Medical providers treat a wide variety of pathologies in all settings. In the United States alone it is reported that 116 million people have and seek medical attention for chronic pain each year [9]. It is therefore imperative for physical therapists to understand the history of onset of the patient’s pain in order to adequately address these impairments. Previous research demonstrates that childhood trauma can produce increased vulnerabilities for psychopathology, including pain conditions, via the change in neurohormonal regulation of the hypothalamic-pituitary-adrenal axis that occurs following the trauma [4]. Regardless of the nature of the trauma endured, the experience has the potential to alter the body in a way that can predispose an individual to chronic pain conditions later in life. The purpose of this systematic review is to examine the prevalence of chronic pain in those who have a history of trauma and how this history alters treatment of chronic pain.

This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases CINAHL, SPORTSdiscus, PubMed, and Ebscohost were searched independently by one of four primary investigators. The terms “childhood trauma”, “sexual abuse”, “domestic violence”, “physical abuse”, “post traumatic stress disorder”, or “trauma”, with “chronic pain”, “fibromyalgia”, or “pelvic floor dysfunction” were used to search all electronic databases.  Eligible studies in this systematic review included human subjects with chronic pain conditions and a reported experience of trauma. Due to the variety of study results obtained, all studies were eligible for inclusion with the exception of scoping reviews, systematic reviews, meta-analyses. Studies were excluded if patients’ age was less than 18 years, if the full text was not published in English, and if they had been published longer than ten years ago. The studies included in this review were analyzed by 4 independent reviewers, using the Joanna Briggs Institute (JBI) critical appraisal tool. The JBI is based on criteria representing methodological quality and risk of bias (depending on study design). The higher the score on the JBI, the higher the quality of the study design.

The database search returned a total of 2,004 articles after duplicates were removed. After the title and abstract screening was conducted, 166 articles were selected for full-text review. Following the full review process, a total of 12 studies met the criteria for the review and were included in this study [5,6,7,10,12,13,14,15]. The 12 studies in this systematic review included a total of 564,311 participants. Two studies examined history of military sexual trauma (MST) [7,15], five studies examined history of sexual abuse/assault [6,7,8,15,17], one examined history of emotional abuse/neglect [8], two examined other types of physical abuse/trauma [8,12], five examined history of PTSD [10,12,15,17,18], five examined childhood adversities/traumatic experiences [5,12,13,15,17], and one examined history of torture [19]. Many articles looked at more than one type of trauma, which included sexual, emotional, and physical traumas. The majority (83%) of studies either included history of sexual trauma (41%) of some type and/or childhood trauma/adversities (41%). Inclusion and exclusion criteria also varied greatly across the studies, with an age restriction of >18 years old being uniform across all 12. The characteristics of the 12 studies are shown in TABLE 1. The absolute degree of rater agreement for both stages of study selection was 100%. The JBI critical appraisal scores for the studies included in this review ranged from 5 to 8 (out of a maximum score of 8), with a median score of 7. 4 (33%). It was found across the majority of studies that there is a strong correlation between chronic pain and trauma. Results of some studies showed that treatment of both the physical and the psychological aspects of chronic pain helped alleviate pain quicker and saw a decrease in mental health symptoms such as PTSD, depression, and anxiety [14,18,19]. The JBI critical appraisal scores for the studies included in this review ranged from 5 to 8 (out of a maximum score of 8), with a median score of 7.

Through the systematic study it was discovered that no matter the trauma: sexual, physical, psychological, or torture, the likelihood of patients later developing chronic pain was significantly higher then those without a traumatic history [5,8,12,14,16,17]. when determining trauma as a risk factor for chronic conditions, it is more relevant to examine the number of traumatic experiences rather than the type of trauma itself.15 Many studies talked on the importance of providers being able to recognize the signs and symptoms of someone with PTSD, anxiety, or depression in order to better tailor treatment. Understanding the signs and symptoms is important in trying to open the dialogue to allow that patient to speak and seek other treatment that might also help improve medical prognosis [18,19].  Regardless of the mechanism of the chronic pain condition, being able to identify its presence is of utmost importance when treating any patient population.

This systematic review found that exposure to physical, psychological, sexual, childhood, or emotional trauma significantly increases the likelihood of developing chronic pain. Thus, it is imperative that providers are able to screen for, identify, and provide appropriate trauma-informed care in their interactions with patients who have chronic pain, fibromyalgia, and/or pelvic floor dysfunctions. When screening patients with the above diagnosis, it is important to take into consideration the biological, social (culture, socioeconomic, and socio-environmental), and physiological factors as they all contribute to the overall health of the patient and disease presentation. With these results in mind, it is important that as a medical profession, we understand that patients need to be observed as a whole person, not just the area in which they report pain or dysfunction. It is already well understood that pain has a large component rooted in psychological principles and that this psychological component, although recognized, is not yet fully understood. By gaining a better understanding of the mental and emotional status of patients, health professionals can better their treatment and provide more comprehensive care.