Psychological, social and academic functioning in university students with chronic pain: A systematic review

Figures & data

Table 2. Quality assessment of included studies.

Study	External validity		Internal validity
	Inclusion criteria clearly defined	Subjects and setting clearly described	Exposure/predictor variable valid and reliable	Objective, standard criteria used for condition measurement	Confounding factors identified	Confounding factors dealt with	Outcomes measured reliably and validly	Appropriate use of statistical analysis	Study summary score
Bottos and Dewey (2004)^48	✔	✔	✔	✔	✔	×	✔	✔	7/8
Feldman et al. (2020)^50	✔	✔	✔	✔	✔	✔	✔	✔	8/8
Furtado et al. (2014)^46	✔	✔	✔	✔	×	×	✔	✔	6/8
Graham and Streitel (2010)^39	✔	✔	✔	✔	✔	✔	✔	✔	8/8
Gulewitsch et al. (2011)^52	unclear	✔	✔	✔	✔	✔	✔	✔	7/8
Gulewitsch et al. (2013)^47	unclear	✔	✔	✔	✔	✔	✔	✔	7/8
Jiang et al. (2019)^43	✔	✔	✔	✔	✔	✔	✔	✔	8/8
Karoly and Lecci (1997)^37	✔	✔	✔	✔	✔	✔	✔	✔	8/8
Kato (2020)^35	✔	Unclear	✔	✔	✔	✔	✔	✔	7/8
Klemenc-Ketis et al. (2011)^51	×	✔	✔	✔	Unclear	Unclear	✔	✔	5/8
Minghelli et al. (2014)^44	✔	✔	✔	✔	✔	Unclear	✔	✔	7/8
Natu et al. (2018)^40	✔	✔	✔	✔	×	×	✔	✔	6/8
Pesqueira et al. (2010)^45	×	×	✔	✔	Unclear	×	✔	✔	4/8
Rachor and Penney (2020)^36	✔	✔	✔	✔	×	×	✔	✔	6/8
Serbic et al. (2020)^42	✔	✔	✔	✔	✔	✔	✔	✔	8/8
Shen et al. (2009)^38	✔	✔	✔	✔	Unclear	Unclear	✔	✔	6/8
Soyuer et al. (2012)^41	✔	✔	✔	✔	Unclear	×	✔	✔	6/8
Thomas et al. (1992)^49	unclear	✔	✔	✔	✔	×	✔	✔	6/8

Figure 1. Flow chart of study selection process.

Table 1. Summary of study and participant characteristics of included studies.

Author/year/country	N/sex (F)/age Total sample (pain groups)	Health issue (HI)/pain duration (PD)/pain intensity (PI)^a	Setting/degree	Design	Analysis	Measured variables^b
Bottos and Dewey (2004)^48 Canada	N: 291 (CP: 18; frequent pain: 179; infrequent pain: 69; incomplete data for pain frequency: 25) F: 85% (CP: 83.3%; frequent pain: 87.2%; infrequent pain: 82.6%) Age: M = 22, SD = 5.32 (CP: M = 20.89, SD = 2.74; frequent pain: M = 21.58, SD = 4.20; infrequent pain: M = 23.45, SD = 7.05)	HI: chronic headache PD: CP: M = 7.67, SD = 1.38; frequent pain: M = 6.47, SD = 10.75; infrequent pain: M = 7.40, SD = 11.43 PI: CP: M = 7.67, SD = 1.38; frequent pain: M = 6.69, SD = 1.32; infrequent pain: M = 6.35, SD = 1.40	University undergraduate psychology students; data collected in person	Cross sectional; questionnaire study	ANOVA	Headache frequency and intensity (Headache Assessment Questionnaire); college student daily hassles (BCSHS); perfectionism (MPS)
Feldman et al. (2020)^50 USA	N: 121 (CP: 45) F: 78.5% (no information for groups) Age: M = 19.6, SD = 1.5 (no information for groups)	HI: variety of chronic health conditions with CP and without CP PD: not reported PI: not reported	University undergraduate students (variety of courses); data collected in person and online	Longitudinal design; questionnaire daily diary study	Correlations; regression	Symptoms of CP (medical providers independently classified chronic health conditions into two categories: chronic conditions with pain as a symptom and conditions without pain as a symptom); perceived social support (MSPSS); illness-related social support (number of friends to whom they disclosed their condition and how supportive their friends had been)
Furtado et al. (2014)^46 Brazil	N: 198 (CP: 58) F: 65.2% (CP: 81%; no CP: 58.6%) Age: M = 22.9 (CP: M = 22.2; no CP: M = 23.1)	HI: chronic nonspecific LBP PD: not reported PI: CP: M = 2.85, SD = 3.13; no CP: M = 1.80, SD = 2.31	University students (degree level and course and reported); data collected in person	Cross sectional; questionnaire; observation	Correlations; t test; Chi-square	Presence of chronic nonspecific LBP (persistence of pain over a period of 3 months); pain severity (visual analogue scale for LBP 0–10 cm); self-rated quality of life (SF-36 Health Survey); self-rated social functioning, mental health, social functioning and role-emotional (these are the domains of SF-36 that are relevant to this review); self-rated anxiety (self-assessment form, no further information provided by authors)
Graham and Streitel (2010)^39 USA	N: 362 (CP:108) F: 73.2% (no information for groups) Age: M = 20.58, SD = 1.56 (no information for groups)	HI: CP (variety of pain locations/conditions) PD: not reported PI: CP: M = 1.64, SD = 1.32; NP: M = 0.00, SD = 0.00 RP: M = 1.33, SD = 1.03	Undergraduate university students (variety of courses); data collected online	Cross sectional; questionnaire study	t Test	CP severity (MPI); perceived stress (PSS); perceived self-esteem (SSES); depressed mood (CES-D)
Gulewitsch et al. (2011)^52 Germany	N: 2196 (IBS: 425) F: 70.9% (IBS: 77.4; no information for no IBS group) Age: M = 24.2, SD = 3.9 (IBS: M = 24.46, SD = 3.84; no IBS: M = 24.18, SD = 3.9)	HI: IBS Symptom duration: not reported Symptom intensity: M = 4.27, SD = 2.11 (F: M = 4.56, SD = 2.13; M: M = 3.86, SD = 2.02)	University students (degree level not reported; variety of courses); data collected online	Cross sectional; questionnaire study	t Test	Presence of IBS (Rome III); health-related quality of life (SF-12)
Gulewitsch et al. (2013)^47 Germany	N: 357 (IBS: 176) F: IBS: 51.7%; non-IBS: 49.7% Age: IB: M = 23.45, SD = 2.48; no IBS: M = 23.55, SD = 2.82	HI: IBS PD: not reported PI: not reported	University students (degree level not reported; variety of courses); data collected online	Cross sectional; questionnaire study	MANOVA; ANOVA	Presence of IBS (Rome III criteria); self-rated perception of impairment/mental strain (SCL-90-R); chronic stress (TICS)
Jiang et al. (2019)^43 China	N: 2053 (IBS: 82; abdominal discomfort: 176; no pain: 1795) F: 35.6% (IBS: 59.8%; abdominal discomfort: 61.4%; no pain: 32%) Age: M = 18.2, SD = 0.9 (IBS: M = 18.1, SD = 0.6; abdominal discomfort: M = 18.1, SD = 0.8; no pain group: M = 18.2, SD = 0.9)	HI: IBS PD: not reported PI: not reported	University undergraduate (freshmen) students (variety of courses); data collected in person	Cross sectional; questionnaire study	Chi-square; ANOVA	Presence of IBS (Rome III); self-rated depression, anxiety and suicidal intention (Rome III Psychosocial Alarm Questionnaire)
Karoly and Lecci (1997)^37 USA	N: 127 (persistent pain: 75) F: 51% (persistent pain: 56%; no pain: 44%) Age: M = 24.4, SD = 3.3 (pain: M = 28.8, SD = 5; no pain: M = 24, SD = 1.7)	HI: persistent pain (variety of pain locations/conditions) PD: not reported PI: not reported	University undergraduate psychology students; data collected in person	Cross sectional; questionnaire study	t Test	Presence of pain (experience of persistent pain for 6 months or more and pain severe enough that it cannot be ignored; assessed twice: during recruitment and 2 months later during data collection to ensure consistency in self-report of pain); goal assessment (GSAB)
Kato (2020)^35 Japan	N: 410 (CP: 320) F: 100% Age: M = 18.64, SD = 0.84 (no information for groups)	HP: CP PD: not reported PI: CP: M = 5.53, SD = 1.83; not reported for no CP group	University students (degree level and course not reported); no information on if data was collected in person or online	Longitudinal (measured at baseline then 8 months later); questionnaire study	t Test; regressions	Presence of pain (experience of pain for at least 3 months; ICD-11); pain intensity (11-Point NRS); psychological inflexibility for pain (AAQ-II); depressive symptoms (PHQ-9)
Klemenc-Ketis et al. (2011)^51 Slovenia	N: 816 (CP: 265) F: 65.9% (no information for groups) Age: M = 22.4, SD = 2.5 (no information for groups)	HI: CP (variety of pain locations/conditions) PD: not reported PI: not reported	University undergraduate students (not clear if postgraduates were included; variety of courses); data collected online	Cross sectional; questionnaire study	t Test; linear regression	Presence of CP (reported CP for at least a year); quality of life (EQ-5D)
Minghelli et al. (2014)^44 Portugal	N: 1493 (TMD: 633) F: 68.5% (TMD: 47.5%; no TMD: 52.5%) Age: M = 24.4, SD = 6.4 (no information for groups)	HI: TMD PD: not reported PI: not reported	University undergraduate students (not clear if postgraduates were included; variety of courses); data collected in person	Cross sectional; questionnaire study	Chi-square	Presence of TMD (FAQ); self-rated anxiety and depression (HADS)
Natu et al. (2018)^40 Singapore	N: 244 (TMD: 102 [mild TMD: 79; moderate TMD: 23]) F: 84.8% (TMD: 83.3%) Age: M = 20.1 (mild TMD: M = 19.65, SD = 2.91; moderate TMD: M = 19.78, SD = 2.89; no TMD: M = 20.51, SD = 3.36)	HI: TMD PD: not reported PI: No TMD: M = 1.70, SD = 2.54; mild TMD: M = 3.04, SD = 2.99; moderate TMD: M = 5.13, SD = 2.92	University (variety of degree levels and courses); data collected online	Cross sectional; questionnaire study	ANOVA	Presence of TMD (FAQ); oral health-related quality of life (OHIP-TMD); self-rated depression, anxiety and stress (DASS-21)
Pesqueira et al. (2010)^45 Brazil	N: 150 (TMD: 61) F: not reported Age range: 17–30 (no information for groups)	HI: TMD PD: not reported PI: not reported	University undergraduates (variety of courses); data collected in person	Cross sectional; questionnaire study	Correlations; Chi-square	Presence of TMD (RDC); self-rated anxiety (STAI)
Rachor and Penney (2020)^36 Canada	N: 179 (all with CP) F: 81.56% Age: M = 22.8, SD = 5.41	HI: CP PD: not reported, but minimum 3 months to be included PI: M = 57.85, SD = 15.37	University undergraduates (primarily psychology students); data collected online	Cross sectional; questionnaire study	Correlations; regressions	Pain intensity, pain disability: interference with daily, social and work activities (CPGS); Health anxiety (SHAI); metacognitions about health (MCQ-HA)
Serbic et al. (2020)^42 UK	N: 311 (CP: 96; acute pain: 102; no pain: 133) F: 69.1% (CP: 67.7%; acute pain: 73.5%; no pain: 66.4%) Age: M = 22.27, SD = 2.65 (CP: M = 22.68, SD = 2.78; acute pain: M = 22.02, SD = 2.63; no pain: M = 22.13, SD = 2.53)	HI: CP (variety of pain locations/conditions) PD: CP: 7.6% had pain lasting 3–6 months, 8.1% had pain lasting 6–12 months, 12.6% had pain lasting 1–2 years, 9.1% had pain lasting 2–3 years, 3.5% had pain lasting 4–5 years, 7.1% had pain lasting 5+ years, and 0.5% had pain lasting 10+ years PI (past week): CP: M = 2.79, SD = 2.38; acute pain: M = 1.89, SD = 1.79 Pain intensity (past 3 months): CP: M = 3.59, SD = 2.16; acute pain: M = 2.75, SD = 2.10	University undergraduate (71.7%) and postgraduate students (variety of courses); data collected online	Cross sectional; questionnaire study	ANOVA (with post hoc tests); regression	Presence of CP (pain duration of at least 3 months); depression and anxiety (HADS); perceived social support (MSPSS); interference with academic progress (three questions were developed relating to how pain interferes with academic functioning)
Shen et al. (2009)^38 China	N: 491 (IBS: 77) F: 50.9% (IBS: 16% of total sample); non-IBS: 83.2% of total sample) Age: M = 23.8, SD = 1.8 for medical students; M = 24.6, SD = 2.2 for non-medical students (not reported for pain subgroups)	HI: IBS PD: not reported PI: not reported	University undergraduate students (variety of courses); data collected in person	Cross sectional; questionnaire	t Test; Chi-square;	Presence of IBS (ROME II); self-rated depression (SDS) and anxiety (SAS)
Soyuer et al. (2012)^41 Turkey	N: 166 (MSC: 58) F: 77.1% (no information for subgroups) Age: M = 20.9, SD = 3.8 (no information for subgroups)	HI: MSC PD: not reported PI: not reported	University students (degree level and course not reported); data collected in person	Cross sectional; questionnaire	Chi-square; logistic regression	Presence of MSC (pain for ≥3 months); self-rated depression (BDI) and anxiety (BAI)
Thomas et al. (1992)^49 Canada	N: 104 (CP: 50) F: CP: 56.2%; no CP: 51.9% Age: CP: M = 22.5, SD = 6.2; no CP: M = 20.2, SD = 1.9	HI: CP (variety of pain locations/conditions) PD: not reported PI: not reported	University undergraduate psychology students; data collected in person	Cross sectional; questionnaire	t Test	Presence of CP (pain lasting >3 months) self-rated depression (BDI); self-rated self-esteem (SES)

a Information is extracted for chronic pain and outcome variables that are used in this review; AAQ-II – Acceptance and Action Questionnaire-II; ANOVA – Analysis of Variance; BAI – Becks’ Anxiety Inventory; BCSHS – Brief College Student Hassles Scale; BDI – Beck’s Depression Inventory; CES-D – Center for Epidemiological Studies Depression Scale; CP– chronic pain; CPGS – Chronic Pain Grade Scale ; DASS -21 – Depression Anxiety Stress Scale; EQ-5D – EuroQoL; ESS – Epworth Sleepiness Scale; F – female; FAQ – Fonseca Anamnestic Questionnaire; GSAB – Goal Systems Assessment Battery; HADS – Hospital Anxiety and Depression Scale; IBS – Irritable Bowel Syndrome; ICD-11 – International Classification of Diseases-11; LBP – low back pain; M – mean; MANOVA – Multivariate Analysis of Variance; MCQ-HA – Metacognitions about Health Questionnaire; MPI – Pain Severity subscale of the West Haven-Yale Multidimensional Pain Inventory; MPS – Multidimensional Perfectionism Scale; MSC – musculoskeletal complaints; MSPSS – Multidimensional Scale of Perceived Social Support; N – number; OHIP-TMD – Oral Health Impact Profile for TMD; PHQ-9 – Patient Health Questionnaire-9; PSS – Perceived Stress Scale; RDC – Research Diagnostic Criteria for TMD; Rome III – diagnostic criteria for IBS; SAS – self-rating instrument for anxiety disorders; SCL-90-R – Symptom Check-List; SD – standard deviation; SDS – Self-rating Depression Scale; SES – Rosenberg Self-Esteem Scale; SF-12 – 12-Item Short-Form health quality of life survey; SF-36 – 36-Item Short-Form health quality of life Survey; SHAI – Short Health Anxiety Inventory; SSES – State Self-Esteem Scale; STAI – Sate-Trait Anxiety Inventory; TICS – Trier Inventory for the Assessment of Chronic Stress; TMD – Temporomandibular Disorder.

Table 3. Synthesis of evidence.

Variables studied in association with chronic pain (outcome variables^a)	Associations between chronic pain and outcome variables (supported with p values, and effect sizes were available^b)	Study
Psychological functioning
Depression & anxiety	The association between the presence of signs of depression and anxiety and presence of TMD was significant (p < .001)	Minghelli et al. (2014)^44
Depression	Participants with chronic pain reported more depressed mood than those without chronic pain (p = .001, d = −.69) and recent pain (p < .05; d = −.29)	Graham and Streitel (2010)^39
	Depression was significantly more common in participants with IBS than in those without IBS (p < .001). In addition, pain intensity predicted higher levels of depression in the chronic pain group (p = .016; 95% CI [0.20, 1.89]) (this model included several other predictors)	Jiang et al. (2019)^43
	Participants with chronic pain had higher levels of depression than those without chronic pain (p = .038).	Kato (2020)^35
	Participants with mild and moderate TMD experienced significantly higher levels of depression compared to those without TMD (p < .001), there were no significant differences between participants with mild or moderate TMD	Natu et al. (2018)^40
	Participants with chronic pain reported more depression than participants without chronic pain (p = .017). No significant differences were found between participants with acute and chronic pain, and between participants with acute pain and those without pain. (Additional results showed that whether pain was acute or chronic did not predict depression within a regression model, which included several other predictors)	Serbic et al. (2020)^42
	Participants with IBS reported significantly higher scores of depression than participants without IBS (p < .001)	Shen et al. (2009)^38
	Participants with musculoskeletal chronic pain reported significantly higher scores of depression compared to those without (p = .008)	Soyuer et al. (2012)^41
	There were no significant differences in depression scores among participants with non-chronic (< 3 months) or chronic pain	Thomas et al. (1992)^49
Anxiety	There were no significant differences in anxiety between those with or without nonspecific chronic low back pain	Furtado et al. (2014)^46
	Anxiety was significantly more common in participants with IBS than in those without IBS (p = 0.007)	Jiang et al. (2019)^43
	Participants with mild TMD experienced significantly higher levels of anxiety compared to those without TMD (p = .003). In addition, those with moderate TMD also experienced significantly higher anxiety compared to participants without TMD (p < .001). While those with moderate TMD experienced significantly higher anxiety than those with mild TMD (p = .015)	Natu et al. (2018)^40
	Participants with chronic pain reported more anxiety than participants without pain (p < .001). No significant differences were found between participants with acute and chronic pain, and between participants with acute pain and those without pain. (Additional results showed that whether pain was acute or chronic did not predict anxiety within a regression model, which included several other predictors)	Serbic et al. (2020)^42
	Participants with IBS reported significantly higher scores of anxiety than participants without IBS (p < .001)	Shen et al. (2009)^38
	Participants with musculoskeletal chronic pain reported significantly higher scores of anxiety compared to those without (p = .001)	Soyuer et al. (2012)^41
State and trait anxiety	The association between chronic TMD pain degrees (no TMD, degree 1, degree 2, degree 3) and trait-anxiety scores was not significant. The association between chronic TMD pain degree and state-anxiety was positive and significant (p = .008)	Pesqueira et al. (2010)^45
Health anxiety	Health anxiety was not correlated with pain intensity in students with chronic pain	Rachor and Penney (2020)^36
Mental distress	Participants with IBS had significantly elevated values on the global mental distress severity in comparison to participants without IBS (p < .001, η^2 = .067); but there was no significant group (IBS/no IBS) × gender interaction. Eight of nine subscales were also all significant at p < .001 and their effect sizes (η^2) are as follows: somatization (.099), obsessive–compulsive (.038), interpersonal sensitivity (.047), depression (.051), anxiety (.056), phobic anxiety (.030), paranoid ideation (.027), psychoticism (.034); while hostility was significant at p < .05 (η^2 = .012).	Gulewitsch et al. (2013)^47
Suicidal intention	Suicidal intention was significantly more common in participants with IBS than in those without IBS (p = .001)	Jiang et al. (2019)^43
Meeting criteria for psychiatric disorder	More participants with IBS met diagnostic criteria for psychiatric disorders (anxiety and depression) compared to participants without IBS (p < .001) (note that this was assessed using one scale only)	Shen et al. (2009)^38
Stress	Participants with chronic pain reported more stress than those with no pain (p = .001, d = −.65) and recent pain (p < .01; d = −.32).	Graham and Streitel (2010)^39
	Participants with IBS reported significantly higher values than participants without IBS on eight of nine stress subscales: social overload (p = .165), work overload: p < .001, η^2 = .040), pressure to succeed (p < .01, η^2 = .032), dissatisfaction with job (p < .05, η^2 = 014), excessive work demands (p < .001, η^2 = .047), lack of social recognition (p < .001, η^2 = .048), social tension (p < .05, η^2 = .012), social isolation (p < .001, η^2 = .043), chronic worries (p < .001, η^2 = .096) and on the screening scale for chronic stress (p < .001, η^2 = .088). Additional analyses showed that there was no significant group (IBS/no IBS) × gender interaction	Gulewitsch et al. (2013)^47
	Participants with mild and moderate TMD experienced significantly higher levels of stress compared to those without TMD (p < .001), there were no significant differences between those with mild and moderate TMD.	Natu et al. (2018)^40
Daily hassles	Participants with chronic headache reported more daily hassles (a type of stressor which was measured by focusing on these areas: school, social, future security, financial, work, environment, family, household and personal appearance) than those with non-chronic (frequent and infrequent) headaches (p < .001)	Bottos and Dewey (2004)^48
State self-esteem	Participants with chronic pain reported lower state self-esteem (related to academic performance and social pressure) than those with no recent pain (p = .001, d = .43). There was no significant difference when comparing the chronic and recent pain groups	Graham and Streitel (2010)^39
Self-esteem	Participants with chronic pain reported significantly lower levels of self-esteem than participants in the non-chronic pain group (p < .01)	Thomas et al. (1992)^49
Perfectionism	Participants with chronic headache reported more self-oriented perfectionism (p < .001) and more socially prescribed perfectionism (p < .01) than those with non-chronic (frequent and infrequent) headaches. No significant differences were found for other-prescribed perfectionism	Bottos and Dewey (2004)^48
Goal setting	Goal systems assessment battery scores were significantly different between participants with persistent pain and no pain (p < .01). Within that, self-efficacy, self-monitoring, self-reward and positive arousal (all p < .01) were significantly lower in participants with persistent pain than pain-free participants. No significant differences were found on other aspects of goal setting: value, social comparison, planning, self-criticisms and negative arousal	Karoly and Lecci (1997)^37
Emotional instability	There were no significant differences in emotional instability reported by those with or without nonspecific chronic low back pain	Furtado et al. (2014)^46
Psychological inflexibility	There was no significant difference in psychological inflexibility between participants with chronic pain and those without chronic pain	Kato (2020)^35
Metacognitions about health	Pain intensity was positively correlated with beliefs about biased thinking (r = .16, p < .05), beliefs that thoughts are uncontrollable (r = .19; p < .05), but not with beliefs that thoughts can cause illness	Rachor and Penney (2020)^36
Social functioning
Social support	When comparing chronic health conditions (CHC) that did or did not involve pain: whether or not the CHC involved pain was not associated with social support received from friends (p > .05, rsp = .06), or significant others (p > .05, rsp = .11). Regarding illness-related support, individuals with CHCs with pain symptomology reported disclosing their CHC status to fewer friends than did those with CHCs without pain (p = .039; rsp = −.20); however, pain status was not associated with perceived support following disclosure (p > .05, rsp = .11)	Feldman et al. (2020)^50
	Participants with chronic pain reported lower levels of overall perceived social support (p = .012) than participants without pain as well as perceived family (p = .003) and friends support (p = .040), but no significant difference was found for perceived significant other support. No significant differences were found between participants with acute and chronic pain, and between participants with acute pain and those without pain on any of these measures	Serbic et al. (2020)^42
Interference with daily, social and work activities	More pain intensity was correlated with more interference with daily, social and work activities (r = .44, p < .01), pain intensity was also its positive predictor (β = .40, p < .001) in a regression model which included several other predictors	Rachor and Penney (2020)^36
Academic functioning
Interference with school work	Compared to participants with non-chronic pain (<3 months), participants with chronic pain reported experiencing significantly higher interferences with school work due to the effects of pain (p < .001)	Thomas et al. (1992)^49
Interference with academic functioning	Whether pain was acute or chronic did not predict interference with academic functioning in a sample of students with mixed pain durations. Within the same model, high levels of pain intensity was a positive predictor (β = .16, p < .05); (this model included several other predictors)	Serbic et al. (2020)^42
Quality of life
	Participants with nonspecific chronic low back pain reported significantly poorer overall quality of life (p < .001) compared to those without pain. When looking at the quality of life subscales: participants with nonspecific chronic low back pain reported significantly poorer social functioning compared to those without pain (p = .002). There was also a negative significant correlation between nonspecific chronic low back pain and social functioning (r = .98, p = .003). There were no significant differences in general mental health between participants with or without nonspecific chronic low back pain (but approaching significance). There were no significant differences between participants with or without nonspecific chronic low back pain in role-emotional (assesses limitations in routine activities due to emotional problems)	Furtado et al. (2014)^46
	Participants with IBS had lower physical (p < .001) and mental (p < .001) health-related quality of life than those without IBS. Separate analyses for male and female students showed no sex differences	Gulewitsch et al. (2011)^52
	Participants with chronic pain reported significantly lower health-related quality of life than those without chronic pain (p < .001); in addition the presence of chronic pain was a significant predictor of lower quality of life (p < .001, B = .51, 95% CI [0.30, 0.73]) in a regression model which contained several other predictors	Klemenc-Ketis et al. (2011)^51
	Global scores and scores on the following quality of life domains: physical, psychological and social disability between participants with and without TMD did not differ significantly. Participants with TMD reported significantly higher scores across other four domains: functional limitation (p < .001), physical pain (p < .001), handicap (p < .001) and psychological discomfort (p = .001)	Natu et al. (2018)^40

a We use the term “outcome variables” tentatively to indicate that we are interested in how chronic pain affects them; however, all included studies used correlational design, therefore no causal relationship can be established.

b Only a small number of studies reported effect sizes: r – Pearson correlation; r_s – Spearman correlation; ß – standardized regression (r, r_s, ß: .1 = small effect, .3 = medium effect, .5 = large effect); d – Cohen’s d (.2 = small effect, .5 = medium effect, .8 = large effect); ηp² – partial eta squared (.01 = small effect, .09 = medium effect, .25 = large effect); p – calculated probability that an observed difference could have occurred by random chance; IBS – Irritable Bowel Syndrome; TMD – Temporomandibular Disorder.

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