Prevalence of dysautonomia in chronic musculoskeletal pain: a cross-sectional study

Background: There is substantial evidence that the autonomic nervous system plays a crucial role in pain modulation and chronicity, but the actual prevalence of dysautonomia in musculoskeletal conditions remains unknown. This study investigated the prevalence of dysautonomia in patients with Chronic Musculoskeletal Pain (CMP) compared to healthy controls, quantified the dysautonomia burden in inflammatory and non-inflammatory musculoskeletal conditions, and evaluated the associations between pain severity, psychological factors, and dysautonomia severity. Methods: This cross-sectional study recruited patients with CMP between October 2024 and July 2025 along with healthy participants with similar age-sex distribution. Inclusion criteria were a clinician-confirmed musculoskeletal condition and pain duration >12 weeks. Assessments included the Composite Autonomic Symptom Score-31, the Brief Pain Inventory, and the Hospital Anxiety and Depression Scale. A COMPASS-31 score of 17 or higher was considered indicative of dysautonomia. Results: Of 896 patients screened, 342 participated, along with 57 healthy controls. Dysautonomia was significantly more prevalent in CMP patients (74%) compared to controls (11%) (adjusted RR = 7.4, 95% CI 1.8-13.1, p=0.010). Dysautonomia rates were similarly high in inflammatory (76%) and non-inflammatory (72%) conditions. Risk of dysautonomia increased with pain severity (RR 1.27 per point on BPI, 95% CI 1.08-1.45, p<0.001), depression (RR 1.12 per HADS depression score, 95% CI 1.06-1.19, p<0.001), and anxiety (RR 1.15 per HADS anxiety score, 95% CI 1.08-1.22, p<0.001), adjusting for age and gender. Conclusion: Dysautonomia is highly prevalent among patients with CMP irrespective of inflammatory status and is associated with pain severity, depression and anxiety. CMP patients should be assessed for dysautonomia as a potential contributor to symptom burden.