Are Levels of Loneliness Associated With Levels of Comfort and Capability in Musculoskeletal Illness?
Authors: Ponce Haley , Cordero Rafael , Ring David , Sayegh George , Azarpey Ali , Jayakumar Prakash 
Published: November 2024

Background
Variation in levels of pain intensity and incapability among patients with musculoskeletal conditions is associated with measures of mindset (unhelpful thoughts [such as hurt equals harm] and feelings of distress [overwhelm, rumination] regarding bodily sensations) and circumstances (social health as well as security in finances, roles, home, and support) as much or more so than pathophysiology severity. Loneliness is an important aspect of social health, it is associated with worse mental health, and it has been identified as worthy of attention and intervention by health authorities in several countries. It is estimated that up to one-third of adults older than 45 years of age experience loneliness. Given that a large percentage of people seeking musculoskeletal specialty care are older than 45 years, identification of notable levels of loneliness and an association with greater levels of pain intensity and incapability would support screening and treatment of feelings of loneliness as part of comprehensive, whole-person, musculoskeletal care strategies.

Questions/purposes
In a cross-sectional study of people seeking musculoskeletal specialty care for upper and lower extremity conditions, we asked: (1) Are there factors associated with levels of capability including greater feelings of loneliness? (2) Are there factors associated with levels of pain intensity including greater feelings of loneliness?

Methods
We recruited 146 new and returning, English-speaking, adult patients without cognitive deficiencies seeking care in metropolitan musculoskeletal specialty offices. Three patients were excluded because they did not complete the measures of pain intensity and incapability, and 143 were analyzed, including 57% (82) women with a mean age ± SD of 56 ± 17 years and 71% (102) with an upper extremity condition. Participants completed validated measures of feelings of loneliness (University of California, Los Angeles [UCLA] Loneliness Scale), thoughts and feelings regarding sensations (three items each validated in a factor analysis of commonly used measures), and levels of incapability (PROMIS Physical Function computer adaptive test), and pain intensity (pain intensity on an 11-point ordinal scale between 0 [no pain] and 10 [the most intense possible pain]). In the multivariable analysis, we measured the relationship between levels of incapability and pain intensity and feelings of loneliness, accounting for demographic factors and thoughts and feelings regarding sensations.

Results
Accounting for potential confounding variables such as income level and insurance status, we found that lower levels of capability were moderately associated with greater feelings of distress regarding symptoms (such as rumination or a sense of overwhelm; regression coefficient [RC] -0.99 [95% confidence interval (CI) CI -1.5 to - 0.51]; p < 0.001) and that higher levels of capability were more modestly associated with having an upper rather than lower extremity condition (RC 4.4 [95% CI 1.5 to 7.3]; p = 0.003) and an income between USD 46,000 and USD 75,000 (RC 6.7 [95% CI 1.4 to 12]; p = 0.01) compared with an income less than USD 24,000 a year. Levels of capability were not associated with levels of loneliness (RC = -0.15 [95% CI -0.38 to 0.086]; p = 0.22), even though the mean level of loneliness was 54, representing moderate to high levels of loneliness. Higher levels of pain intensity were moderately associated with greater feelings of distress regarding symptoms (RC 0.35 [95% CI 0.22 to 0.47]; p < 0.001) and also modestly associated with greater level of unhelpful thoughts about symptoms (such as pain equating to injury) (RC 0.19 [95% CI 0.036 to 0.34]; p = 0.002), having a 4-year college degree (RC -1.4 [95% CI -2.4 to -0.26]; p = 0.02), and having a postcollege graduate degree (RC -1.35 [95% CI -2.4 to -0.26]; p = 0.02) compared with high school or less education but not with higher levels of loneliness.

Conclusion
The observation that levels of musculoskeletal incapability and pain intensity have limited association with loneliness reinforces the evidence that other cognitive and emotional factors are the key modifiable personal factors in musculoskeletal illness. Our findings do not discount the importance of addressing loneliness in musculoskeletal care, but efforts to tackle loneliness alone may be less effective than efforts to focus on loneliness in addition to thoughts and feelings regarding bodily sensations.

Level of Evidence
Level II, prognostic study.