Is There a Relationship Between Social Health and Musculoskeletal Discomfort and Incapability? A Systematic Review

The notable and consistent evidence that musculoskeletal symptom intensity varies according to thoughts and feelings as much or more so than pathophysiologic factors has firmly established the importance of comprehensive, biopsychosocial, whole-person health strategies in orthopaedic surgery. A systematic review of existing knowledge of the role of social health factors (defined as security in relationships, roles, finances, housing, and sustenance) as sources of variation in levels of musculoskeletal discomfort and incapability could further inform the development and dissemination of comprehensive musculoskeletal health strategies, inform public health efforts, and identify areas that merit further investigation.

In a systematic review of quantitative evidence regarding the relationship of social health to levels of musculoskeletal discomfort and incapability, we asked: To what degree are various aspects of social health associated with levels of musculoskeletal discomfort and incapability?

A search of three databases (PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) was performed on December 4, 2023, and 5518 studies were screened after removing duplicates. We included peer-reviewed, original studies in English with participants age 18 years or older that addressed the relationship between social health and levels of musculoskeletal discomfort and incapability. Qualitative studies, case reports, preprints, and studies with < 50 participants were excluded. We did not search reference lists. Given the use of three complementary databases with broad coverage of biomedical, public health, and social research, we anticipated that additional yield from reference lists would be minimal. Two independent reviewers screened titles and abstracts, with disagreements resolved by a senior author, resulting in 226 articles eligible for a full-text secondary screen, of which 86 fit the criteria. The 86 studies included in this review, containing a total of 1,341,143 participants, were mainly observational, employing cross-sectional, longitudinal, and database designs. Study populations were diverse, representing both a variety of international settings and a mix of urban and rural communities. Overall, these studies primarily described associations between social factors and levels of musculoskeletal discomfort or incapability rather than evaluating interventions. Among studies that reported gender distribution (82 of 86), there was a median (IQR) of 56% (50% to 66%) women. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool, with scores ranging from 0 to 16 and higher scores representing better quality. The median (IQR) score was 13 (12 to 14), indicating that the studies selected were generally of moderate methodological quality with limited variability. The most common methodological limitation was lack of an a priori sample size calculation. We calculated standardized correlation size metrics (such as Cohen d, standardized β coefficient, η 2 , and Pearson correlation coefficient) based on reported values to estimate the strength of association between each social health factor and levels of musculoskeletal discomfort and incapability.

The strength of association for social support outside of work was generally small (range of standardized β coefficient 0.14 to 0.36), and the strength of association for social deprivation was consistently small to negligible (range of Cohen d 0.10 to 0.18; range of standardized β coefficient 0.03 to 0.33). Other social health factors, such as limited health insurance (range of Cohen d 0.01 to 1.59), lower level or less secure employment (range of Cohen d 0.04 to 1.11; range of standardized β coefficient 0.19 to 1.21), and low level of education (range of Cohen d 0.03 to 1.02; range of standardized β coefficient 0.01 to 0.59) were generally associated with greater levels of discomfort and incapability, but showed variable strength of association. More disadvantaged occupational factors, while generally associated with greater levels of discomfort and incapability, showed less consistent and more varied direction of correlations. Combined socioeconomic factors had an inconsistent association, and in one study, household income showed a moderate association (range of standardized β coefficient 0.30 to 0.61).

The finding that multiple aspects of social health are relatively consistently associated with levels of musculoskeletal discomfort and incapability can alert specialist clinicians to partner with patients to anticipate and identify social stressors (for instance, using screening tools and compassionate inquiry) and develop health strategies that account for their contribution to the illness (increased attunement and priority). Whereas greater levels of discomfort and incapability might traditionally trigger orthopaedic surgeons to more readily offer biomedical tests and treatments, the evidence that social factors are an important source of variation in musculoskeletal symptoms-along with the known importance of thoughts and feelings-can catalyze musculoskeletal specialty care units to develop more comprehensive biopsychosocial approaches to health and care. When disadvantaged social health is identified as a potential contributor to worse musculoskeletal health, strategies that can assist people with access to financial, food, job, or housing resources; medical-legal support; and other social supports can be considered, and in some cases prioritized, along with biomedical interventions such as medications, injections, and surgery. More widespread use of comprehensive, quantitative social health measures instead of sociodemographics may also facilitate the identification of specific social health needs, including their relative contribution to musculoskeletal health.

Level III, therapeutic study.