Which psychological factors influence musculoskeletal pain?

An umbrella review of systematic reviews

  • Lots of attention in literature for factors with negative influence
  • Only 12 out of 59 studies provide evidence for protective factors
  • Strict checklist: quality of included studies very low

In this umbrella review – a systematic literature review including only systematic reviews – Spanish scientists analysed 59 reviews including data from almost 250,000 participants regarding the influence of psychological factors on musculoskeletal pain. Many studies point towards the same direction and the reviews do not have not much overlap of included studies. Nevertheless, when drawing conclusions, the authors are cautious because of the low quality of many of the systematic reviews.

Umbrella review

The researchers conducted an umbrella review: a review of reviews, often termed as ‘the next generation of reviews’. They scored each study according to the AMSTAR-2 (see frame). According to this strict checklist, all included review were labelled as 'critically low confidence'. The authors make several recommendations for future research: researchers should look more into protective factors and present their data in such a way that meta (regression) analyses can be conducted.

> From: Martinez-Calderon et al., Clin J Pain 36 (2020) 626-637 . All rights reserved to Wolters Kluwer Health, Inc. Click here for the online summary. Translation by Willem-Paul Wiertz

Table 1:  Measuring instruments

Measuring instrument

Psychological factor

Fear Avoidance Beliefs Questionnaire

Fear and avoidance beliefs 

Tampa Scale for Kinesiophobia


Coping Strategies Questionnaire

Coping strategies

Chronic Pain Coping Index

Coping strategies

Pain Self-Efficacy Questionnaire

Pain-related self-efficacy

Pain Catastrophising Scale

Pain-related catastrophising

Coping Strategies Questionnaire

Pain-related catastrophising



A MeaSurement Tool to Assess systematic Reviews (AMSTAR) is an international checklist for the quality of systematic reviews. The second edition was presented in 2017. This consists of 16 items, among which seven critical items for validity: 1) protocol preceding to research; 2) adequate search strategy; 3) arguments for the exclusion of individual studies; 4) risk of bias of individual studies; 5) correct method of meta analysis/ statistical combination of results; 6) consideration of bias when interpreting the results; 7) checking for publication bias and its impact.

Expert opinion by Aleid de Rooij, PhD

Despite the fact that the quality of studies needs to improve in the future, this umbrella review provides a nice overview of the negative psychological and protective factors that are (seemingly) related to the onset and/ or persistence of musculoskeletal pain. When screening a patient, both th negative as well as the protective factors should be taken into account. These factors can be utilised to make an estimate of the vulnerability for the developing pain and the course of chronic pain. MOre insight in these factors leads to more possibilities for interventions. 

Mapping psychological factors can be done based on your anamnesis, supported by diagnostics from questionnaires (see frame). Research shows that negative psychological factors can be influenced with, for instance, education on the neurobiological basis of pain, cognitive behavioural therapy and Acceptance and Commitment Therapy. If there are evident psychological factors, patients can be referred to other professionals, such as a family physician and/ or a psychologist, to decrease the odds of the development or persistence of (chronic) pain. In a Dutch report ‘Psychosomatic care in serious somatic disorders’ from 2015 states that the entire care chain is responsible for detecting psychosocial problems. Thus, the physiotherapist potentially has an important role in early detection of psychosocial problems.

Finally, apart from paying attention to negative factors, it is also very meaningful to pay attention to the protective factors for the development and persistence of pain. By discussing these protective factors, patients can be stimulated to continue certain behaviour and thoughts despite their pain. 

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