Stress-related musculoskeletal pain.

While stress is often considered by patients and clinicians alike as an important factor in the onset and maintenance of widespread musculoskeletal pain, the relationship is more complex than appears on initial consideration. The types of event that lead to stress need description, and the role of traumatic events are particularly important because of the shared association with post-traumatic stress disorder. The substantial overlap with psychiatric disorders and the role of stress in their aetiology must be assessed in patients. The lack of specificity of the symptoms of the different disorders used to describe widespread musculoskeletal pain may be explained by their shared aetiology, including neural sensitization and alterations of the hypothalamic-pituitary-adrenal (HPA) axis due to stress. Fear avoidance is a central stress-related perceptual characteristic and behavioural dimension in these disorders. Treatment depends on thorough assessment, including psychiatric diagnosis, avoiding simplistic attributions and implementing evidence-based treatments that are well documented.