Psychosocial Predictors of Chronic Musculoskeletal Pain Outcomes and their Contextual Determinants Among Black Individuals: A Narrative Review

Abstract

Black communities are disproportionally affected by Chronic Musculoskeletal Pain (CMP), but little is known about the psychological predictors of CMP outcomes and their contextual determinants among Black individuals. To address this gap, we conducted a narrative review of extant literature to (1) report the major conceptual models mentioned in prior work explaining the link between contextual determinants and psychological responses to pain among Black individuals with CMP; and (2) describe psychological factors related to CMP outcomes in this population that are highlighted in the literature. We searched 4 databases (APA PsycNet, PubMed/MEDLINE, Scopus, and Google Scholar) using the following search terms: musculoskeletal pain, chronic pain, mental health, psychological, coping, health disparities, contextual factors, conceptual models, psychosocial, Black, African American, pain, disability, and outcomes. We illustrate 3 relevant conceptual models – socioecological, cumulative stress, and biopsychosocial – related to contextual determinants and several psychological factors that influence CMP outcomes among Black individuals: (1) disproportionate burden of mental health and psychiatric diagnoses, (2) distinct coping strategies, (3) pain-related perceived injustice and perceived racial/ethnic discrimination, and (4) preferences and expectations related to seeking and receiving pain care. The detailed clinical and research implications could serve as a blueprint for the providers and clinical researchers to address health disparities and improve care for Black individuals with CMP.

Chronic musculoskeletal pain (CMP) affects up to 50% of the adult population and is associated with high health care utilization (eg, primary care visits, surgeries) and adverse health and economic outcomes (eg, opioid misuse, emotional distress, missed work).⁹⁰ Mounting research suggests that Black individuals are disproportionally affected by CMP and experience worse CMP-related outcomes than Non-Hispanic White (NHW) individuals.^10,34 Black individuals with CMP experience greater pain intensity, pain interference, pain-related opioid and other substance use, higher rates of co-morbid psychiatric disorders like depression and post-traumatic stress disorder (PTSD), and lower quality of life, compared to NHW individuals.^{57,63,121,133} These findings are largely the result of predisposing factors such as limited access to health care and economic and social disadvantages due to systemic racial inequality.¹³⁹

While Black communities are disproportionally affected by CMP, psychosocial treatment development and testing has focused almost exclusively on NHW populations.^1,51 Most randomized controlled trials of Cognitive Behavioral Therapy and Acceptance and Commitment Therapy (ACT) –highly efficacious treatments for CMP – have been conducted in predominantly White European countries and typically only include a small percentage of Black individuals.^66,140,159 As such, CBT/ACT and other treatments carrying the label of “empirically supported” for CMP beg the question, “empirically-supported, for whom?” Psychosocial interventions for Black individuals with CMP must explore and address lived experiences, cultural beliefs, chronic stressors, and how these factors influence pain-related outcomes.⁵³

A systematic review showed that, compared to NHW individuals, Black individuals more often used prayer to cope, endorsed higher levels of pain catastrophizing (ie, negative thinking about pain and its consequences),¹²⁷ and reported lower perceived control over their pain.^{35,106,117,134} These findings highlight potential individual differences across ethno-racial groups, but effective strategies for managing CMP among Black individuals must acknowledge the interaction between individual and contextual factors (eg, how perceptions of injustice and discrimination influence the pain experience).³¹ No review to date has considered how broader socio-cultural and structural factors (ie, economic, social, policy, and organizational environments that “structure” a person’s context) – henceforth referred to as contextual determinants – contribute to pain-related psychological phenomena among Black individuals with CMP. Further, no review has focused on the associations between these pain-related psychological factors and CMP outcomes (eg, pain interference, physical/emotional functioning) among Black individuals.

To address this gap, we conducted a narrative review of the extant literature on psychological predictors of CMP outcomes and relevant contextual determinants among Black individuals. We selected the narrative review method given the paucity of studies in this area. We tried to locate and synthesize past publications and present knowledge gaps. We focus on Black individuals because, in addition to carrying a disproportionate burden of CMP related outcomes, historically this group is more impacted by contextual determinants of health outcomes (eg, racial discrimination, socio-economic disadvantages), compared to other ethno-racial groups in the United States.⁵² In this review, we: (1) report the major conceptual models mentioned in prior work explaining the link between contextual determinants and psychological responses to pain among Black individuals with CMP; and (2) describe psychological factors related to CMP outcomes in this population that are highlighted in the literature. We conclude with clinical implications and recommendations for future research.

Method

We employed a narrative review method consisting of 4 steps: article identification/collection, article selection, article abstraction, and review/synthesis.⁵⁴ We searched 4 databases from inception to August 2021 (APA PsycNet, PubMed/MEDLINE, Scopus, and Google Scholar). We limited our search to peer-reviewed publications in English. We used the following search terms in combination with Boolean search modifiers (AND, NOT and OR): musculoskeletal pain, chronic pain, mental health, psychological, coping, health disparities, contextual factors, conceptual models, psychosocial, Black, African American, pain, disability, and outcomes. Consistent with our study objectives, we selected only publications that specifically addressed pain-related psychological factors or relevant conceptual models involved in CMP outcomes, psychosocial adjustment to CMP, and long-term outcomes for Black individuals with CMP. We selected studies that were based on US population samples. Among the samples that were not all Black, we included studies with a sample of at least 25% Black participants. To provide greater perspective, we supplemented our findings with research from the broader literature on adjustment to chronic health conditions. Fig 1 offers a summary of key results from this review.

Figure 1.

The influence of psychosocial factors and contextual determinants on CMP outcomes among black individuals impacting pain outcomes and suggested underlying contextual factors. Note. Synthesis of psychological predictors of CMP outcomes among Black individuals, and their contextual determinants, according to the socio-ecological, cumulative stress and biopsychosocial models. Socio-ecological factors at the individual (eg, biological), relational (eg, social support), and societal level (socioeconomic disadvantage, systemic racism) increase cumulative stress and, together, increase risk for development of CMP. These socio-ecological factors also influence psychological responses to CMP, which, together with cumulative stress, increase risk of more negative CMP outcomes relative to non-Hispanic White individuals. Negative CMP outcomes add to cumulative stress, diminish coping capacity, and perpetuate pain-related disability. Social factors are depicted in yellow, pain-related psychological factors in orange, and individual (biological and psychological) factors in orange with a pattern fill of grey.

Results

Conceptual Models of Contextual Determinants of Psychological Factors

We identified the 3 following models as the most prominently highlighted conceptual frameworks involved in elucidating the role of contextual determinants and the development and maintenance of psychological vulnerability to pain and its related outcomes among Black individuals with CMP: 1) Socio-ecological model; 2) Cumulative stress model; and 3) Biopsychosocial model.

Socio-Ecological Model

The socio-ecological model posits that individual behaviors, perceptions, and attitudes toward chronic health conditions do not exist in a vacuum. Rather, there is an interplay between interpersonal, community, and societal contexts.^{64,89,101,116,132} Accordingly, individual perceptions of chronic pain (eg, catastrophizing pain outcomes) may stem from (1) pre-existing factors that play into chronic pain appraisal (eg, personality, gender, disabilities), (2) community contexts (eg, non-profit organizations, schools, and Black churches that facilitate local opinions about and access to healthcare) as well as societal contexts (eg, who delivers healthcare, local, state, and federal laws, regulations, policies on how healthcare ought to be delivered), and (3) the interdependent relations between the individual and their environment (eg, social support).^{115,135,144,146} For example, major lifetime discriminatory events on the societal level are associated with higher likelihood of back pain among Black individuals, and perceived day-to-day discrimination on the community level is strongly associated with reported back pain among Black women.⁵⁰ Similarly, non-White Emergency Department prescribers more frequently produced clinically significant pain reduction when compared to non-Hispanic White prescribers, despite prescribing the same amount and strength of pain medications.⁶⁹

The socio-ecological model provides a framework to describe the ways in which racism and oppression, at interpersonal or structural levels,⁸⁵ can drive psychological vulnerability to CMP among Black individuals at multiple interacting levels.¹¹⁵ Notably, structural racism may negatively impact health outcomes, including pain, among Black Americans.^13,59 Structural racism describes “a system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequality.”¹⁰ Examples of such systems include education, employment, earnings and benefits, credit, housing, media, criminal justice, and health care.¹³ For instance, it is well documented that the War on Drugs and tougher police enforcement policies in the 1970s and 1980s disproportionately targeted Black individuals for incarceration, despite similar prevalence of illicit drug use among White Americans.^2,17,72 Such policies likely contributed to stereotyping Black individuals as “drug addicts” and “criminals.”¹³ This may partially explain why medical providers are less likely to prescribe opioids to Black patients compared to White patients across the lifespan and pain conditions (for review, see Ghoshal et al., 2020).⁵⁹ Moreover, it is well documented that Black individuals, on average, have considerably less wealth compared to NHW individuals in the United States, with the average White-headed household owning nearly 6.5 times greater wealth compared to Black-headed households.³ This disparity has contributed to historical and ongoing discriminatory practices in the housing market, labor markets, and credit markets (for review, see Herring & Henderson, 2016).⁷¹ Such practices contribute to economic barriers to afford and access quality pain care among Black Americans.⁵⁹ Further, limited access to resources and safe housing may contribute to increased stress over time, which can negatively impact pain outcomes among Black individuals.^76,98

Cumulative Stress Model

This model describes the additive adverse impact of stressful conditions on psychological and physical health outcomes over time. The “weathering hypothesis” of the degradation of health over time discusses how Black individuals may experience early health problems as a result of the continual stress of being subject to racial discrimination and lifetime disadvantages (eg, adverse childhood experiences, poverty).¹⁴³ Black individuals who are exposed to these stressors are prone to decreased coping capacity and increased vulnerability for negative CMP outcomes.⁷³ These psychological vulnerability factors include mental health issues (eg, depression), the use of maladaptive coping styles (eg, activity avoidance), unrealistic beliefs and expectations (eg, pain catastrophizing), as well as poor health and social support seeking behaviors, which in turn, could lead to worse pain and related outcomes (eg, self-reported pain intensity, pain related disability, opioid misuse).⁴³ For example, lifetime exposure to discriminatory events has shown a positive dose-dependent association with chronic low back pain related disability and emotional distress, through injustice appraisals (ie, an appraisal reflecting the severity of pain-related loss, blame and unfairness) related to pain.¹⁶¹ Similarly, female Black patients with greater level of lifetime experiences of day-to-day discrimination and unfair treatment demonstrate worse pain outcomes through exacerbation of pain catastrophizing.¹⁵⁰ These examples demonstrate how exposure to contextual stressors such as racial discrimination and lifetime disadvantages across the life span increase psychological vulnerability for development and maintenance of CMP.¹⁰⁴ Alternatively, psychological resilience factors (eg, optimism), as the capacity to adjust to cumulative adverse events, promote adjustment to CMP among Black individuals.^68,151,156

Biopsychosocial Model

The biopsychosocial model is a holistic approach to evaluating “whole person” health through recognition of the dynamic interactions between biological (eg, sex, age, comorbidities), psychological (eg, mood, coping), and social (eg, history of discrimination, disadvantages) components of CMP.^19,21 According to this model, these components have a reciprocal and synergistic interplay which influences the experience of CMP and related outcomes (eg, disability).²³ The pain related degenerative processes or wear and tear on the musculoskeletal (MSK) system contributes to both physiological and psychosocial dysregulation (ie, allostatic overload), and contextual factors such as racial discrimination and social disadvantages can amplify these impacts (as moderators of these relationships).¹²⁸ Related to the current review, the cascade of CMP-related biological stressors, in synergy with social factors (eg, disadvantages and stigma) can impact psychological regulation capacity and adaptive coping strategies to pain among Black individuals. For example, chronic low back pain (biological factor), race, experiences of discrimination, and educational level (social factors), and pain coping capacity (psychological factor) have shown to have a three-way interplay, such that Black individuals with lower education show poorer coping and pain-related physical disability, compared to other racial groups.³⁵ Further, the impact of low literacy and poverty on pain catastrophizing, can in turn exert a negative impact on pain interference, pain severity, and disability.¹¹² These studies depict biopsychosocial interactive processes leading to psychological vulnerability for CMP-related disability and poor outcomes.

Psychological Factors Involved in Chronic MSK Pain Outcomes Among Black Individuals

Mental Health and Psychiatric Diagnoses

There is a robust bidirectional association between mental health and CMP outcomes among all populations.⁷⁵ Research demonstrates that depression, anxiety, and PTSD symptoms contribute to the development and maintenance of CMP and related disability.^{94–96,100,113} However, there is minimal research examining mental health and psychiatric diagnoses related to CMP among Black individuals. Existing work focuses on associations between depression and pain severity. Among Black individuals, data suggest depression increases risk for CMP among older women¹⁵ and following traumatic injury (eg, motor vehicle accident),¹⁶ In a sample comprised of 28% Black individuals, psychosocial distress predicted increased risk of first-onset temporomandibular disorders (causing chronic pain).⁵⁵ Another study with a smaller proportion of Black individuals reported depression as a significant predictor of future development of musculoskeletal pain.⁹⁷ While studies focused exclusively on Black individuals are lacking, it appears that depression is associated with increased risk of CMP among this population. Notably, research focused on the role of depression in CMP-related outcomes (eg, pain interference, disability) is lacking. It can be assumed however, that such an association exists given findings from predominantly NHW samples.^14,97,99 Because Black individuals often experience numerous sociocultural stressors, this association may be even more pronounced among this population (See Table 1).

Table 1.

Summary of Psychological Factors Involved in Chronic Musculoskeletal Pain Outcomes Among Black Individuals.

Theme	Definitions	Summary of Findings
Mental health and psychiatric diagnoses	Conditions that involve changes in behavior, thinking, and/or emotion that may induce distress or difficulty functioning in usual activities120	Within samples consisting of Black individuals, depression and psychosocial distress are significant predictors of development of CMP
Coping strategies more frequently reported by Black individuals	Coping is the conscious mobilization of thoughts and behaviors to manage external and internal stressors56	Black individuals with CMP commonly utilize praying and hoping, diverting attention, emotion-focused coping, and catastrophizing – all of which are generally related to worse pain outcomes (ie, greater pain severity, worse emotional functioning, greater pain-related disability) There is disagreement among scholars on labeling these strategies as “passive” coping strategies. Namely, some researchers now acknowledge that “passive” coping erroneously implies maladaptive coping without considering cultural context Importantly, Black individuals also engage in Africultural coping (eg, spiritual-centered coping) which is predictive of positive outcomes.
Pain-related perceived injustice and perceived Racial/Ethnic discrimination	Pain-related Perceived Injustice: Cognitive appraisal involving a sense of unfairness, external blame, exaggerated severity, and perceived irreparability of loss in relation to pain or injury Perceived Racial/Ethnic Discrimination: The perception of negative attitudes, judgments, or unfair and unfavorable treatment from others because of one’s racial/ethnic background	Compared to White and Hispanic individuals, Black individuals endorse greater pain-related perceived injustice. Within a sample of all Black individuals, pain-related perceived injustice predicted greater pain-related disability and depression severity Among Black individuals with CMP, perceived racial/ethnic discrimination contributes to greater pain frequency, greater clinical pain severity, and greater experimental pain sensitivity Mediation models suggest that pain-related perceived injustice may help explain the association between perceived racial/ethnic discrimination and pain-related outcomes (ie, disability and depression) Greater perceived racial/ethnic discrimination predicts greater pain-related perceived injustice, which in turn predicts greater disability and depressive severity
Preferences and expectations related to seeking and receiving pain care	Learned Stoicism: Repressing emotions or acting with indifference in response to pain Mistrust in Medical Providers: The belief that health care entities are acting against one’s best interest or well-being81	Black individuals with CMP may underreport pain in part due to culturally influenced desires to conceal the expression of pain/distress (eg, learned stoicism) and mistrust in the medical community stemming from historical and ongoing racism in the health care system This may also partially contribute to Black individuals’ undertreatment of pain

Coping Strategies More Frequently Reported by Black Individuals

Compared to NHW individuals, Black individuals with CMP tend to rely more on coping strategies traditionally identified as “passive” (ie, the process of indirectly reducing, avoiding, or circumventing the effects of a stressor) – praying and hoping,^{20,35,61,84,86} diverting attention,^35,84,86 emotion-focused coping,^4,61 and catastrophizing^39,61,84 – compared to “active” strategies (ie, the process of initiating action or increasing one’s efforts to directly alter the effects of a stressor).¹⁴⁵ While “active” coping is associated with improved pain outcomes such as less pain severity, better emotional functioning, and less functional impairment among individuals with chronic pain,^29,78,105 the so-called “passive” coping strategies are generally related to worse pain outcomes including greater pain severity, worse emotional functioning, and greater pain-related disability. Of important note, researchers have raised concerns that labeling these strategies “passive” (vs “active”), including prayer,^107,157 may erroneously imply maladaptive coping without considering context.^36,42,108

Indeed, it is likely that the “active/passive” categorization is less meaningful when applied to certain groups. Research has demonstrated that Black individuals utilize culture- and race-specific coping strategies that differ from other racial/ethnic groups.^22,109 For instance, Africultural coping – culture-specific practices used by Black individuals including cognitive/emotional debriefing, spiritual-centered coping, collective coping, and ritual-centered coping – predicts positive psychological outcomes (eg, quality of life).^22,154,155 Black individuals may also use different coping strategies for different stressors (eg, racial vs non-racial stressors such as marital stress), with strategies varying widely based on demographic, socioeconomic, and psychosocial factors within the Black community.²⁸ For instance, Brown and colleagues observed that Black young adults rely more on positive reframing, acceptance, and planning in response to general, non-racial stressors and utilize religion, emotional support, and instrumental support in response to racism-specific situations.³⁰ In the same study sample consisting of Black young adults, women were more likely than men to utilize religion in response to general, non-racial stressors; meanwhile, in response to racism-specific situations, men were more likely to use humor and substance use, while women relied more on religion, instrumental support, and emotional support.³⁰ Some scholars even posit that Black individuals have a more diverse set of coping strategies than other racial/ethnic groups due to handling multiple and more stressors over time, highlighting the need to consider contextual determinants when considering interventions.^28,58

To further illustrate, there is disagreement among scholars on whether praying is solely a “passive,” and thus maladaptive coping strategy.^107,157 Several studies examining prayer as a coping strategy for CMP have utilized the Coping Strategies Questionnaire (CSQ),^{35,61,78,86,129} which largely conceptualizes prayer as a passive strategy (eg, “I pray for the pain to stop”).^106,157 Findings indicate that prayer as captured by the CSQ is associated with worse CMP outcomes including greater functional impairment, pain severity, and pain-related disability.¹²⁹ However, other research has taken a more nuanced measurement approach by capturing active versus passive prayer. Meints and colleagues observed that pain-free individuals who engaged in active prayer (eg, “God, help me endure the pain”) during an experimental cold pressor task demonstrated greater pain tolerance compared to those who engaged in passive prayer (eg, “God, take the pain away”) and no prayer conditions.¹⁰⁷ Because Black individuals commonly engage in spiritual/religious-based pain coping,^26,104 active prayer may be a promising intervention target for this population.

Pain-Related Perceived Injustice and Perceived Racial/Ethnic Discrimination

The constructs of pain-related perceived injustice (ie, “perceived injustice” or “injustice appraisal”) and perceived racial/ethnic discrimination have received increasing attention over the past decade alongside mounting literature on discrimination’s negative health impacts. Perceived injustice is described as a cognitive appraisal reflecting a sense of unfairness, external attributions of blame, exaggerated severity, and perceived irreparability of loss consequent to pain or injury.^138,142,147 Perceptions of injustice are likely to arise when an individual experiences situations that violate just world beliefs (ie, the assumption that people get what they deserve and deserve what they get in life) and perceive undeserved suffering and loss that interfere with goals, as with chronic pain.^102,142 Among individuals with CMP, perceived injustice contributes to greater pain severity, disability, depressive symptoms, and attentional bias to painful stimuli^148,153 along with poorer working alliance with health care providers.¹⁴¹ Injustice perceptions may contribute to maladaptive CMP outcomes through a series of processes including cognitive (eg, excessive focus on loss and perceived irreparability consequent to pain, blame attributions), affective (eg, depression, anger), and physiological mechanisms (eg, impaired endogenous opioid system, sustained muscle reactivity).¹⁴²

Until recently, nearly all studies on pain-related perceived injustice have been conducted with largely White samples.¹⁶¹ Emerging research on CMP now reveals that Black individuals endorse greater pain-related perceptions of injustice than other racial/ethnic groups, including White and Hispanic people.^152,161 To our knowledge, no studies have examined the impact of perceived injustice among a sample of solely Black individuals with CMP. However, in one study examining a racially diverse sample (32% Black people) of individuals with chronic low back pain, perceived injustice predicted greater pain-related disability and depressive severity above and beyond demographic and pain-related covariates.¹⁵² Perceived injustice may be an important intervention target for this population.

Perceived racial/ethnic discrimination is defined as perceiving negative attitudes, judgments, or unfair and unfavorable treatment from others because of one’s racial/ethnic background.^11,161 A large body of work has underscored the deleterious impact of perceived racial/ethnic discrimination across a range of mental and physical health outcomes.⁹¹ These threat appraisals about the experience of discrimination have shown to have more impact than the actual experience of discrimination. Related to CMP, numerous studies suggest perceived racial/ethnic discrimination contributes to worse CMP outcomes among Black individuals including greater pain frequency,⁵⁰ clinical pain severity,¹⁵⁸ and experimental pain sensitivity.⁶² While the underlying mechanisms for these associations remain unclear,¹⁶¹ hypervigilance and maladaptive physiological changes induced by the chronic stress of discrimination may play a role by creating a vicious cycle of interoceptive sensitivity and pain catastrophizing.⁶² Though this explanation is plausible, some studies have observed no associations between perceived racial/ethnic discrimination and CMP outcomes (eg, pain severity, cortisol concentration) among Black individuals,⁷⁰ indicating that more work is needed.

Racial discrimination may also influence pain-related perceptions of injustice to worsen CMP outcomes. In a heterogeneous racial sample (31% Black individuals) of individuals with chronic low back pain, pain-related perceived injustice mediated the association between perceived racial/ethnic discrimination and pain-related outcomes (ie, disability and depression), such that greater perceived racial/ethnic discrimination significantly predicted greater pain-related injustice perceptions, which in turn predicted greater disability and depression.¹⁶¹ It may be that individuals who experience unfair treatment and hardship due to their race/ethnicity perceive their pain condition as being more unfair, which subsequently leads to a cascade of negative health consequences over time.¹⁶¹

Preferences and Expectations Related to Seeking and Receiving Pain Care

Learned stoicism (ie, repressing emotions or acting with indifference in response to pain)⁷⁷ may influence how Black individuals with CMP communicate about their pain with friends, family, and providers, thus influencing pain-related outcomes. Stoic individuals are described as being less expressive about their pain with a tendency to “grin and bear it.”⁴⁵ Stoicism in the face of pain is viewed positively by some in the Black community,¹⁰³ which may stem from the “transgenerational transmittal of social and health behaviors of slaves whose survival mechanisms included overlooking their pain.”²⁵ Thus, appearing less sensitive to pain and less willing to report pain may be perceived as a positive trait in this population.⁷⁴ In a recent study of older Black individuals with osteoarthritis pain, most participants chose to not to tell others they were in pain, which was fueled in part by learned stoicism.²⁵ Instead, participants tended to communicate their pain with others by using indirect statements (eg, “I don’t feel good”) or by responding to others’ inquiry with an “I’m fine” statement. Learned stoicism may also help explain why many Black individuals wait until their pain is severe or unbearable before communicating their concerns with medical providers,^8,9,26 setting the stage for worse pain-related outcomes.

Mistrust in medical providers may also influence expectations and treatment outcomes among Black individuals with CMP. Black individuals have experienced a long history of discrimination and unequal care from the medical community, including in research,^18,27 general health services,⁸⁰ and pain treatment.^7,149 Black individuals are nearly 3 times more likely than Whites to view racism as a major health care issue.⁹² Consequently, Black individuals experience high levels of stereotype threat in medical encounters³³ and may be less willing to report pain to medical providers, as they believe providers will discount or dismiss it.⁷⁴ Hiding pain from providers may be primarily due to transgressions of trust on behalf of the healthcare system rather than learned stoicism or other intrapersonal factors among Black individuals.

Mistrust in medical providers may contribute to consistently low rates of surgery for joint and knee replacement among racial/ethnic minorities.¹⁴⁹ Mistrust may also contribute to low expectations of benefit from these surgeries among Black individuals.^25,103 In a study of men (50% Black individuals) with osteoarthritis of the hip or knee, greater trust in physicians was a significant predictor of better expectations of joint replacement surgical outcomes,⁶⁵ and greater expectations can predict better CMP outcomes. In a mixed chronic pain sample including individuals with musculoskeletal pain (eg, spinal cord injury), those with high pain relief expectations reported significantly better outcomes (ie, changes in pain intensity, pain interference, and pain catastrophizing) at 6-month follow-up compared to those with lower pain relief expectations.^41,79 Taken together, multiple pain-related perceptions may interact to exacerbate negative emotions and physiological stress (eg, perceived injustice and discrimination), impede effective social support (eg, learned stoicism), and hinder medical care for CMP. However, given data showing that healthcare providers often deliver inferior pain care for Black individuals (if treatments are even accessible to this population at all)⁵⁹ systemic changes in physician behavior and pain treatment accessibility are a challenging but important targets.

Discussion

We identified 3 conceptual models – socioecological, cumulative stress, and biopsychosocial – that help provide insight into how contextual determinants impact psychological responses to pain at different levels of care among Black individuals with CMP. For instance, within the framework of the socio-ecological model, we described potential pathways through which structural racism may contribute to unequal pain care and worse pain outcomes for Black individuals. Although similar in overall perspective, these models have different focus on biological, behavioral, environmental, and temporal aspects of adaptation to chronic pain, with socioecological model being central to the impact of structural racism in CMP outcome of Black individuals at different levels.⁸³ We also identified several psychological factors that influence CMP outcomes among Black individuals: (1) disproportionate burden of mental health and psychiatric diagnoses, (2) distinct coping strategies (eg, praying and hoping, diverting attention, emotion-focused coping, and catastrophizing), (3) perceived pain-related injustice and racial/ethnic discrimination, and (4) preferences and expectations related to seeking and receiving pain care (eg, stoicism, mistrust).

Understanding the contextual as well as individual psychological factors that contribute to worse CMP related outcomes among Black individuals may help explain existing disparities. Findings point to clear disadvantages for Black communities^49,57,63 and a clear need for multilevel strategies to optimize pain-related treatment for this population. Of note, pain-related psychological factors have bidirectional and interrelated associations.^{32,47,60,110,152} This evidence highlights the importance of efforts aimed at addressing both psychological and contextual determinants in order to stop the vicious cycle of maladaptive attributions about CMP and poor CMP outcomes (see Fig 1). Below we describe the clinical and research implications relevant to the main findings from our narrative review.

Clinical Implications

First, it is important that intervention programs consider the specific psychological and contextual factors involved at various levels in the development and maintenance of CMP and related outcomes. A culturally responsive holistic model which focuses on caring for the whole individual across different levels of contextual influence could optimize the care and improve satisfaction of Black individuals with CMP.⁴⁸ A small but growing literature suggests that multilevel culturally tailored programs for Black individuals with CMP may be feasible and efficacious.^{5,40,46,82,131} There is limited focus in the extant literature about treatments that leverage culture-specific resilience factors for racial/ethnic minorities. As described earlier, studies have found that Africultural coping (eg, spiritual-centered coping) is predictive of positive psychological outcomes.^154,155 It may be worthwhile to consider integrating such Africultural coping into culturally tailored programs for Black individuals with CMP.^137,136 Further, personalized therapy approaches, in which treatment modalities are tailored to each individual’s needs and lived experience (eg, anxiety symptoms, experiences of discrimination and injustice) may boost intervention acceptability, satisfaction, and potentially efficacy among Black individuals with CMP.¹²⁵

To this end, clinicians can assess CMP multi-dimensionally with consideration of biopsychosocial (eg, family history, perceived stress, coping) and system level factors (eg, racial discrimination) as well as the cumulative impact of trauma (eg, race-related, childhood adversity).⁴⁸ The multilevel intervention components could address individual (eg, psychological coping, health literacy), relationship (eg, social support networks), and community factors (eg, healthy environmental practices). Tailoring interventions to this population could help address key cultural factors such as spirituality, cultural values of control and positivity, and community engagement, and be applicable to a variety of clinical settings.¹³⁷ Importantly, clinicians should always be in check of their own racial biases and try to improve their ability to interact with Black individuals with CMP. Clinicians can also advocate for addressing structural barriers embedded in clinical settings (institutional racism), and community/society (discriminatory social policies) that could improve the care of these individuals.

Second, providers should assess for depressive and anxiety symptoms and refer patients to higher levels of care if needed. A streamlined intuitional screening and referral systems where providers can simultaneously assess childhood adversities and other contextual moderators of the impact of emotional distress could improve the quality of these referrals. Other facilitators of such approach include engagement of patient support system (eg, partner) and advocating for addressing barriers to access at community/society level that could aid with such approach (safe and clean housing, insurance, community mental health resources).

Third, greater attention to improving patients’ self-efficacy and sense of control over pain is needed. This may be achieved by focusing on how providers foster trust with the patient. Given the failings of the health care system in its treatment of Black patients, providers must intentionally work toward developing patient rapport and collaboration with Black individuals. This can be achieved by training providers in cultural humility, empathic engagement, active listening, and culturally sensitive communication to deliver comprehensive care. With enhanced trust and communication with the provider, patients may feel more at ease about their pain condition and have a better understanding about treatments available, which may lead to improved pain outcomes. Providers should also assess the experience of pain among Black individuals clearly/directly using specific questions (eg, about specific quality, sites, or frequency of pain). Through this approach, providers may collect a more accurate and thorough pain assessment leading to better informed treatment of Black patients.¹²⁶ In addition to providers working to strengthen patient-provider relations, patients may benefit from acceptance and commitment therapy techniques⁴⁴ (delivered by a culturally competent therapist) to encourage value-based goal setting and action-planning leading to empowerment and reduced negative reactivity to pain. Further, provision of incentives for appropriate referrals, establishing a diverse workforce and an institutional culture that is open to diversity can also improve the quality of such care.

Fourth, maladaptive coping styles such as catastrophizing and stress over-reactivity can be reduced through a variety of interventions teaching adaptive coping skills. Mind-body interventions are suitable methods for addressing such issues.¹⁶⁰ The focus of these interventions on biopsychosocial resilience factors involved in MSK health such as distress tolerance is consistent with the affinity of Black individuals with CMP for positive psychology-based interventions.¹³⁶ Simultaneously, the providers in tandem with organization should advocate for educational and media campaigns targeting patient, family, and community health literacy regarding cultural barriers for CMP care such as learned stoicism, and mistrust. Given the poor pain expectations among Black individuals with CMP and their families, education-oriented or acceptance-based interventions could help with improving such expectations as has been demonstrated in other communities.¹¹⁴ However, reducing structural discrimination through policy change is the ultimate cure to the built mistrust and resultant poor expectations among Black individuals with CMP.

Fifth, to address perceived pain-related injustice and racial/ethnic discrimination, interventions may target coping skills related to the violations of just-world beliefs. Importantly, patients must not be held responsible for managing the consequences of social injustices that are perpetuated upon them. Before considering patient-level interventions, providers must first take an active role in advancing social justice. This includes educating oneself about racial inequality, intervening when one witnesses unfair treatment of vulnerable groups, and examining how one’s own beliefs and values may contribute to inequity and harm of minorities. At the patient-level, acceptance- and mindfulness-based interventions are potentially effective treatments for Black individuals whose CMP is impacted by perceptions of injustice and discrimination.^122,123 Building on awareness of discrimination and injustice, providers can collaboratively help patients distinguish between the adaptive (eg, valued action) and maladaptive (eg, rumination) effects of perceived pain-related injustice and racial/ethnic discrimination on CMP related outcomes through a comprehensive assessment of socio-environmental factors.^24,87,118

Involving persons from the patient social network in these discussions helps with normalizing and reducing the subjective impacts of perceived racial/ethnic discrimination and injustice, while at the same time validating these feelings. A comprehensive assessment of “cumulative” lifetime experiences of racial discrimination (eg, living in high crime low resource neighborhoods), in collaboration with the patient, could help with identifications of perceived versus actual stress. Importantly, applying these interventions should not absolve clinicians from advocating for system-level change that would address the underlying issues of racism that contributes to the injustice and discrimination experienced by individuals. These include institutional strategic initiatives to address structural inequities in healthcare system, and societal/policy changes aimed at eliminating systems of oppression and racisms and improving the social capital and collective efficacy of Black individuals.

Finally, an effective model of multilevel strategies to address CMP among Black individuals is meeting patients where they are in the community, such as Black churches, barbershops, and beauty salons. Given the pre-existing social networks in these places, this approach could help overcome barriers to access and delivery for Black individuals who may feel alienated from the predominant models of healthcare.^111,119 Specifically, provision of multilevel interventions addressing individual, relationship, and sociocultural factors by Black community providers/peer coaches who share common cultural values could improve the success of such interventions.^37,38,67 Using a holistic care approach, Black community providers/peer coaches can facilitate the implementation of evidence-based interventions by helping the individual navigate their social and financial needs, providing support/resource seeking, circumventing language and health literacy barriers, and liaising between the patient and his/her specialty providers.

Research Implications

Despite the gradual increase in research focused on the interplay of contextual (eg, structural racism) and psychological factors in predicting the CMP outcomes among Black individuals, there are still considerable gaps in the field, exploring different elements of this issue. We recommend the following avenues for future investigations in this area. Given the nascence of CMP intervention research among Black individuals, feasibility and efficacy trials examining culturally tailored multilevel interventions across different Black samples, settings, and geographical locations, with considerations for patient and non-patient factors are needed. This research should also examine strategies for provision of personalized services for Black individuals with CMP. That includes the following: 1) holistic treatments targeting bio-psycho-social factors involved in CMP among Black individuals through a multilevel approach (patient, relationship, community, and societal levels), 2) addressing the CMP related misconceptions specific to Black individuals while reducing the contextual barriers to care, and 3) leveraging the social networks provided by community-based organizations (eg, black churches, beauty salons) and Black community providers/peer coaches to optimize the effectiveness of the interventions.^48,124,130

Most of research on interplay of mental health issues and CMP among Black individuals has been focused on depression. Future research needs to elucidate the role of anxiety and PTSD symptoms in predicting CMP outcome among Black individuals.⁶ This research should also examine the moderating role of other contextual nonpatient factors (eg, family factors, health systems, social support, and other mental health resources) for the impact of emotional distress on CMP outcome among Black individuals. Future work also needs to elucidate the role of transdiagnostic factors other than catastrophizing or pain anxiety (eg, intolerance of uncertainty, mindfulness) in CMP outcome among Black individuals.⁸⁸ Importantly, research should investigate the role of cumulative stress factors (eg, childhood adversity, everyday experience of racial and structural discrimination) in development and maintenance of such transdiagnostic vulnerabilities. These factors could be potential targets for personalized treatments addressing CMP and related outcomes. A more in-depth investigation on adaptive and maladaptive functions of perception/awareness of discrimination as underlying processes of CMP, and the role of support networks, health care systems and policy makers in validation and advocacy for eliminating structural discrimination, is also needed.⁸⁷

Given the substantial role of structural barriers to care (eg, financial, access) in Black communities, the multilevel intervention development research should focus on brief, accessible methods of intervention delivery (eg, web-based interventions).⁶⁶ Further, community-based participatory research through partnership with community organizations that deliver services to Black individuals in trusted spaces can help with improving the sustainable dissemination of such multilevel interventions among Black individuals with CMP (see clinical implications for details).^12,119 For example, Black churches are good point of first contact with Black individuals with CMP, who may gravitate toward spirituality/religion, in part, to cope with pain.¹² Given the competing interests black churches maybe dealing with (eg, other non-health related community-based services), black barbershops and beauty salons as safe spaces for cultural presentations of communalism and expressiveness are alternative candidate venues for such research.⁹³ Further, conducting ethnographic/formative evaluations through focus groups/qualitative interviews among all stakeholders in these venues can help identify structural barriers and facilitators at each level of CMP care and optimize the compatibility and sustainability of such programs. Using designs (eg, quasiexperimental, multiphase optimization), and analytical methods (eg, multilevel modeling) that are well-suited for multilevel interventions helps with elucidating the effective components of these strategies.

Limitations

This narrative review has several limitations. First, although we discussed resilience factors helping with adaptive coping to CMP, these factors were not the central focus of this narrative review. Future work needs to compressively examine the positive psychology/resilience factors involved in adjustment to CMP among Black individuals. Second, most of the selected studies used cross-sectional designs. Future longitudinal studies are needed to explore the dynamic coping, mood, and CMP processes in Black individuals. Third, given the observed heterogeneity of measurement methods across studies assessing similar constructs, applying unified assessment strategies can help optimize the interpretation of the observed differences across the studies. Fourth, most of the psychological assessments used self-report measures. Future research can also benefit from an objective quantitative and qualitative assessment of the psychological characteristics of Black individuals with CMP. Fifth, given the dearth of data on the psychometric properties of the self-report assessments for Black individuals with CMP, researchers should evaluate the validity of each measure for the study sample. Sixth, future work should examine the observed differences in unexplored CMP conditions such as chronic pelvic pain and chronic whiplash-associated disorders. Finally, future systematic/meta-analytic reviews are needed to examine the effect size estimates of the interplay of contextual and psychological factors in predicting CMP outcomes among Black individuals.

Conclusions

This narrative review underscores the importance of considering psychological factors and contextual determinants for Black individuals coping with CMP. The detailed clinical implications could serve as a blueprint for the providers to improve care and pain-related outcomes for Black individuals with CMP. Research implications could inform translational and clinical research aimed to address health disparities within CMP. Educational programs can enhance providers’ understanding of race-based individual differences in CMP outcome, within a larger call to address societal forces like racism that perpetuate these disparities.

Perspective:

This narrative review illustrates conceptual models explaining the link between contextual determinants and psychological responses to pain among Black individuals with chronic musculoskeletal pain. We discuss 3 relevant conceptual models – socioecological, cumulative stress, biopsychosocial –, and 4 psychological factors: disproportionate burden of mental health, distinct coping strategies, perceived injustice/discrimination, preferences/expectations.