic musculoskeletal pain. Discussion: To our knowledge, this review will be the first to systematically explore the available evidence on the aetiological role of psychosocial stress for the development of chronic musculoskeletal pain disorders. This review has the capacity to inform clinical practice on the importance of an early identification and, consequently, treatment of individuals who present with acute musculoskeletal disorders accompanied by a high level of stress. Systematic review registration: PROSPERO CRD42017059949
Systematic review; Psychosocial stress; Musculoskeletal pain disorders; Prospective longitudinal studies
Musculoskeletal disorders (MDs) are the second most
common cause of disability worldwide, causing absence
from work and increased costs for employers and the
health care system. Disability rates due to chronic MDs
rose by 45% between 1990 and 2010, and this figure is
expected to increase further in future [
]. Although the
term MDs indicates pains or aches of the
musculoskeletal body system (muscles, joints, ligaments or tendons)
], cognitive and psychosocial factors are also associated
with MDs. Moreover, psychosocial factors have been
shown to have a role in the transition to chronic low
back pain. For example, observational longitudinal
studies have shown that emotional distress (e.g. depression
and anxiety) and maladaptive cognition (e.g.
fearavoidance and pain catastrophizing) negatively influence
the progression of acute low back pain towards a
chronic state [
Another psychosocial factor, often studied in MDs, is
psychosocial stress. Psychosocial stress is defined as a
“perception of threat, with resulting discomfort,
emotional tension, and difficulty in adjustment” [5: p.4].
Psychosocial stress can be triggered by different types of
stressors, such as adverse life events (e.g. job loss or loss
of a loved one), daily hassles (e.g. financial uncertainty
or difficult relationships) or work-related stressors (e.g.
low decision authority, job dissatisfaction or high job
Work-related stress, occurring when work demand
exceeds an individual’s knowledge and capacity to cope [
has been explored extensively in different MDs and
types of jobs. Studies have identified work-related stress
as a significant risk factor for the development of
chronic pain conditions [
]. In particular, a recent
systematic review has shown that highly monotonous
work and low social support are antecedents of MDs,
with an OR (odds ratio) ranging from 1.15 to 1.6 . In
contrast, no systematic review has evaluated whether
non-work-related psychosocial stress has an aetiological
role in the development of chronic MDs. This review
will be the first to systematically and critically evaluate
the evidence on the causative role of non-work-related
psychosocial stress in chronic MDs. A better
understanding of the influence of psychosocial stress in
chronic MDs is essential to facilitate treatments that
target this aspect of a common and debilitating health
The following protocol has been written according to
the MOOSE Guidelines for Meta-Analyses and
Systematic Reviews of Observational Studies and the
PRISMAP (Preferred Reporting Items for Systematic Reviews and
Meta-Analyses) guidelines [
] [see Additional file 1].
The protocol has been registered at the International
Prospective Register of Systematic Reviews (PROSPERO;
registration number CRD42017059949).
Does non-work-related psychosocial stress have an
aetiological role in the development of chronic MDs in
the general population?
In order to answer the review question, an association
between exposure (psychosocial stress) and outcome
(chronic musculoskeletal pain) will be sought.
Specifically, a meta-analysis of the available scientific literature
looking at the causal role (or aetiological role) of stress
on pain outcome will be conducted. Only longitudinal
prospective studies will be included, where stress is
considered the exposure of interest, measured at baseline in
an inception cohort, or a cohort that has not yet
developed chronic pain. Adjustment for confounding factors
(i.e. other psychological factors) will also be taken into
account in the data extraction and analysis.
Studies will be included if they are full-text articles, in
press, accepted or published before the screening phase.
The search will be carried out across the following
databases: MEDLINE, Embase, PsychINFO, Pubmed, Scopus
and CINAHL. The specific search strategy will be created
by the project team with the support of a Health Science
Librarian expert in systematic review searching. Only
articles written in English will be included.
Keywords and Medical Subject Headings (MeSH)
regarding stress and musculoskeletal pain will be used.
Examples of the search terms include Stress*, mental
fatigue, psycho* strain or burden or fatigue, demand*,
pain, acute or chronic musculoskeletal pain, back pain,
neck pain, upper and lower limb pain, cohort or
longitudinal study. The combination of musculoskeletal pain,
psychosocial stress and longitudinal studies search terms
will be used in varying combinations to identify relevant
literature. Search strategies will be customised to suit
each database. An additional file shows a draft of the
MEDLINE search strategy [see Additional file 2]. The
reference lists of all relevant articles will be manually
searched to identify any studies missed by electronic
The study population will be adults (aged over
18 years) selected from the general population
suffering from pain derived from any type of MD (e.g. back
pain, neck pain, temporomandibular pain). Studies
will be excluded if they investigate pain that is not of
musculoskeletal origin, such as visceral or cancer pain
or pain derived from central neurological conditions
(e.g. stroke, spinal cord injury).
No restriction will be placed on participants’ gender.
Since the aim of this study is to evaluate whether
previous high levels of stress, or high stress present at the
time of pain onset, have an aetiological role in the
development of chronic MDs, studies will be included if
participants are pain free at baseline, or if their pain,
deriving from a MD, is acute (between 0 and 6 weeks
from pain onset) [
Types of studies
Studies will be accepted if (i) they are longitudinal
observational studies measuring psychosocial stress at baseline
and (ii) they use one or more scales or questionnaires to
assess non-work-related psychosocial stress. Studies will
be excluded if they (i) assess work-related stress, or use
occupational stress models such as the Karasek
demandcontrol model or the Siegrist effort-reward imbalance
], (ii) assess distress and post-traumatic
stress disorder (PTSD), as these are considered to relate to
a specific psychological disorder, and (iii) are based on
serious childhood events, such as assaults or maltreatment,
as these are considered traumatic life events and may lead
to serious mental health problems (e.g. PTSD).
Eligible studies should report the development of
chronic musculoskeletal pain, lasting 3 months or longer
], as the primary outcome.
The primary investigator will conduct the search strategy
and remove duplicates using Endnote X7 (Thomson
Reuters, USA). Studies obtained through the search
strategy will be screened by two independent reviewers
according to the inclusion and exclusion criteria. At the
first stage, the reviewers will evaluate the title and
abstract of each article and the full text of all eligible
studies will be retrieved. If the reviewer is unsure about a
study’s eligibility, a full-text evaluation will be conducted.
Throughout data collection, disagreement will be
resolved by consensus and, if unresolved, a third reviewer
will be consulted. Included and excluded studies will be
recorded in each screening phase.
Two reviewers will independently conduct the following
data extraction from each study using a pre-defined data
extraction sheet [see Additional file 3]: (1) participant
information (gender, sample size, drop-out rate, type of
MD); (2) methods (study design, duration of follow-up);
(3) type of scale or questionnaire used to assess stress;
(4) strength of the association between the exposure of
interest (non-work-related psychosocial stress) and the
primary outcome, in terms of mean difference, odds
ratio (OR), or relative risk (RR) and their 95% CI and (5)
presence of comorbidities at baseline and/or follow up.
Authors will be contacted a maximum of three times by
e-mail if further information is needed. If the authors do
not reply after the third attempt at contact, the data will
be considered irretrievable.
Assessment of methodological quality (risk of bias)
The methodological quality of the included studies will
be assessed using a customised version of the Quality
Assessment Tool for Observational Cohort studies and
Cross-Sectional studies [
]. Two additional items from
the QUIPS (Quality in Prognostic Studies) tool (Q6: Did
the authors attempt to collect information on
participants who dropped out? Q7: Are there important
differences between participants who completed the study
and those who did not?) [
] and two items considered
important by the research team (whether loss to
followup is accounted for in the analysis and whether the
source of funding is provided) have been added to the
risk of bias assessment tool [see Additional file 4]. Two
independent reviewers will undertake the assessment of
methodological quality. Any disagreement will be
resolved by a third reviewer.
Strategy for data synthesis
A quantitative synthesis is planned to pool data from
included studies. Results from different stress-related
questionnaires and single items, in case the entire
questionnaire is not provided, will be aggregated to perform
separate meta-analyses using RevMan (Version 5.3.
Copenhagen: The Nordic Cochrane Centre, The Cochrane
Collaboration, 2014). A minimum of two studies will be
considered sufficient to perform a meta-analysis [
pool data using a random effects model.
The χ2 will be used to estimate heterogeneity between
studies with a statistical significance of p 0.10. The I2
will be used to identify the degree of heterogeneity, and
I2 50% will be considered a substantial heterogeneity
]. Effect estimates with 95% CIs will be presented.
If significant heterogeneity is found, a subgroup analysis
will be conducted according to the type of pain
condition (e.g. low back pain, neck pain) or type of
psychosocial stress scale (e.g. Perceived Stress Scale).
A score will be given to the included studies when assessing
their methodological quality. The median value of the
overall score will be used as a cut-off point to cluster the studies
into low or high risk of bias groups. A further analysis will
be conducted excluding studies with high risk of bias.
If quantitative analysis is not possible, due to statistical or
clinical heterogeneity, a narrative analysis will be
undertaken. Narrative synthesis will be conducted based on levels
of evidence used in previous systematic reviews [
– Strong evidence: consistent findings from two or
more high-quality cohorts.
– Moderate evidence: consistent findings from at least
one high-quality study and one or more low-quality
– Limited evidence: findings of one high-quality study
or consistent findings in one or more low-quality
– Conflicting evidence: inconsistent findings
irrespective of study quality.
– No evidence: no studies found.
In order to investigate the introduction of publication
bias, a random effects version of Egger’s test will be
utilised and visualised through a funnel plot [
minimum number of articles suggested to examine
publication bias is ten [
To our knowledge, this review will be the first to
systematically explore the evidence available on the aetiological role
of non-work-related psychosocial stress in the development
of chronic MDs. This review has the capacity to inform
clinical practice regarding the importance of early
assessment, identification and treatment of patients with MDs
who are also experiencing high levels of stress. Indeed,
stress can be considered a modifiable factor that, if assessed
and promptly recognised, can be addressed and potentially
prevent the development of chronic pain. This study should
help practitioners to become more aware of the effect of
stress on pain, and, on the importance of working alongside
mental health clinicians in order to minimise stress in
people with acute musculoskeletal disorders.
Finally, a better understanding of the role of psychosocial
stress in the development of chronic MDs should facilitate
further research in the area of prevention and early
interventions, through stress management programs for those who
present with high levels of stress at the onset of their MD.
As data will be extracted using only full-text articles and
excluding data from grey literature, potential publication
bias may be introduced.
Ethics and dissemination
This systematic review does not require ethical approval,
as only a secondary analysis of data already available in
scientific databases will be conducted. The results of this
review will be submitted for peer-reviewed publication
and will be presented at relevant conferences.
The reviewers have commenced searching relevant
studies on the electronic databases. This review is expected
to be complete by September 2017.
Additional file 1: PRISMA-P (Preferred Reporting Items for Systematic
review and Meta-Analysis Protocols) 2015 checklist. Recommended items
to address in a systematic review protocol. (DOCX 15 kb)
Additional file 2: MEDLINE search strategy. MEDLINE search strategy that
will be used to conduct the proposed systematic review. (DOCX 12 kb)
Additional file 3: Data extraction sheet. Pre-defined data extraction sheet
that will be used to extract data of the included studies. (DOCX 14 kb)
Additional file 4: Checklist to assess methodological quality of studies.
Checklist that will be used to assess the included studies. (DOCX 16 kb)
MD: Musculoskeletal disorders; MOOSE: Meta-analysis of Observational
Studies in Epidemiology; OR: Odds ratio; PRISMA-P: Preferred Reporting Items
for Systematic Reviews and Meta-analyses; PTSD: Post-traumatic stress
SMS (#1105040), JHMA, WJC and MBL receive salary support from the
National Health and Medical Research Council of Australia. VB receives salary
support from Western Sydney University Postgraduate Research Award
Availability of data and materials
Supporting data is attached in the Additional files.
VB, WJC, ML, JHMA and SMS were each involved in the conception, design,
writing, and editing of the study protocol. The final protocol was approved
by VB, WJC, ML, JMA and SMS. All authors read and approved the final
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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