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

Abstract

Objective: Chronic pain is a prevalent health issue among young adults; however, there is limited understanding on how it affects university students. This is the first systematic review of evidence relating to the association between chronic pain and psychological, social and academic functioning in university students. Participants: Four databases were searched for relevant published studies. Data from 18 studies including 10,069 university students, of which 2895 reported having chronic pain, were included in the synthesis. Methods: Due to heterogeneity of data and methodologies, meta-analysis was not possible; therefore, data were synthesized narratively. Results: Our findings showed that students with chronic pain have poorer psychological, social and academic functioning and quality of life, compared to students without chronic pain. Conclusions: These findings suggest that chronic pain presents a challenge in university settings. Research is urgently needed to enable an understanding of how universities can support students who experience chronic pain.

Keywords:

• Chronic pain
• functioning
• quality of life
• students
• young adults

Introduction

University students are faced with a variety of challenges and they are often perceived as a distinct population when considering health. Recently, a lot of attention has been given to mental health in students, as psychological difficulties are highly prevalent in this population.¹ However, less is known about the impact of physical health, and in particular, chronic pain in university students. Chronic pain is a persistent or reoccurring pain lasting at least 3 months.² It affects an estimated 20% of people worldwide, and between 13% and 50% of adults in the UK, of which 10.4–14.3% have moderate to severe disabling pain.^3,4 These figures are similar in the US, with an estimated 20.4% of adults experiencing chronic pain and a further 8% experiencing high-impact chronic pain.⁵ Chronic pain conditions lead to a lot of disability and reduced functioning, with chronic low back pain now recognized as the global leading cause of disability and work absence.^6,7 Chronic pain is also associated with reduced psychological, social and work functioning in adults, resulting in high health and societal costs.^8,9 Research focusing on pediatric chronic pain samples has also shown that pain is associated with higher school absenteeism and poorer peer and social functioning and quality of life.^10–12

Several studies have examined prevalence and correlates of health complaints, including pain, in student samples. These studies show that pain is a common problem among university students and is linked to reduced psychological and social functioning and wellbeing.^13–15 For example, the annual prevalence of low back pain in university students, one of the most common pain conditions, was found to be around 40% and it was associated with a variety of psychosocial factors.^16–18 University students are also reporting high prevalence of chronic pain, with 54% reporting chronic pain of over 3 months in at least one pain site in a recent study.¹⁹ Among those students, 19.1% reported chronic pain in at least three pain sites. However, the majority of past research focused on pain prevalence rather than chronic pain and its impact on function in university students.

Examining such relationships is important as university life is marked with heightened stress and psychological distress, which is in turn associated with disability and poorer academic attainment.^15,20 Many students are also likely to be inactive, due to studying for long periods of time.²¹ All in all, university students are faced with a variety of challenges, often associated with the start of independent living and moving away from home. This is also a period commonly associated with being healthy, agile and enjoying oneself, therefore having a chronic health issue such as chronic pain may be perceived as unusual or may even be stigmatized. In a study by Vickerman and Blundell,²² it was found that 25% of students with disability did not want to identify as disabled on their university application due to the fear that they might be rejected a place. There is also some evidence that many university students are reluctant to disclose their disability or chronic illness to their university’s disability services.²³

Even though chronic pain is a highly prevalent health issue, which can have a substantial impact on an individual’s functioning and society as a whole, it is insufficiently researched in university settings.²⁴ To our knowledge, this review is the first attempt to provide an understanding of the underlying evidence for the role of chronic pain in university students’ lives, covering a wide range of chronic pain concerns. Specifically, the current review aims to identify, assess and synthesize research evidence relating to the relationship between chronic pain and psychological, social and academic functioning and quality of life in university students.

Methods

Study protocol

This review methodology was guided by a prospectively registered protocol (PROSPERO: CRD42018111890) with a pre-defined search strategy and registered outcomes of interest. The protocol was developed based on guidance from the Center for Review and Dissemination and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (see Supplementary Files).^25,26 Minor deviations from this protocol are noted in the study limitations section.

Information sources

We carried out initial searches of four databases (PsycINFO, PubMed/MEDLINE, Scopus and Web of Science), as recommended by the Center for Review and Dissemination.²⁶ After this, we were able to develop a final list of terms ensuring a balance of specificity and sensitivity when completing the final systematic search. The following key words (MeSH and text words) were used: student, pain, chronic pain, functioning, social, academic, psychological, quality of life, wellbeing. The full search string for one database is included in the Supplemental Materials. The four databases were searched from their beginnings to the 3rd of September 2018 and searches were updated on the 6th of March 2021. Additionally, reference list searches of the initially sourced articles were conducted in order to find additional relevant studies.

Study inclusion and exclusion criteria

Studies were included if they were empirical and were published in peer-reviewed journals anywhere in the world, in English language, and with no time limits imposed. Both quantitative and qualitative studies were eligible for inclusion.

The population of interest was university students, attending higher education institutions and experiencing chronic pain. Such students are typically aged ≥18 years. Studies were excluded if they focused on primary and secondary school students/pupils. Studies were excluded if pain experiences were related to education specializations and demanding training – for example, physically demanding training such as use of frequent repetitive movements of a particular body part, specific body posture or frequent high stress exposure. This included specific student groups, such as music, athletics, dance, nursing, physical therapy, dental and medical students. There is substantial evidence showing that chronic pain prevalence rates are high among these student groups, associated with the physical demands of the training involved. For example, medical students are typically exposed to high stress and spend more than 7 hours a day sitting down to study,²⁷ while physical therapy students have higher frequency of low back pain than other medical students, which is often linked to bad body posture.²⁸ Studies focusing on these groups often specifically focus on pain associated with the high/specific demands of their training. In order to avoid ambiguity in the interpretation of our findings, studies were also excluded if they did not specifically focus on demanding training. However, if one or more of these groups were part of a larger mixed student sample, a study was included. These specific groups had to comprise less than 50% of the total sample or statistical analysis had to show that they do not differ from other student groups on chronic pain variables. Furthermore, where students were mixed with other populations, such as workers or teachers and their results were not separately analyzed, these studies were excluded.

Chronic pain was our primary variable of interest. Therefore, studies were included if they included participants who reported chronic pain (either primary or secondary chronic pain, according to the International Classification of Diseases-11).²⁹ Chronic primary pain is defined as pain that persists beyond 3 months, causes distress, impairs functioning and cannot be explained by another condition; while chronic secondary pain is described as persistent pain which arises due to other medical conditions.²⁹ Studies were excluded if they solely focused on acute pain. If a study included participants with both acute and chronic pain, it was included if these groups were also analyzed separately and compared.

Studies were excluded if they measured pain prevalence rates or risk factors for developing pain. This is because the main aim of this review was to examine chronic pain in relation to psychological, social and academic functioning and quality of life, as outcome variables. We use the term ‘outcome’ variable tentatively because we anticipate that many included studies will have correlational and/or cross-sectional design. Therefore, our outcome variables of interest were indicators of either psychological, social or academic functioning, as well as quality of life. As chronic pain has been reported to carry adverse effects on psychological, social and occupational functioning and quality of life,³⁰ these outcomes are of particular interest in this population. These variables had to be studied in association with chronic pain variables, such as presence of chronic pain or chronic pain severity. Studies were excluded if they solely measured physical variables (eg, outcomes of physiotherapy, physical activity, physical functioning, body mass index (BMI), sleep, etc.). If a study measured a range of different variables and relationships, results for variables that were not clearly either psychological, social, academic or quality of life were not extracted and included in our synthesis. Finally, if a study used students as a convenience sample and fulfilled all other inclusion criteria, it was included.

Screening of publications

All screening was conducted by three reviewers (DS, CF, RM). Abstracts of all articles were extracted and screened for eligibility by two independent reviewers. Following the initial screening of abstracts, full texts of all included articles were extracted and assessed for eligibility, where at least two reviewers had to agree on the exclusion or inclusion of articles. If necessary, a third reviewer was consulted for a final decision. Deduplication and screening of publications during the first database search was conducted in EPPI Reviewer 4.0.³¹ Rayyan was used when the search was updated in March 2021.³²

Quality assessment of individual studies

Studies were assessed using the Joanna Briggs Institute Critical Appraisal tool.³³ Table 2 shows the assessment questions and whether each study meets each of the criteria. Studies were independently assessed by two reviewers (CF, RM). Disagreements were resolved by consulting a third reviewer (DS), who also assessed a sample of studies to ensure consistency of this processes. We also calculated how many criteria were met by each study; we used these values for guidance only, rather than for excluding studies.

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

Data extraction

Three reviewers (DS, CF, RM) were involved in all stages of data extraction and synthesis. Information from each study was independently extracted by two reviewers and any discrepancies were discussed and resolved with a third reviewer.

The following information was extracted from studies: authors, year of publication, country where the study was conducted, sample size, participants’ sex, age, health issue, pain duration/intensity and university degree, study design, analysis, measured variables (chronic pain and outcome variables relevant to this review) and findings. Findings were extracted narratively (see next section), and they were supported with p values (and effect sizes where available).

Data synthesis

Due to anticipated heterogeneity of data and methodologies, meta-analysis of quantitative evidence was not possible. Consequently, we planned to synthesize evidence narratively. We followed the guidance by the Center for Review and Dissemination which recommend a general narrative synthesis framework consisting of four stages/elements.²⁶ These stages can overlap and do not need to follow this order: (a) developing a theory; (b) developing a preliminary synthesis of findings; (c) exploring relationships within and between studies and (d) assessing the robustness of the synthesis. We decided to group and synthesize extracted findings thematically, according to the variables that were studied in association with chronic pain: psychological functioning variables, social functioning variables, academic functioning variables and quality of life variables. Qualitative studies were planned to be synthesized using a thematic synthesis approach;³⁴ however, since no qualitative studies were identified for inclusion in the synthesis, no further detail is provided here.

Results

Database searching and coding

Figure 1 shows the PRISMA flow diagram of the full study selection process conducted for the both the original and updated search; numbers presented in Figure 1 combine searches. It also provides reasons for exclusion. The database searches resulted in identifying 11,621 records; three additional records were identified through hand searching references in eligible records. After deduplicating records; the titles and abstracts of 8183 unique records were screened; 8056 records were excluded at this stage, resulting in a final 127 records for screening at full text. After excluding 109 full-text records, 18 studies were found to be eligible and were included in the final synthesis. All studies were quantitative; no qualitative studies were identified.

Figure 1. Flow chart of study selection process.

Study characteristics

Table 1 shows study and participant characteristics. In summary, the 18 studies included in the synthesis were published between 1992 and 2020. Studies were published in the United Kingdom (n = 1), Portugal (n = 1), Singapore (n = 1), Turkey (n = 1), Slovenia (n = 1), Japan (n = 1), Brazil (n = 2), Germany (n = 2), China (n = 2), Canada (n = 3) and the United States (n = 3). All studies recruited participants from universities. Six studies collected data online, 10 studies collected data in person, one study did not report their method of data collection, and one study collected data both in person and online. Sixteen studies were cross-sectional and two were longitudinal. All studies used questionnaire design and employed either t test, Chi-square test, MANOVA, ANOVA, correlational or regression analysis, or a combination of these analyses. Three studies included students as convenience sample.^35–37

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.

Participant characteristics

The 18 studies included 10,069 university students, of which 2895 reported having chronic pain. One study included participants with chronic nonspecific low back pain, one study included participants with chronic musculoskeletal pain, one study included participants with chronic headaches, three studies included participants with Temporomandibular Disorder (TMD), four studies included participants with Irritable Bowel Syndrome (IBS) and eight studies included participants with more than one chronic pain diagnosis or pain location (mixed chronic pain). Thirteen studies used undergraduate students, two of which also included postgraduate students, while two other studies did not specify clearly if any postgraduate students were included. Five studies did not provide information about university degree level. Three studies used psychology students, three studies did not provide information about degree course studied, and the remaining twelve studies included a variety of university degrees. One of these studies had a sample of over 50% of medical students; however, there was no significant difference between them and non-medical students on prevalence of chronic pain, hence this study was included.³⁸ Please see Table 1 for more information.

Quality assessment

Quality assessment information for all studies is presented in Table 2. Five studies met 8/8 criteria, five studies met 7/8 criteria, six studies met 6/8 criteria, one study met 5/8 criteria and one study met 4/8 criteria. In some cases, it was unclear if a criterion was met; this was calculated as not meeting that criterion. No studies were excluded based on quality assessment. All studies satisfied the following criteria: using valid and reliable predictors, using objective and standard criteria for measuring conditions (in this case, pain), assessing outcomes with reliable and valid measures, and applying appropriate statistical methods. Five studies failed to clearly define their inclusion criteria and two studies did not report subjects and study settings in enough detail. Where studies failed most prominently to satisfy criteria was in the reporting of and dealing with confounding factors; seven studies failed to report on potential confounders, while 10 did not take measures to deal with confound variables in their analyses.

Synthesis of evidence

Table 3 shows how evidence from included studies was synthesized. Results were synthesized narratively and grouped according to the variables that were associated with chronic pain, resulting in four broad categories: (1) psychological functioning; (2) social functioning; (3) academic functioning and (4) quality of life. The majority of studies compared students with chronic pain to those without pain on various psychological, social, academic and quality of life measures. While a small number of studies examined relationships between these variables and pain severity/intensity. Below is a narrative summary of all key findings from Table 3.

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.

Associations with psychological functioning

Several psychological variables were examined across the studies included in the synthesis:

Depression: Results from eight out of nine studies showed that students with chronic pain (mixed chronic pain, TMD, IBS and musculoskeletal chronic pain) had higher levels of depression and that depression was more common among students with chronic pain than in those without, or with infrequent or acute pain.^35,38–44 Although, these differences were not found between acute/mild and chronic pain groups in two of these studies.^40,42 When measures of depression and anxiety were combined in one of these studies,⁴⁴ the association between depression and anxiety and presence of TMD was significant.

Anxiety: Results from six out of eight studies showed that students with chronic pain (mixed chronic pain, TMD, nonspecific chronic back pain, IBS and musculoskeletal chronic pain) had higher levels of anxiety or that anxiety was more common than in those without pain.^{38,40–43,45} Again, this difference was not found between acute and chronic pain in one of these studies.⁴² Furthermore, state vs. trait-anxiety were found to correlate with the outcomes differently; Pesquiera et al.⁴⁵ report that the association between TMD presence/severity and trait-anxiety scores was not significant, while the association with state-anxiety was positive and significant.

Mental distress, suicidal indention & meeting criteria for psychiatric disorder: One study found no significant difference in general mental health (a subscale of quality life measure, see below) between students with or without nonspecific chronic low back pain.⁴⁶ In a second study, suicidal intention was significantly more common in students with IBS than in those without IBS.⁴³ A third study showed significantly elevated values on a mental distress scale and all its subscales (somatization, obsessive–compulsive, interpersonal sensitivity, depression, anxiety, phobic anxiety, paranoid ideation, psychoticism and hostility) for the IBS group, in comparison to non-IBS group, indicating a generally higher mental strain in those with IBS.⁴⁷ Finally, a fourth study found that students with IBS were more likely to be diagnosed with a psychiatric disorder (anxiety/depression) than those without IBS.³⁸ The last two studies examined depression and anxiety as part of general mental health assessment; these findings support the depression and anxiety results reported in the previous paragraphs.

Stress: Associations between chronic pain and stress were assessed in four studies, all of which found that students with chronic pain (mixed chronic pain, IBS, chronic headache and TMD) reported higher levels of stress than those without pain.^39,40,47,48 One of these studies found a significant difference when comparing students with and without TMD; however, there was not a significant difference between students with mild and moderate TMD.⁴⁰ In another study, students with IBS reported significantly more stress on eight out of nine stress subscales, many of which related to work and social functioning, so these results to an extent support the social and academic functioning results below.⁴⁷ Finally, one of these studies specifically focused on the role of daily hassles (defined as a type of stressor), many of which focused on work and social functioning, again supporting our social and academic functioning results below.⁴⁸

Self-esteem: Associations between pain and self-esteem were assessed by two studies which found that students with chronic pain reported significantly lower levels of self-esteem than those without pain.^39,49

The following psychological variables were assessed by one study only:

Perfectionism: Students with chronic headaches reported more self-oriented and socially prescribed perfectionism than those with non-chronic headaches, but no significant difference was found for other-oriented perfectionism.⁴⁸ Goal setting: One study found that four out of nine aspects of goal setting (self-efficacy, self-monitoring, self-reward and positive arousal) were significantly lower in students with persistent pain than in those without pain.³⁷ Emotional instability: There were no significant differences in emotional instability reported by students with or without nonspecific chronic low back pain.⁴⁶ Psychological inflexibility: There were no significant differences in psychological inflexibility between students with chronic pain and those without chronic pain.³⁵ Metacognitions about health: In a sample of students with chronic pain, pain intensity was positively correlated with certain metacognitions about health, including the belief that thoughts are uncontrollable.³⁶

Associations with social functioning

Four studies assessed the relationship between chronic pain and social functioning.^36,42,46,50 One study found that students with chronic pain reported lower levels of overall perceived social support than those without pain, as well as perceived family and friends support, however, no significant difference was found for perceived significant other support.⁴² In the same study, no significant differences were found between students with acute and chronic pain, and between students with acute pain and those without pain on any of these measures. In another study, more pain intensity was correlated with more interference with daily, social and work activities in students with chronic pain.³⁶ A third study found that 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 or significant others.⁵⁰ 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; however, pain status was not associated with perceived support following disclosure.⁵⁰ Finally, a fourth study reported that students with nonspecific chronic low back pain reported significantly poorer social functioning (subscale of a quality of life measure, see below) compared to those without pain.⁴⁶

Associations with academic functioning

Only two studies assessed the relationship between pain and academic functioning.^42,49 One study found that compared to those with non-chronic pain, students with chronic pain reported experiencing significantly higher interferences with schoolwork due to the effects of pain.⁴⁹ A second study found whether pain was acute or chronic did not predict interference with academic functioning in a sample of students with mixed pain durations.⁴² However, high levels of pain intensity (regardless of pain being acute or chronic) predicted high levels of interference with academic functioning.⁴²

Associations with quality of life

Three studies found that chronic pain (mixed chronic pain, IBS and nonspecific chronic low back pain) was associated with poorer overall quality of life and several quality of life domains/subscales.^46,51,52 A fourth study found a non-significant difference for overall quality of life but it found several significant differences on a number of quality of life domains/subscale; for example, students with chronic pain had more psychological discomfort than those without chronic pain.⁴⁰

Discussion

We aimed to systematically review and integrate research evidence from studies that examined the relationships between chronic pain and psychological, social and academic functioning and quality of life in university students. The findings were synthesized narratively and indicate that chronic pain is associated with poorer functioning across all studied domains, and that students with chronic pain are faced with greater challenges than those without pain.

Variables that were captured most frequently were depression and anxiety. Higher levels of depression were found in students with chronic pain (compared to students without pain) in all but one study. Interestingly, the only study that did not show a significant difference was published much earlier than the studies that showed significant differences.⁴⁹ This may suggest that depression has become a more substantial problem in recent years. It might also reflect a shift in public perceptions relating to mental health, and young people’s greater readiness to share their concerns. Similar findings were found for anxiety, where the majority of studies showed that students with chronic pain were more anxious than those without chronic pain. More prominent differences were found between chronic pain and no pain groups, than when comparisons were made between acute/infrequent and chronic pain groups.^40,42 However, only a small number of studies made such comparisons, therefore this finding should be interpreted with caution. Overall, findings related to depression and anxiety are supported by past research, which repeatedly finds a positive relationship between chronic pain and depression and anxiety in non-student samples.^53–55 Generally, university life is associated with poorer mental health compared to the general population.²⁰ Our findings suggest that this may be more prominent in students who experience chronic pain than those who do not, as indicated by elevated mental distress, suicidal intention and meeting criteria for psychiatric disorder in groups with chronic pain.^38,43,47 These findings indicate a higher mental strain on students with IBS specifically and further research is needed to examine this in other chronic pain groups. However, there were no significant differences in emotional instability and psychological inflexibility between students with and without chronic pain.^35,46

Students with chronic pain reported higher perfectionism and lower self-esteem.^39,48,49 This is supported by research involving non-student populations which found a link between pain and lower self-esteem in adults and between perfectionism and pain in youth.^56,57 The association between perfectionism and academic variables has been described as complex, as it can have both a positive and negative relationship with academic attainments.⁵⁸ Furthermore, several aspects of goal setting were significantly lower in students with chronic pain than in students without pain,³⁷ which may have implications for their academic functioning.

The majority of findings reported in this review indicate that students with chronic pain have significantly poorer quality of life compared to those without pain. These findings are in line with past research showing a relationship between chronic pain and quality of life in both adults and adolescents.^10,59 Being at university is also associated with stress,¹⁵ for example, stress is considered a leading cause of headaches in university students.⁶⁰ All studies that examined the relationship between stress and pain in our review found that students with chronic pain had higher levels of stress than those without pain, indicating that chronic pain might bring added pressure to students who experience it. In addition, university students with chronic pain reported more work-related stress and stress relating to social recognition, tension and isolation than students without pain.⁴⁷ This suggests that providing appropriate support to students with chronic pain within university settings is crucial; this is indicated by the studies which reported significantly lower perceived social support in students with chronic pain compared to those without pain,⁴² more interference with daily, social and work activities,³⁶ and unwillingness to disclose their pain condition.⁵⁰ Academic support is also important, as pain is likely to interfere with academic tasks and progress as shown by two studies in this review.^42,49 Evidence from studies addressing both adult and adolescent samples support these findings.^61,62

Implications for future research and practice

More research is needed to examine the impact of chronic pain on university students’ functioning. Such research is currently scarce, particularly research relating to social and academic functioning. Only a small number of studies included in our review examined this. In comparison, the majority of past research focused on examining pain complaints (regardless of pain duration or chronicity), pain prevalence rates and/or risk factors for developing pain in students. Such studies were excluded from our review as they lacked a clear focus on students who suffer from chronic pain and the impact of this pain on their functioning and quality of life. When such research is conducted, it is important that researchers clearly measure and report their assessment of pain chronicity;⁶³ some studies had to be excluded from this review due to this issue. There is also a need for longitudinal research in this population, in particular the transition from secondary to tertiary education is important to study as it is filled with challenges. More understanding is required on the challenges that students with chronic pain face as they progress through higher education and transition to employment/further education, and how this might hinder their success and affect their wellbeing.

A potential barrier to supporting students with chronic pain at university is their unwillingness to disclose their chronic pain condition. For example, one of the studies included in this review found that students with chronic health conditions and pain symptomology reported disclosing their chronic health status to fewer friends than those that had chronic health conditions without pain symptomology.⁵⁰ Pain is not commonly associated with young age, therefore social perceptions and stigma may contribute to young people hiding their chronic pain condition from others. Research is needed to examine public attitudes toward chronic pain in young people. University support services may need to encourage these students to come forward and seek support, but currently there is a lack of understanding and clear pathways for detecting students with chronic medical conditions.⁶⁴ Our findings suggest that students who experience chronic pain may need a diverse support package that would address their psychological, social and academic needs. Research suggests that certain interventions may be helpful in university settings; for example, Firth et al.⁶⁵ examined the role of mindfulness and self-efficacy in pain perception, stress and academic performance in university students. Their findings suggest that self-efficacy is important for both pain and academic performance, while mindfulness influenced wellbeing and lowered stress. University health services may also consider introducing peer support schemes. Finally, the majority of past research has focused on undergraduate students or mixed groups, more research is needed on postgraduate students who experience chronic pain.

Limitations

This is the first systematic review of evidence focusing on chronic pain in university students and its relationship with their psychological, social and academic functioning and their quality of life. As such, the review helps to provide directions for future research and practice. However, there are some limitations to this review. Due to a diversity of measures used in the included studies and/or insufficient number of studies, a meta-analysis of results was not possible. The majority of studies included in this review were cross-sectional and questionnaire-based studies, this means that the findings should be interpreted with caution and no causal relationships can be inferred. This also means that we were not able to develop a theoretical model based on these findings, which we proposed to do in our pre-registration report. It was also difficult to make meaningful comparisons between different chronic pain conditions because a small number of studies assessed the same chronic pain condition.

A further limitation is that not many studies included participants who reported on a physician-confirmed chronic pain diagnosis; the majority of studies based this on self-report. Moreover, due to a lack of clarity about whether chronic or acute pain was assessed, we excluded several studies that might have provided further evidence on our relationships of interest. However, we believe that our strict inclusion criteria contributed to the clarity of our findings. Our review represents a culturally diverse sample of university students (see Table 2); this of course is an advantage as it contributes to the external validity of our findings. However, higher education systems differ across the world, therefore culture can also be viewed as a potential confound within our synthesis of evidence. Finally, because some outcome variables were assessed by a single study, their findings should be interpreted with caution.

Conclusion

Overall, the findings from this review indicate that students with chronic pain are faced with greater psychological, social and academic challenges and have poorer quality of life, compared to students without chronic pain. These findings are in line with evidence from studies examining non-student populations. They suggest that university students are not protected from experiencing adverse effects of chronic pain due to their youth or agility; this is a misconception that may prevent these students disclosing and discussing their pain experiences openly with others.²³ More young people go to university today than ever before and chronic pain is a substantial health issue, yet research on the impact of chronic pain on university students and support they need is lacking. Such research is urgently needed to enable a better understanding and support of this growing population.

Conflict of interest disclosure

The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of UK.

Funding

The author(s) reported there is no funding associated with the work featured in this article.