ORIGINAL ARTICLE
Year : 2022 | Volume
: 6 | Issue : 3 | Page : 173--182
Effects of Perceived Stress with Musculoskeletal Pain in Hong Kong
Pui Wing Ho1, Adrian Low2, Joey Lam2,
1 Hong Kong Chiropractic Wellness Center, Hong Kong, China
2 Hong Kong Association of Psychology, Kowloon, Hong Kong, China
Correspondence Address:
Dr. Adrian Low
Hong Kong Association of Psychology, Room 906, 9/F, Office Tower 2, Grand Plaza, 625 Nathan Road, Mongkok, Kowloon, Hong Kong
China
Abstract
Objective: Previous psychological research has been made on the role of perceived stress on musculoskeletal pain among adolescents and people working in different job sectors. However, no research has been made on this subject toward the Chinese population and especially the Hong Kong population. Hence, the objective of this research is to evaluate the effects and relationship between perceived stress and musculoskeletal pain and identify the statistical reasoning results of the research through looking into the specific situation in Hong Kong. Methods: In this research, data from Perceived Stress Scale-14 and a self-made pain questionnaire on perceived stress and musculoskeletal pain were collected from the patients of a registered chiropractor in Hong Kong to provide an in-depth study of how musculoskeletal pain correlated with perceived stress and how an individual's mental health would further be affected by both subjects among the Hong Kong population. Results: The findings of the research indicated that perceived stress is correlated with a combination of rather than one type of musculoskeletal pain and there is a significant correlation between one's posture, musculoskeletal pain, and psychological distress. In addition, in terms of the situation in Hong Kong; the working lifestyle and the prevalence of sedentary lifestyle may act as a risk factor on the results related to one's posture being correlated to musculoskeletal pain and perceived stress. Conclusion: It is hoped that this research could enlighten people working in the clinical psychology and chiropractor industries in Hong Kong on the subject of perceived stress and musculoskeletal pain and inform psychology researchers from other countries the situation regarding bodily pain and perceived stress in Hong Kong.
How to cite this article:
Ho PW, Low A, Lam J. Effects of Perceived Stress with Musculoskeletal Pain in Hong Kong.Heart Mind 2022;6:173-182
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How to cite this URL:
Ho PW, Low A, Lam J. Effects of Perceived Stress with Musculoskeletal Pain in Hong Kong. Heart Mind [serial online] 2022 [cited 2023 Jun 10 ];6:173-182
Available from: http://www.heartmindjournal.org/text.asp?2022/6/3/173/357545 |
Full Text
Introduction
Musculoskeletal pain is prevalent globally, with 1.71 billion people being diagnosed with musculoskeletal disorders worldwide.[1] Acquiring musculoskeletal pain can often bring about inconvenience and worsen working performance and physical activity; creating a fear of being criticized and discriminated against, thus workplace stress that may eventually result in poorer psychological well-being. Consequently, researchers have been discussing the role of perceived stress in affecting and helping prevent chronic musculoskeletal pain,[2] and some researchers have made discussions on the effects of perceived stress and musculoskeletal pain on adolescents.[3] However, no research on this subject has been made focusing on either the Hong Kong workforce or population.
Therefore, in this research, exploration was made on whether musculoskeletal pain has a reciprocal relationship with perceived stress in Hong Kong's situation. The following three research questions were considered in the research:
How does perceived stress have a particular correlation with musculoskeletal pain among different types of bodily pain?Does perceived stress have a stronger correlation with a specific type or a combination of musculoskeletal pain?Is there a correlation between one's posture, psychological distress, and intensity of pain?
The above three research questions were examined by Pearson correlation analysis alongside the data collected through the Pain Perceived Scale and online Pain questionnaire issued by Dr. Adrian Low and Dr. Albert Ho, a researcher in Psychology and a registered chiropractor in Hong Kong.
Research Methods
To investigate whether musculoskeletal pain is associated with perceived stress, participants were instructed to indicate their stress levels in relevance to musculoskeletal pain under the Perceived Stress Scale (PSS). PSS is a 14-item scaling system that assesses the degree to which subjects perceive their lives as stressful by asking them questions about how often they have found their lives unpredictable, uncontrollable, and overloaded on a scale of 0 (never) to 4 (very often). The total score of PSS is obtained by reversing the scores for the positively stated items (items 4r, 5r, 6r, 7r, 9r, 10r, 13r) and then summing all items across the scale. The scaling system has been used in numerous investigations on assessing the stressfulness of specific situations, the effectiveness of stress-reducing interventions, and associations between psychological stress and psychiatric and physical disorders. The Cronbach's alpha coefficient for the internal reliability of the PSS was 0.78 and the validity of the scale depends on its correlation in a predicted way with other measures of stress such as the Job Responsibilities Scale and life events scales. Reliability and validity studies were made on the PSS in Greece and the Czech Republic, in the study made by Andreou in 2011, an examination was made of the psychometric properties of PSS-10 and 14 in the general population of Greece by confirmatory factor analysis and research results supports the reliability and validity of the Greek version of the PSS to a large extent.[4] As for the study made by Figalova and Charvat in 2021, the study focused on examining the reliability and validity of Czech adaptation of PSS-4, 10, and 14 on randomly selected participants, the research results support the adequate validity and reliability of all three versions of the Pain Perceived Scale (see [Appendix A] for demographic information).[5][INLINE:1]
The stress index in the pain questionnaire issued by Dr. Adrian Low and Dr. Albert Ho based on perceived stress and pain is also utilized in this study as parameters to assess the specific relationship between stress and musculoskeletal pain. In the pain questionnaire, patients answer questions on the details of the bodily pain they complained of and how the pain they complained of has affected their psychological conditions and daily lives on a scale of 0 (never) to 5 (very often).
As for the data analysis method, Pearson correlation analysis was applied to analyze the results of the research data, it measures the effect of change in one variable when the other variable changes. The formulas lie between a value of −1 and 1, where 1 indicates a strong positive relationship, −1 indicates a strong negative relationship and 0 indicates no relationship at all.
Participants
The study population consisted of male and female chiropractic patients of Dr. Albert Ho, a registered chiropractor in Hong Kong. These patients were aged between 27 and 64-year-old and their working hours ranged from under 30 h to above 80 h weekly. The sample included participants that are employed, self-employed, retired, or homemakers.
Study sample
Inclusion/exclusion criteria
The chosen study population are both male and female chiropractic patients that have a history of complaints of pain in common locations that have musculoskeletal pain, this includes the upper and lowers back neck, and shoulder areas. These patients have expressed feeling the moderate or high intensity of pain and believe that the pain has a considerate impact on their lifestyles through scoring around 6–10 out of 10 on multiple questions on the intensity and impact of pain in the pain questionnaire issued by Dr. Adrian Low and Dr. Albert Ho and 3–4 out of 4 on multiple questions in PSS.
Hence, chiropractic patients scoring an average score of 1–4 out of 10 in the pain questionnaire and 0–2 out of 4 in PSS would be excluded from the study as the pain did not show a considerate impact on their lifestyles. The questionnaire results of 110 patients were eventually selected to be valid for data analysis.
Sampling procedures
After the participating patients of the chiropractor signed the informed consent forms, they will fill in the online pain questionnaire as well as the PSS-14 questionnaire. Once the questionnaires were filled up, the chiropractor will collect the questionnaires, and the researcher would manage and analyze the collected questionnaire.
Results
Perceived stress scale
1. How does perceived stress have a particular correlation with musculoskeletal pain among different types of bodily pain?
Overall, participants' responses to the PSS were generally weakly associated with different items related to bodily pain that are mentioned in the scale, whether positive or negative. Nevertheless, some responses still showed strong significance at PSS-14 (see [Appendix B] for demographic information). For instance, feelings about “difficulties are piling up so high that you couldn't overcome them” were positively associated with “the intensity of pain” (r = 0.232, P < 0.010) and “intensity of pain affecting lifestyle” (r = 0.270, P < 0.000); and there is a significant positive association between “the intensity of pain” and “intensity of pain affecting lifestyle” (r = 0.693, P < 0.000).[INLINE:2]
The results from the PSS-14 illustrated that perceived stress does not have a particular positive correlation with either bodily or musculoskeletal pain, yet there are appearances of correlation as the results indicated that inconvenience and difficulties trigged by pain in daily lives practices have a significant positive relationship with the severity of the pain; and since musculoskeletal pain will occur during movement, this indicates that stress might not directly correlate with musculoskeletal pain but indirectly specifically through stressful events such as burdened difficulties.
Stress index
2. Does perceived stress have a stronger correlation with a specific type or a combination of musculoskeletal pain?
The stress index was fairly and positively correlated with responses from participants who had incurred pain in their neck, upper back, waist, and wrist (r = 0.333, P < 0.010) and participants who had pain in their head and shoulder (r = 0.360, P < 0.010).
Hence, the results from the pain questionnaire showed that perceived stress has a comparatively stronger positive correlation with a combination of musculoskeletal pain compared to musculoskeletal pain involving musculoskeletal one or two areas, such as neck and waist (r = 0.172, P < 0.072) or chest (r = 0.086, P < 0.373) (see [Appendix C] for demographic information).[INLINE:3]
3. Is there a correlation between one's posture, psychological distress, and intensity of pain?
In addition, significant and strong, positive correlations were found between stress index and the responses from participants with pain in their neck, shoulder, waist, and wrist (r = 0.620, P < 0.010) and participants with pain in their neck, shoulder, and waist (r = 0.500, P < 0.010). Since one's neck, shoulder, waist, and wrist would often be involved in occupational movement and posture; particularly works related to the repetitive motion of the above body parts, consequently, the research results in the stress index of the pain questionnaire also hinted that one's posture might be involved with musculoskeletal pain, which consists of a positive correlation with one's stress levels (see [Appendix C] for demographic information).
Discussion of the Findings
1. How does perceived stress have a particular correlation with musculoskeletal pain among different types of bodily pain?
With references to the finding in PPS, it could be concluded that the above results demonstrated that perceived stress does not have either a positive or negative correlation with not only musculoskeletal pain, but bodily pain in general since no significant correlation could be observed between different items related to bodily pain such as duration and location of pain, felt pain, daily duration of pain, etc. However, perceived stress may have a particular correlation with musculoskeletal pain indirectly through the inconvenience and difficulties it can lead to concerning the results shown in the PSS-14. The positive correlation between feelings about “difficulties are piling up so high that you couldn't overcome them” and “the intensity of pain” (r = 0.232, P < 0.010) could be explained by the nature of musculoskeletal pain wear and tear of muscle tissues during daily activities. A lot of daily activities and labor-related occupations require a lot of muscle movement, if a person acquired musculoskeletal pain and it might also bring about several difficulties in their work-life and daily lives; the burdened difficulties may be an important factor in one's psychological distress. Despite studies have been made by Chen in 2005 that occupational stress among Chinese offshore oil installation workers does affect musculoskeletal pain through either neuromuscular tension, increased sensitivity to pain and vibration, and ergonomic factors, the study revealed that there is lacking objective measurements on determining whether these factors of stress did affect musculoskeletal pain directly.[6] Further investigation should be conducted to ascertain whether musculoskeletal pain has a direct or indirect association with perceived stress among the Hong Kong population as a psychosocial risk factor.
2. Does perceived stress have a stronger correlation with a specific type or a combination of musculoskeletal pain?
In addition, the findings in the stress index demonstrate that stress correlates with a combination of musculoskeletal pain rather than pain just focusing on one area in the musculoskeletal system. There has been previous research made by Østerås et al. in 2015[3] on the correlation between perceived stress and musculoskeletal pain among adolescents suggesting that perceived stress correlated with a combination of musculoskeletal pain as musculoskeletal pain sites were associated with psychosocial problems and school-related stress is an important factor to intensify the pain; yet the research did not specify the psychosocial problem and how did stress intensify the musculoskeletal pain.
It could be suggested that this psychosocial problem might be pain catastrophizing which further leads to the causation of fibromyalgia syndrome, a disorder characterized by widespread musculoskeletal pain. Patients diagnosed with fibromyalgia have a high tendency of experiencing high levels of stress because of pain catastrophizing, caused by the patient's negative orientation to pain, which provokes anxiety, fear, and discomfort,[7] the example of fibromyalgia can deduce that patients with pain in multiple musculoskeletal sites would acquire higher levels of perceived stress; and the higher the stress and anxiety levels the more intensify the combination of pain in multiple musculoskeletal sites would become. This is also supported by Malin and Littlejohn's research in 2013 in which the research stated that the fibromyalgia phenotype of pain, sleep, and fatigue still show a significant positive relationship, including depression and anxiety to a lesser extent in the aspect of controlling one's stress (see [Appendix D] for demographic information).[8] Therefore, fibromyalgia might be the explanation behind a combination of musculoskeletal pain having a stronger correlation toward perceived stress compared to a sole type of musculoskeletal pain.[INLINE:4]
3. Is there a correlation between one's posture, psychological distress, and intensity of pain?
The findings above also suggested that there is a cycle existing between one's posture, psychological condition, and intensity of pain. Since findings in the stress index demonstrate that stress has a high positive correlation with shoulder and neck pain, and the wrong posture is often correlated with the two as spinal posture is mentioned as one of the important risk factors causing shoulder and neck pain; in addition, in France, it is illustrated that among assembly workers, forestry workers, and elderly female computer users showed that perceived stress was often associated with shoulder pain,[9] showing that shoulder pain has been involved with multiple occupations. Therefore, it can be deduced that incorrect occupation posture can be related to stress due to the prevalence of shoulder and neck pain among the research findings. Perceived stress from the pain caused by posture would gradually lead to one's psychological condition deteriorating, as musculoskeletal pain brings about difficulties in work, particularly physical labor, leading to decrease work performances and one's ability to achieve activities of daily living, acquiring both work-related stress and difficulties brought by disability from pain could lead to an individual having catastrophic thinking (see [Appendix E] for demographic information).[10] This is one of the causes of anxiety; disability causing anxiety could also be proven in the research results in PSS-14 in which the two items “difficulties are piling up so high that you couldn't overcome them” were positively associated with “the intensity of pain” (r = 0.232, P < 0.010). This proves that the neck and shoulder pain brought by posture would further affect one's psychological condition negatively due to the appearance of catastrophic thinking. Moreover, the difficulties caused by pain would further circulate to the increasing intensity of pain as according to the findings on the PSS, the participants' psychological and physical difficulties correlate with pain intensity. This is because when an individual is overburdened by difficulties, they will become psychologically distressed; and it is discovered that a significant positive relationship was found between alexithymia and psychological distress in fibromyalgia syndrome, as study results from Italy implied that when the symptoms of psychological distress and alexithymia were subthreshold, correlations with pain experience and intensity became stronger (see [Appendix F] for demographic information).[11] The term alexithymia is mentioned in the Freudian psychodynamic theories for the inability to express emotions, implying that a cyclical experience exists between the intensity of pain in chronic and musculoskeletal pain syndromes and mental well-being due to psychological distress and the subclinical inability to identify and describe emotions.[INLINE:5][INLINE:6]
This could be concluded that posture aggravates musculoskeletal pain in the neck and shoulder areas. Moreover, the more difficulties a patient has encountered from musculoskeletal pain, the more stress and anxiety a patient will perceive, and gradually this increases the intensity of pain.
Hong Kong population's working and living lifestyle could also be a cause of one's posture being significantly positively correlated to the intensity of musculoskeletal pain. Prolonged sedentary working and entertainment lifestyles have been found among Hong Kong employees and school children due to the heavy usage of computers and electronic devices, and the limitation of physical activity and outings due to the COVID-19 pandemic. In addition, a sedentary lifestyle can increase the risk of developing chronic pain resulting in muscle atrophy in the shoulders, neck, and back areas,[12] and hence, Hong Kong's working, and sedentary culture could also act as an explanation for the results in the pain questionnaire in which musculoskeletal pain intensifies particularly with pain in their neck, shoulder, waist, and wrist (r = 0.620, P < 0.010). PSS-14 results from this study also indicated that one's working and living lifestyle could positively affect each other as the items “the intensity of pain” and “intensity of pain affecting lifestyle” in PSS-14 show a significant positive correlation according to the research results.
Limitations
A limitation observed in this research is related to its accuracy, as participants are not experiencing the pain at the exact moment when they are responding to the PSS and pain questionnaire. Instead, their responses are based on recalling their past experiences, potentially leading to inaccuracy and measurement bias in the results. The weakness may be addressed by doing retests with the same participants or conducting regular biological assessments with participants to increase the legitimacy of this research.
Recommendations for further research
The purpose of further research and replications would be to strengthen the hypothesis that perceived stress is a factor affecting the intensity of musculoskeletal pain. Other research can be conducted to investigate other issues related to this topic. For instance, studies may investigate the specific population in Hong Kong who has the highest perceived stress from musculoskeletal pain to see which population would need the most mental health support for their pain. Research could also explore the effectiveness of stress-reducing interventions on musculoskeletal pain to see if there is an effective intervention for tackling the impact of perceived stress, particularly shoulder and neck pain.
Conclusion
This research focuses on looking into the correlation between the effects of perceived stress with musculoskeletal pain in Hong Kong by analyzing data from PSS-14 and a musculoskeletal pain questionnaire designed by Dr. Adrian Low and Dr. Albert Ho. Previous research on perceived stress and musculoskeletal pain in other populations and musculoskeletal diseases were also taken into account in analyzing the collected research data.
Results from the study show that three significant positive correlations were found between difficulties that one could not overcome, one's lifestyle and intensity of pain according to the PSS, and between one having musculoskeletal pain in the upper back area with perceived stress, and intensity of pain from the results in the pain questionnaire.
Two surprising findings have been found in the research which involves musculoskeletal pain sites and Hong Kong's working and daily living lifestyle. In terms of musculoskeletal pain sites, this research discovered that perceived stress has a stronger correlation with a combination of musculoskeletal pain; the rationale behind this finding might be a musculoskeletal illness known as fibromyalgia syndrome, an illness involving multiple musculoskeletal pain sites that could be aggravated by stress and anxiety. As for Hong Kong's working and daily living lifestyle, the surprising finding is that one's sedentary lifestyle in Hong Kong could be the risk factor of acquiring musculoskeletal pain in the upper back area, which further intensifies and correlates with perceived stress.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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