Psychosocial factors associated with pain in spinal cord injury: a systematic review and meta-analysis

Background: Spinal cord injury (SCI) affects over 20 million people worldwide, and pain is the most prevalent secondary condition with substantial psychosocial consequences. However, evidence on these consequences remains fragmented, limiting theoretical and practical integration. The aim of this study was to synthesise evidence on associations between pain intensity and psychosocial outcomes in adults with chronic SCI. Methods: CINAHL, Embase, PubMed, and Web of Science were searched from inception to 8 March 2026. Peer-reviewed studies were included if they reported associations between pain intensity and psychosocial factors in adults with chronic SCI (≥1 year post-injury). Screening and data extraction were conducted in duplicate in accordance with systematic review and meta-analysis guidelines. Random-effects models were used for all meta-analyses. Correlations were synthesised using Fisher's z transformation, and meta-regressions examined potential moderators. The review protocol was registered in PROSPERO (CRD42021276170). Findings: 78 studies (n = 19,785 participants) were included. Most were cross-sectional, with sample sizes ranging from nine to nearly 5000 participants. Study quality was predominantly moderate, with seven high-quality and six low-quality reports. Moderate positive correlations were found between pain and depression (r 0.34, 95% CI 0.30 to 0.38), anxiety (0.34, 95% CI 0.28 to 0.40), catastrophising (0.37, 95% CI 0.29 to 0.44), anger (0.34, 95% CI 0.17 to 0.49), and fatigue (0.43, 95% CI 0.31 to 0.53). Moderate negative correlations were observed with psychological health (−0.30, 95% CI −0.36 to −0.24), self-efficacy (−0.29, 95% CI −0.38 to −0.20), acceptance (−0.27, 95% CI −0.38 to −0.16), resilience (−0.27, 95% CI −0.29 to −0.24), social functioning (−0.28, 95% CI −0.34 to −0.22), and quality of life/life satisfaction (−0.29, 95% CI −0.36 to −0.22). Meta-regression analyses showed limited and inconsistent moderation, with most tested moderators not significantly influencing associations. Sensitivity analyses supported the robustness of findings. Interpretation: This review provides a comprehensive synthesis of psychosocial correlates of SCI-related pain. Despite limitations related to cross-sectional designs and heterogeneity in measures, findings highlight the importance of integrating psychosocial processes into SCI pain management and support the development of more tailored interventions. Funding: Craig H. Neilsen Foundation, Rebecca L. Cooper Medical Research Foundation, and NSW Health.