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. 2025 Jan 20;10(3):616–624. doi: 10.1177/23971983241312542

Psychosocial moderators of the association between pain intensity and physical function in people with systemic sclerosis

Daniel Whibley 1,✉, Deeba Minhas 2, John A Sturgeon 3, Yen T Chen 1,2,4, Anna Kratz 1, Dinesh Khanna 2,4, Susan L Murphy 1,2,4
PMCID: PMC11748139  PMID: 39845450

Abstract

Background:

Pain is a prevalent symptom of systemic sclerosis. While previous studies have demonstrated a correlation between higher pain intensity and lower physical function in individuals with systemic sclerosis, the potentially moderating effect of psychosocial factors on the association has yet to be explored.

Methods:

This cross-sectional study used data from a fatigue self-management trial for adults with systemic sclerosis. Baseline questionnaire instruments measured pain intensity (11-point scale), physical function (PROMIS 4a short form), and psychosocial factors: positive and negative affect (Positive and Negative Affect Schedule), resilience (Connor–Davidson Resilience Scale), anxiety, depression (PROMIS short forms), and self-efficacy domains (PROMIS item banks). Linear regression quantified the pain intensity–physical function association with interaction terms for candidate psychosocial moderators included in separate models (adjusted for age, systemic sclerosis subtype, and disease duration).

Results:

Among 173 participants (mean age 54.5, Standard Deviation 11.7, 93% female, 83% White), 47% had diffuse cutaneous systemic sclerosis, 35% limited, 13% overlap, and 5% other/unsure. Mean pain intensity was 4.9 (Standard Deviation 2.3) and mean physical function T-score was 38.5 (Standard Deviation 6.4). Pain intensity accounted for 31% of the variability in physical function (B −1.34, 95% confidence interval −1.69, −0.99). Statistically significant interactions were found between pain intensity and negative affect and anxiety, with higher levels of these factors amplifying the negative pain–physical function association.

Conclusion:

These findings suggest that higher levels of negative affect and anxiety exacerbate the negative effect of pain on physical function in individuals with systemic sclerosis. Interventions targeting these factors may help improve overall physical function regardless of pain intensity.

Keywords: Systemic sclerosis, physical function, psychosocial factors, chronic pain, patient-reported outcomes

Key messages

  1. Higher levels of negative affect and anxiety were found to significantly increase the negative association between pain intensity and physical function in individuals with systemic sclerosis.

  2. Targeting negative affect and anxiety may help mitigate the disabling effects of pain among people with systemic sclerosis.

Introduction

Systemic sclerosis (SSc) is a chronic autoimmune disease with a global prevalence of 18.87 per 100,000 persons. 1 It is characterized by immune system activation, microvascular damage, and fibrosis of the skin and internal organs. 2 Pain is a common SSc symptom, affecting more than 80% of those living with the disease, with over a third experiencing moderate-to-severe pain.3,4 Although joint pain is very common, other painful manifestations include Raynaud’s phenomenon, back pain, headache, chest pain, odynophagia, and painful digital ulcers. 5

Similar to observations from studies conducted with people with other rheumatic and musculoskeletal diseases,6,7 higher pain intensity is associated with poorer physical function among people with SSc. 8 Recent data from the Scleroderma Patient-Centered Intervention Network (SPIN) cohort showed that, after adjusting for various sociodemographic, lifestyle, and disease-specific factors, each standard deviation increase in PROMIS-measured pain intensity score was associated with a 4.55-point reduction in PROMIS-measured physical function (T-score scale; 95% confidence interval (CI) −4.87, −4.24). 9 This finding builds on previous cross-sectional studies that have reported a negative association between tender joints and physical function in SSc.10,11

Although pain is recognized as a key contributor to impaired physical function in people with rheumatic and musculoskeletal diseases, 12 research has identified additional important factors to consider. In studies of systemic autoimmune rheumatic diseases, including SSc, factors associated with poorer physical function have included older age, female sex, and higher levels of fatigue.12,13 More recently, a study of 71 individuals with SSc highlighted significant associations between emotional status, pain, and function. 14 Furthermore, research in other chronic pain conditions has demonstrated that association between pain intensity and functional outcomes may be dependent on level of self-efficacy,15,16 psychological distress,17,18 positive affect, 19 severity of depressive and anxious symptoms, 20 and resilience.21,22 Despite these intriguing data, the influence of psychosocial factors on the pain intensity–physical function association in people with SSc remains understudied. Specifically, the potentially modifying effects of variables, such as positive and negative affect, resilience, anxiety, depression, and self-efficacy on the pain intensity–physical function association have yet to be examined. Given that SSc-related vasculopathy and fibrosis may contribute to functional limitations, psychosocial factors might only play a minor (if any) role in modulating the pain–physical function association in this population. However, it is also plausible that consideration of an individual’s psychosocial context may help explain why some people with SSc experience greater functional limitations than others, despite reporting similar levels of pain intensity.

If psychosocial factors do moderate the pain intensity–physical function association in SSc, identifying and addressing them may attenuate the functionally limiting impact of pain. This would be clinically pertinent, as a primary goal of care for people with SSc is to reduce disability and improve quality of life. 23 Accordingly, this study aimed to ascertain whether psychosocial factors—namely affect, resilience, anxiety, depression, and different domains of self-efficacy—moderate the cross-sectional association between pain intensity and physical function in adults with SSc.

Methods

This cross-sectional, observational study used baseline data collected from participants recruited to a randomized control trial (RCT) of a 12-week, digitally delivered and peer-supported fatigue self-management program designed for people with SSc—the “Resilience-building Energy management to Enhance Well-being” (RENEW) intervention (NCT04908943). Further details on the study are available elsewhere. 24 The RENEW trial protocol was approved by the institutional review board at the University of Michigan (HUM00195121), and the study was conducted in accordance with Good Clinical Practice guidelines and the ethical principles of the Declaration of Helsinki.

Participants

Eligibility criteria for the parent RCT included being 18 years of age or older, having a physician diagnosis of SSc (any subtype) and, due to the symptom target of the RENEW intervention, experiencing at least a moderate level of fatigue (defined as an average score of 4 or more on the Fatigue Severity Scale). 25 Full inclusion and exclusion criteria are reported elsewhere. 24 Participants were recruited between August 2021 and March 2023 out of SSc specialty scleroderma centers in the United States and through collaborations with rheumatologists and scleroderma foundations in Canada, France, Australia, Guatemala, Israel, New Zealand, and the United Kingdom. Recruitment efforts were also supplemented by advertising the study on SSc-related social media pages and using an existing SSc research registry. Interested individuals underwent a phone screening, and those who were eligible and willing to participate provided electronic informed consent before commencing study-related activities. This secondary analysis included all participants with complete baseline data for the study variables of interest.

Measures

The baseline questionnaire for the parent RCT, administered via a secure online REDCap survey, included items about demographics, SSc characteristics, pain and physical function, and various psychosocial variables. Questions about demographic factors included age, sex, race (National Institutes of Health race categories), education level, employment status, and marital status. SSc subtype (diffuse, limited, overlap, unspecified/other, e.g. SINE), and duration since diagnosis were collected through self-report or, for participants receiving care at the University of Michigan, from medical records.

Pain and physical function

Pain intensity was assessed with the question “In the past 7 days how would you rate your pain on average?” on an 11-point scale (0 = no pain; 10 = worst imaginable pain). This single-item has been shown to perform comparably to multi-item pain intensity measures in individuals with SSc. 26 Physical function was measured using the PROMIS short-form v2.0 Physical Function 4a. This instrument consists of four items related to physical function (performing chores, going up and down stairs, walking for at least 15 min, running errands, and shopping) on a five-point scale (1 = unable to do; 5 = without any difficulty). A summed raw score can be translated to a standardized T-score. Higher scores reflect higher levels of functioning and can be compared to a general population T-score mean of 50 and standard deviation of 10. A T-score cut point < 35 has been identified by patients as indicating severe physical function impairment, while health care providers have endorsed a T-score cut point < 25 as reflecting a severe problem with physical function. 27

Candidate psychosocial moderators

The parent RCT survey included several putative psychosocial moderators of the pain intensity–physical function association, including positive affect, negative affect, resilience, symptoms of anxiety, symptoms of depression, and five domains of self-efficacy: self-efficacy for managing daily activities, managing emotions, managing medications or treatment, managing social interactions, and managing symptoms.

Affect

Levels of affect were assessed using the Positive and Negative Affect Schedule (PANAS). 28 This 20-item instrument is comprised of two 10-item subscales: one measuring positive affect and the other negative affect. Respondents indicate the extent to which they experienced each named mood or emotion over the past week (1 = very slightly or not at all; 5 = extremely). For the Positive Affect subscale, descriptors include “alert,” “inspired,” and “enthusiastic.” For the Negative Affect subscale, descriptors include “distressed,” “upset,” and “guilty.” Scores for each subscale are summed to generate a total score, with higher scores reflecting higher levels of the respective affect construct.

Resilience

Resilience was assessed using the Connor–Davidson Resilience Scale (CD-RISC-10). 29 Participants rate their agreement with 10 statements reflecting resilience-related traits, including the perceived ability to adapt to change, handle stress, and bounce back from difficult situations on a five-point Likert-type scale (0 = not true at all; 4 = true nearly all the time). Higher scores indicate greater resilience. The CD-RISC-10 has been shown to be a reliable tool for measuring resilience in people with SSc. 30

Symptoms of anxiety

Symptoms of anxiety were assessed using the PROMIS v1.0 Emotional Distress-Anxiety—Short Form 4a.31,32 This instrument includes four items that ask about feeling fearful, finding it hard to focus on anything other than anxiety, being overwhelmed with worries, and feeling uneasy over the past 7 days, rated on a five-point Likert-type scale (1 = never; 5 = always). A summed raw score can be translated to a standardized T-score, with higher scores indicating greater anxiety. These scores can be compared to a general population T-score mean of 50 and standard deviation of 10.

Symptoms of depression

Depression was assessed using the PROMIS v1.0 Emotional Distress-Depression—Short Form 4a.31,32 This instrument includes four items that ask about feelings of worthlessness, helplessness, depressed mood, and hopelessness over the past 7 days rated on a five-point Likert-type scale (1 = never; 5 = always). A summed raw score can be translated to a standardized T-score. Higher T-scores reflect higher levels of depression and can be compared to a general population T-score mean and standard deviation of 50 and 10, respectively. A T-score > 60 has been identified by patients with rheumatic diseases as indicating severe depressive problems, while a T-score > 65 has been endorsed by health care providers as reflecting a severe problem with depression. 27

Domains of self-efficacy

Five different domains of self-efficacy were assessed using PROMIS Self-Efficacy for Managing Chronic Conditions short-form item banks—self-efficacy for managing: daily activities, symptoms, medications and treatments, emotions, and social interactions. Each domain is assessed with four items, all scored on a five-point Likert-type scale (1 = I am not confident at all; 5 = I am very confident). A summed raw score for each self-efficacy domain can be translated to a standardized T-score, with higher scores indicating greater self-efficacy. 33

Statistical analysis

Descriptive statistics were calculated for demographic factors, disease-related variables, and candidate psychosocial moderators of the pain intensity–physical function association. Continuous variables were summarized as mean and standard deviation or median and interquartile range, depending on data distribution. Categorical variables were summarized as number and proportion of the sample. Linear regression was used to quantify the association between pain intensity and physical function, with model assumptions examined using standard regression diagnostics (tests for normality of residuals, heteroscedasticity, and model specification). To examine the possibility of moderation of the pain intensity–physical function association by candidate psychosocial factors, interaction terms were added for the pain intensity variable and each putative moderator in separate models, all adjusted for age, SSc subtype, and disease duration. A case for moderation was supported if the interaction effect did not cross the null (p < 0.05). All analysis were conducted using Stata/IC 15.1.

Results

There were 173 participants who met eligibility criteria for the parent RCT and were randomized. All were included in this cross-sectional analysis of trial baseline survey data. The mean age of participants was 54.5 years, standard deviation (SD) 11.7 (range 26.6–87.0). The sample was mostly female (93.1%), White (83.2%), and non-Hispanic/non-Latino (86.7%). Of the sample, 65% were married, 57.8% had attained a college degree or higher, 42.8% were currently working full time or part time, 47% had diffuse cutaneous SSc, 35% limited, 13% overlap, and 5% other/unsure, with, overall, a median of 4 years since diagnosis (Table 1).

Table 1.

Baseline demographic and disease-related variables.

RENEW participants (N = 173)
Age, mean (SD) 54.5 (11.7)
Female, N (%) 161 (93.1)
Race, N (%)
 White 144 (83.2)
 Non-White 25 (14.5)
 Missing data 4 (2.3)
Ethnicity, N (%)
 Non-Hispanic/Non-Latino 150 (86.7)
 Hispanic/Latino 11 (6.4)
 Choose not to report 1 (0.6)
 Missing data 11 (6.4)
Marital status, N (%)
 Married 113 (65.3)
 Not married 56 (32.4)
 Missing data 4 (2.3)
Employment status, N (%)
 Full time 54 (31.2)
 Part time 20 (11.6)
 Homemaker 11 (6.4)
 Retired 40 (23.1)
 Disability 44 (25.4)
 Missing data 4 (2.3)
Education, N (%)
 High school/GED 14 (8.1)
 1–3 years of college or technical school 54 (31.2)
 4 years of college 50 (28.9)
 Graduate school/advanced degree 50 (28.9)
 Missing data 5 (2.9)
Systemic sclerosis subtype, N (%)
 Diffuse 82 (47.4)
 Limited 61 (35.3)
 Overlap 22 (12.7)
 Unspecified/other 8 (4.6)
Disease duration, years, median (interquartile range) 4 (2, 12)
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Pain and physical function

Mean (SD) pain intensity for the sample was 4.9 (2.3) out of 10, and the mean (SD) physical function T-score was 38.5 (6.4). To provide context, this T-score is 1.2 SD below the general population average, classifying it as a moderate problem based on both patient and health care provider suggested thresholds. 27 Results from regression diagnostic tests supported a linear association between pain intensity and physical function (e.g. errors were normally distributed; error variance was constant), with pain intensity explaining 31% of the variability in physical function, after adjusting for age, SSc subtype, and disease duration (unstandardized B = −1.34, 95% CI −1.69, −0.99, p < 0.001) (Figure 1).

Figure 1.

Figure 1.

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Cross-sectional association between pain intensity and physical function (Ordinary Least Squares Best fit line with 95% Confidence Interval; N = 173).

Psychosocial factors

Summary statistics for psychosocial variables are presented in Table 2. Sample PROMIS T-scores were higher than the general population for anxiety and depression, and lower than the general population for all self-efficacy domains. For PROMIS variables with published cut-points, 27 symptoms of depression were classified as a mild problem based on patient-suggested thresholds and not a problem based on health care provider suggested thresholds.

Table 2.

Summary statistics of putative psychosocial moderator variables.

Psychosocial variable M (SD) N
Negative affect subscale score of the Positive and Negative Affect Schedule 22.5 (8.0) 167
Positive affect subscale score of the Positive and Negative Affect Schedule 29.8 (7.3) 168
Connor–Davidson Resilience Scale (CD-RISC-10) score 26.2 (6.5) 169
PROMIS v1.0 Emotional Distress-Anxiety—Short Form 4a T-Score 58.7 (8.1) 173
PROMIS v1.0 Emotional Distress-Depression—Short Form 4a T-Score 54.7 (7.6) 173
PROMIS Self-Efficacy for Managing social interactions T-Score 47.3 (8.2) 173
PROMIS Self-Efficacy for Managing daily activities T-Score 42.1 (5.4) 173
PROMIS Self-Efficacy for Managing emotions T-Score 45.1 (6.9) 173
PROMIS Self-Efficacy for Managing medications and treatments T-Score 49.5 (7.6) 173
PROMIS Self-Efficacy for Managing symptoms T-Score 44.2 (6.8) 173
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The moderating effect of psychosocial factors on the pain–physical function association

Of the candidate psychosocial moderators examined, statistically significant interaction effects with pain intensity on physical function were observed for negative affect and anxiety (Figures 2 and 3). In both cases, higher psychosocial symptom burden amplified the negative association between pain intensity and physical function. For those in the highest quartile for negative affect or anxiety (highest levels of the symptom), pain intensity was a strong predictor of level of disability across all levels of pain intensity. For those in the lowest quartiles (lowest levels of the symptoms), the association between pain intensity and level of physical function was weaker. There were no significant moderating effects of all other candidate psychosocial variables (positive affect, resilience, depression, and all self-efficacy variables) (Table 3).

Figure 2.

Figure 2.

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Negative affect as a moderator of the pain–physical function association in SSc.

Figure 3.

Figure 3.

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Anxiety as a moderator of the pain–physical function association in SSc.

Table 3.

Unstandardized regression coefficients (B) for interaction terms between putative psychosocial moderators and pain intensity on physical function. a

Interaction term (separate models): Psychosocial variable × pain intensity B (95% CI) p
Negative affect subscale score of the Positive and Negative Affect Schedule −0.05 (−0.10, −0.008) 0.02
Positive affect subscale score of the Positive and Negative Affect Schedule 0.01 (−0.03, 0.06) 0.57
Connor-Davidson Resilience Scale (CD-RISC-10) score 0.02 (−0.03, 0.07) 0.46
PROMIS v1.0 Emotional Distress-Anxiety—Short Form 4a T-Score −0.05 (−0.08, −0.01) 0.01
PROMIS v1.0 Emotional Distress-Depression—Short Form 4a T-Score −0.03 (−0.08, 0.01) 0.17
PROMIS Self-Efficacy for Managing social interactions T-Score −0.001 (−0.04, 0.04) 0.96
PROMIS Self-Efficacy for Managing daily activities T-Score 0.02 (−0.03, 0.07) 0.38
PROMIS Self-Efficacy for Managing emotions T-Score 0.01 (−0.04, 0.06) 0.58
PROMIS Self-Efficacy for Managing medications and treatments T-Score 0.0003 (−0.05, 0.05) 0.99
PROMIS Self-Efficacy for Managing symptoms T-Score 0.02 (−0.03, 0.06) 0.42
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a

Estimates generated from separate models, all adjusted for age, disease subtype and duration since diagnosis.

Discussion

In this cross-sectional study of adults with SSc experiencing at least moderate levels of fatigue, we identified a linear association in which pain intensity accounted for 31% of the variability in physical function, after adjusting for age, SSc subtype, and disease duration. Notably, 2 of the 10 candidate psychosocial factors—negative affect and anxiety—were identified as moderators of the pain intensity–physical function association. In both cases, the negative association between pain intensity and physical function was stronger when these symptoms were more severe; when symptom burden was low, the slope of the pain intensity–physical function model was less pronounced. In other words, higher pain intensity was linked to greater physical limitations when negative affect or anxiety levels were high. It is, therefore, possible that addressing negative affect and/or anxiety in individuals with SSc who have elevated levels of these symptoms may decouple the pain–physical function association, potentially improving functional status and quality of life, even in the presence of significant pain intensity.

Negative affect and anxiety may adversely affect physical function due to alterations in motivation or avoidance behaviors. Indeed, individuals managing both high levels of pain and affective distress may be vulnerable to lower motivation and adherence to tasks that are painful or challenging due to interruptions in directed attention 34 or goal conflict (e.g. pain relief vs rewarding approach behavior). 35 Furthermore, there is robust evidence that individuals with chronic pain show differential adjustment to pain based on their interpretation of pain (e.g. fears about damaging the body), which in turn may affect patterns of fear-avoidant behavior that may reduce pain or distress in the short term but exacerbate functional problems in the longer term. 36 Notably, pain-related fear avoidance is associated with both negative affect and anxiety. 37 The current findings may reflect these patterns to some degree.

In contrast to other negative psychological factors, depression was not a moderator. This may be explained by the unique nature of the sample, recruited based on clinically significant levels of fatigue. Recent research has highlighted key measurement issues in the overlap between depression and chronic pain, given that several symptom clusters may be attributable to both (e.g. slowed or impaired movement, fatigue, poor sleep).38 –40 Selection of participants based on fatigue level may have diminished the relative predictive value of depression, particularly as fatigue may mediate the association between pain intensity and functional outcomes.41,42 Positive psychosocial factors (self-efficacy, resilience, positive affect) were also not identified as moderators. This may also be due to the fatigue status of the sample, given prior research demonstrating negative associations between fatigue and positive affect,43 –45 resilience43,46 –48 and self-efficacy.48,49

It is possible that many of the candidate moderators may, in fact, be mediators of the pain–physical function association. In the current, cross-sectional study, we focused on identifying moderators as this information may be collected at an initial clinical encounter, highlighting targets for intervention to optimize physical function. However, further study using longitudinal data could examine mediation pathways to elucidate mechanisms linking pain and physical function in SSc. This should consider potential differential stability of psychosocial factors across time, either due to natural fluctuations or in response to intervention. Consideration of motivation/avoidance and overlap of psychiatric distress/depression with fatigue would also be warranted to help to disentangle any effects on physical functioning.

In comparison to other studies of people with SSc, on average, our sample had a markedly lower level of physical function: mean (SD) 38.5 (6.4) compared to 43.7 (8.9) in the SPIN cohort. This difference may also be attributed to the fatigue severity inclusion criterion. We, therefore, hypothesize that in more heterogenous samples of people with SSc (i.e. without the fatigue severity criterion), the magnitude of interaction effects may be greater. This remains an open question worth investigating.

Study strengths include collection of information on a broad array of psychosocial factors to examine as potential moderators of the pain–physical function association in SSc, and a robust sample size to support analysis and detection of interaction effects. The wide geographic reach of participant recruitment also adds to the study’s strengths. Limitations include the cross-sectional design, which prevents establishing causality, and the restriction of the sample to people with at least moderate fatigue, thereby limiting generalizability. However, given that fatigue is a common corollary of SSc, 50 this may be less of a concern than the homogeneity of the cohort in terms of race, ethnicity, and sex. Further studies should replicate these analyses in more diverse samples. Additional limitations relate to the measures of pain intensity and physical function. Regarding pain intensity, a generic instrument was used which is not SSc-specific and does not allow the source of the pain to be identified; for example, it is likely that joint pain has a greater impact on physical function than odynophagia. Future studies that include SSc-specific measures of pain would be beneficial, as would information on the pain generator. Regarding physical function, reliance on self-report and recall over the past 7 days may be subject to recall bias; integration of wearable technology to provide an objective measure of movement patterns as a proxy for functional status may prove enlightening.

In conclusion, our findings add to the growing body of evidence highlighting the negative association between pain intensity and physical function in SSc, while also suggesting that negative affect and anxiety may modulate this association. Future research could enhance understanding by examining whether managing pain effectively improves physical function in SSc—although this may not be the case given several biomechanical drivers of poor physical function in SSc. In addition, further investigations of the effect of addressing psychosocial factors on the pain intensity–physical function association may provide valuable insights and guide the development of interventions aimed at improving the functioning and quality of life of people with SSc.

Footnotes

Data availability statement: Data are available from the study team on reasonable request.

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare no conflicts of interest with respect to the research, authorship, and/or publication of this article. During the conduct of this project, Y.T.C. was supported by a postdoctoral fellowship award funded by the University of Michigan’s Advanced Rehabilitation Research Training Program in Community Living and Participation from NIDILRR, Administration for Community Living (grant no. #90ARCP0003; PIs Murphy/Kratz), and is currently supported by a T32 Scientist Training in Rheumatology Research postdoctoral fellowship (grant #T32AR007080; PI Knight).

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Data collection for this study was funded by a Rheumatology Research Foundation Innovative Research Award (grant no. #AW-D016916).

The statement: The Editor/ Editorial Board Member of JSRD is an author of this article; therefore, the peer-review process was managed by alternative members of the Board and the submitting Editor/Board member had no involvement in the decision-making process.

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