To what degree do shoulder outcome instruments reflect patients' psychologic distress?

Patient-reported outcomes measurement information system depression psychometrically underperforms compared to legacy measures and is poorly associated with postoperative functional outcomes in shoulder arthroplasty patients

Background

The purpose of this study was to investigate the associations between each mental health patient-reported outcome measure with postoperative functional outcomes following shoulder arthroplasty, and to compare psychometric properties of patient-reported outcomes measurement information system depression to the legacy (VR-12 Mental) patient-reported outcome measure.

Methods

Patients who underwent primary shoulder arthroplasty from July 2018 to February 2019 were retrospectively reviewed. Patient-reported outcomes measurement information system depression and VR-12 Mental were administered preoperatively; American Shoulder and Elbow Surgeons and Single Assessment Numeric Evaluation were administered at 6-month and 1-year postoperatively. Rasch partial credit modeling analysis was used to compare psychometric properties of legacy versus patient-reported outcomes measurement information system instruments in assessing mental health.

Results

Ninety-three patients who underwent total shoulder arthroplasty (n = 52), reverse total shoulder arthroplasty (n = 39), or hemiarthroplasty (n = 2) were included. Preoperative VR-12 Mental scores were moderately associated with American Shoulder and Elbow Surgeons at 6-months (coefficient: 0.52, P = 0.026) and 1-year (coefficient: 0.65, P = 0.002), while preoperative patient-reported outcomes measurement information system depression scores were not. Patient-reported outcomes measurement information system depression demonstrated significant floor effects (16%); VR-12 Mental demonstrated minimal floor and ceiling effects (1.1% for both). VR-12 Mental demonstrated broader coverage of mental outlook on Rasch modeling than patient-reported outcomes measurement information system depression and had adequate model fit after one round of reiterative item elimination.

Discussion

Patient-reported outcomes measurement information system depression was poorly associated with postoperative American Shoulder and Elbow Surgeons scores, demonstrated significant floor effects, and had limited coverage of mental health on Rasch modeling with reiterative elimination.

Level of Evidence

IV.

The impact of psychological distress on quality of care and access to mental health services in cancer survivors

Introduction

Psychological distress is highly prevalent among cancer survivors and significantly impacts their health outcomes. Our study aim is to examine the impact of psychological distress on the quality of care in cancer survivors.

Methods

We utilized longitudinal panels from the Medical Expenditure Panel Survey data spanning from 2016 to 2019 to estimate the impact of psychological distress on quality of care. We compared a sample of cancer survivors with psychological distress (N = 176) to a matched sample of cancer survivors without psychological distress (N = 2,814). We employed multivariable logistic regression models and Poisson regression models. In all models, we adjusted for age at the survey, sex, race/ethnicity, education, income, insurance, exercise, chronic conditions, body mass index, and smoking status. Descriptive statistics and regression models were performed using STATA software.

Results

Our findings revealed a higher prevalence of psychological distress among younger survivors, females, individuals with lower incomes, and those with public insurance. Cancer survivors with psychological distress reported more adverse patient experiences compared to those without distress. Specifically, survivors with distress had lower odds of receiving clear explanations of their care (OR: 0.40; 95% CI: 0.17-0.99) and lower odds of feeling respected in expressing their concerns (OR: 0.42; 95% CI: 0.18-0.99) by their healthcare providers. Furthermore, psychological distress was associated with increased healthcare utilization, as evidenced by a higher number of visits (p = 0.02). It also correlated with a decrease in healthcare service ratings (p = 0.01) and the affordability of mental health services (p < 0.01) for cancer survivors.

Discussion

These findings indicate that psychological distress can significantly impact the delivery of healthcare and the patient experience among cancer survivors. Our study underscores the importance of recognizing and addressing the mental health needs of cancer survivors. It provides insights for healthcare professionals and policymakers to better understand and cater to the mental health needs of this population.

Should we separately measure the pain parameter of the Constant-Murley score in patients with chronic shoulder pain?

BACKGROUND

The Constant-Murley Score (CMS) is a relatively unique shoulder assessment tool because it combines patient-reported outcomes (pain and activity), performance measurement and clinician-reported outcomes (strength and mobility). With these characteristics, the effect of patient-related psychological factors on the CMS remains debated. We aimed to investigate which parameters of the CMS are influenced by psychological factors by assessing the CMS before and after rehabilitation for chronic shoulder pain.

METHODS

This retrospective study screened all patients (18-65 years old) who were admitted for interdisciplinary rehabilitation for chronic shoulder pain (≥ 3 months) between May 2012 and December 2017. Patients with unilateral shoulder injuries were eligible. Exclusion criteria were shoulder instability, concomitant neurological injuries, complex regional pain syndrome (including Steinbrocker syndrome), heavy psychiatric issues, and missing data. The Hospital Anxiety and Depression Scale, Pain Catastrophizing scale, and Tampa Scale of Kinesiophobia were administered before and after treatment. Regression models were used to estimate associations between psychological factors and the CMS.

RESULTS

We included 433 patients (88% male, mean age 47±11 years) with a median duration of symptoms of 392.2 days (interquartile range: 266.5-583.5). Rotator cuff issue was present in 71% of patients. During interdisciplinary rehabilitation, patients were followed for a mean of 33.6±7.5 days. The mean CMS at entry was 42.8 ±15.5. The mean gain in CMS after treatment was 10.6 ±10.9. Before treatment, psychological factors were significantly associated with only the pain CMS parameter: -0.37 (95% CI: -0.46 to -0.28), p <0.001. After treatment, psychological factors were associated with the evolution of the four CMS parameters: -0.12 (-0.23 to -0.01) to -0.26 (95% CI: -0.36 to -0.16), p<0.05.

CONCLUSIONS

This study raises the question of a distinct assessment of pain when assessing shoulder function with CMS in patients with chronic shoulder pain. The separation of the "pain parameter" from the overall CMS score seems illusory with this tool that is used worldwide. However, clinicians should be aware that psychological factors can negatively influence the evolution of all CMS parameters during follow-up, which argues for a biopsychosocial approach to patients with chronic shoulder pain.

Comparison of Pain Catastrophic Scale and Anxiety in Patients With Boxer's Fracture and Other Types of Hand Fractures

OBJECTIVE

 The Pain Catastrophic Scale (PCS) is generally associated with high and low post-recovery satisfaction and measures the pain perception of patients in the literature. This study aims to evaluate the association of deliberate (as in a fight or anger causing punching a wall) boxer's fractures with catastrophic pain compared to accidental (as in a fall, accidental knocking it against a wall, etc.) fractures and evaluate the effect of anxiety about fracture union and functional recovery on clinical outcomes.

MATERIALS AND METHODS

 A total of 62 male patients with metacarpal fractures, 31 as a result of deliberate punching (1st group) and 31 with metacarpal fractures as a result of an accident (2nd group), who applied to the emergency department or orthopedic clinic with the diagnosis of metacarpal fracture between January 2021 and October 2022, were included in the study. All patients were selected from patients who were followed up with conservative plaster/splint. The PCS scores of the patients were evaluated comparatively with the clinical results measured after at least six weeks.

RESULTS

 The mean age of the patients was 30.8 (18-50) in the 1st group and 34.8 (18-64) in the 2nd Group, and no statistically significant difference was found (p=0.274). While the median PCS score was 10.5 (interquartile range {IQR}: 12.3) for the 1st group, the median PCS score was 17.5 (IQR: 14.5) for the 2nd group, and the PCS score was statistically significantly lower in group 1 (p=0.009). While the median Visual Analogue Scale (VAS) value was 0 (IQR: 0.3) for the 1st group, the median VAS value was 1 (IQR: 2.0) for the 2nd group, and the VAS score was statistically significantly lower in the 1st group (p<0.001). While the median 'quick disabilities of the arm, shoulder, and hand' (Q-DASH) value was 0 (IQR:2.3) for the 1st group, the median Q-DASH value was 3.4 (IQR:6.3) for the 2nd group, and the Q-DASH score was statistically significantly lower in the 1st group (p=0.001). No significant difference was observed between the 1st and 2nd groups in terms of grip strength values (p=0.815).

CONCLUSION

The etiology of patients presenting with a boxer's fracture should be well understood, and if necessary, these patients should be treated multidisciplinary, with psychiatric help. Better satisfaction can be achieved with lower results in patients whose PCS scoring system has lost its eigenvalue.

Depression and Anxiety Are Associated With Worse Subjective and Functional Baseline Scores in Patients With Frozen Shoulder Contracture Syndrome: A Systematic Review

Purpose

To investigate whether psychological factors, such as avoidance behavior, fear, pain catastrophization, kinesiophobia, anxiety, depression, optimism, and expectation are associated with different subjective and functional baseline scores in patients with frozen shoulder contracture syndrome (FSCS).

Methods

Searches were conducted in MEDLINE, Cochrane Library (CENTRAL Database), PEDro, Pubpsych, and PsychNET.APA without restrictions applied to language, date, or status of publication. Two authors reviewed study titles, abstract, and full text based on the following inclusion criteria: adult population (≥ 30 < 70 years old) with FSCS.

Results

Seven hundred and seventy-six records were included by the search strategies. After title final screening, 6 studies were included for the qualitative synthesis. Psychological features investigated were anxiety, depression, pain-related fear, pain catastrophizing, and pain self-efficacy; reported outcomes included pain, function, disability, quality of life, and range of motion. Data suggest that anxiety and depression impact self-assessed function, pain, and quality of life. There is no consensus on the correlation between psychological variables and range of motion. Associations were suggested between pain-related fear, pain-related beliefs, and pain-related behavior and perceived arm function; pain-related conditions showed no significant correlation with range of motion and with perceived stiffness at baseline.

Conclusion

Scores traditionally thought to assess physical dimensions like shoulder pain, disability, and function seem to be influenced by psychological variables. In FSCS patients, depression and anxiety were associated with increased pain perception and decreased function and quality of life at baseline. Moreover, pain-related fear and catastrophizing seem to be associated with perceived arm function.

Heterogeneity of pain-related psychological distress in patients seeking care for shoulder pathology

BACKGROUND

Psychological distress is associated with disability and quality of life for patients with shoulder pain. However, uncertainty around heterogeneity of psychological distress has limited the adoption of shoulder care models that address psychological characteristics. In a cohort of patients with shoulder pain, our study sought to (1) describe the prevalence of various subtypes of psychological distress; (2) evaluate associations between psychological distress and self-reported shoulder pain, disability, and function; and (3) determine differences in psychological distress profiles between patients receiving nonoperative vs. operative treatment.

METHODS

The sample included 277 patients who were evaluated in clinic by a shoulder surgeon and completed the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Assessment Tool (OSPRO-YF) from 2019 to 2021. This tool categorizes maladaptive and adaptive psychological traits, and the number of yellow flags (YFs) ranges from 0 to 11, with higher YF counts indicating higher pain-related psychological distress. Operative and nonoperative cohorts were compared using χ² test and Student t test. Linear regression was used to evaluate the association between pain, disability, and YFs, whereas Poisson regression evaluated the association between operative treatment and psychological distress. K-means cluster analysis was performed to propose potential psychological distress phenotypes.

RESULTS

Two hundred fifty-one patients (91%) had at least 1 YF on the OSPRO-YF tool, with a mean number of 6 ± 3.5 YFs. YFs in unhelpful coping (85%) and helpful coping domains (78%) were most prevalent. The number of YFs was significantly associated with baseline shoulder pain (P < .001), Single Assessment Numeric Evaluation (P < .001), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) scores. Comparing operative and nonoperative cohorts, the operative cohort had a significantly higher mean number of YFs (6.5 vs. 5.6, P = .035), presence of any YF (94.3% vs. 85.7%, P = .015), and presence of YFs within the unhelpful coping domain (91.8% vs. 75.6%, P < .001). Three phenotypes were described, corresponding to low, moderate, and severe psychological distress (P < .001), with females (P = .037) and smokers (P = .018) associated with higher psychological distress phenotypes.

CONCLUSIONS

YFs, particularly within the unhelpful coping and helpful coping domains, were highly prevalent in a cohort of patients presenting to a shoulder surgeon's clinic. Additionally, operative patients were found to have a significantly higher rate of YFs across multiple dimensions of psychological distress. These findings stress the importance of routine attentiveness to multiple dimensions of pain-related psychological distress in shoulder populations, which can provide an opportunity to reinforce healthy interpretation of pain while minimizing distress in appropriately identified patients.

The influence of psychosocial factors on patient-reported outcome measures in rotator cuff tears pre- and post-surgery: a systematic review

PURPOSE

Recent research shows that major levels of psychological distress correlate with higher pain and reduced function in patients with shoulder and rotator cuff pathology. A systematic review updating a review published in 2016 was conducted to determine the degree of consistency and the strength of association between psychosocial factors and patient-reported outcomes (PROMs) in patients with rotator cuff repair (RCR) with new high-quality literature.

METHODS

The bibliographic searches were conducted from May to June 2020 within the following databases: MEDLINE/PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Web of Science. The articles included should discuss the association between psychosocial factors and outcomes in patients with documented or diagnosed rotator cuff tears through clinical and/or radiological examination. The Methodological Index for Non-Randomized Studies (MINORS) tool was used to assess the methodological quality.

RESULTS

Fifteen articles were included. Negative psychosocial factors were found consistently associated with worse function and disability in the pre- and post-operative period. In particular, psychosocial factors regarding emotional or mental health were associated with a weak to a substantial degree with preoperative and postoperative function/disability and pain intensity in patients undergoing RCR.

CONCLUSION

In patients undergoing repair of the rotator cuff tear, there was a correlation between poor psychological function before surgery and worsening post-surgical outcomes, such as persistence of postoperative pain intensity and worse levels of function/disability.

Influence of mental health on postoperative outcomes in patients following biceps tenodesis

PURPOSE

To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis.

METHODS

The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS.

RESULTS

Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008).

CONCLUSION

Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.

Increased Health Care Costs and Opioid Use in Patients with Anxiety and Depression Undergoing Rotator Cuff Repair

PURPOSE

To (1) quantify the prevalence of mood disorders in patients undergoing arthroscopic rotator cuff repair (RCR) by use of a large claims database and (2) compare opioid use and medical costs in the year before and the year after RCR between patients with and without comorbid mood disorders.

METHODS

A large claims database was queried to identify patients who underwent arthroscopic RCR (Current Procedural Terminology code 29827) between October 2010 and December 2015. All patients were then screened for insurance claims relating to either anxiety or depression. We compared net costs and opioid use both 1 year preoperatively and 1 year postoperatively between patients with and without mood disorders by use of an analysis of covariance.

RESULTS

A total of 170,329 patients (97,427 male patients [57.2%] and 72,902 female patients [42.8%]) undergoing arthroscopic RCR were identified. Of the 170,329 patients, 46,737 (27.4%) had comorbid anxiety or depression, and after adjustment for preoperative cost, sex, age, and both preoperative and postoperative opioid use, the 1-year postoperative cost was 7.05% higher for those with a preoperative mood disorder than for those without a mood disorder. In addition, opioid use both in the 180 days prior to surgery (36.7% vs 26.9%) and more than 90 days after surgery (33.0% vs 27.2%) was substantially greater in the group with comorbid depression or anxiety.

CONCLUSIONS

In patients with comorbid mood disorders, opioid use and health care costs were increased both preoperatively and postoperatively. The increased cost in this patient population is estimated at $62.3 million annually. In an effort to provide high-quality, value-based care, treatment strategies should be developed to identify these patients preoperatively and provide the appropriate resources needed to improve the probability of a successful surgical outcome.

LEVEL OF EVIDENCE

Level III, retrospective, comparative therapeutic study.

The Distress and Risk Assessment Method predicts postoperative narcotic use in patients undergoing rotator cuff repair

BACKGROUND

The Distress and Risk Assessment Method (DRAM) predicts poor outcomes in spine, hip, and knee surgery. Unlike other areas of orthopedic surgery, DRAM scores are not predictive of lower postoperative patient-reported outcomes after arthroscopic rotator cuff repair (RCR).

PURPOSE

As concerns for opioid dependence and abuse grow, the purpose of this study was to analyze the correlation between preoperative DRAM scores, modified Zung scores, and postoperative narcotic use in patients who underwent arthroscopic RCR.

MATERIALS AND METHODS

This prospective cohort study identified and enrolled patients >18 years of age with full-thickness rotator cuff tears at a single institution. Patients with prior shoulder surgery, greater than 1-tendon RCR, and preoperative narcotic use were excluded. One-hundred and fifty patients were enrolled, with 114 (76%) completing all preoperative and postoperative questionnaires. Preoperative DRAM scores were collected from every patient. Postoperative narcotic use was evaluated via survey and converted to total morphine equivalents.

RESULTS

Increased preoperative DRAM scores predicted higher postoperative morphine equivalent units (P = .002, r = 0.29). When dividing patients into those <17 or ≥17 on the modified Zung score, 44 of 114 (39%) met criteria for "at risk or depressed." This group showed a statistically significant trend toward higher postoperative morphine equivalent unit intake (P = .004).

CONCLUSION

Baseline psychological distress (DRAM) can predict narcotic requirements after RCR and serve as a powerful tool to identify patients at risk for increased narcotics requirements postoperatively. In our cohort, 39% of patients showed evidence of baseline depression, which highlights a potential role of the modified Zung score to identify patients in need of preoperative psychological counseling.

Prognostic effect of pain sensitization in patients with de Quervain's tenovaginosis receiving corticosteroid injection

We investigated the influence of pain sensitization on the prognosis of de Quervain's tenovaginosis after a local corticosteroid injection. One hundred and fifteen patients with de Quervain's tenovaginosis who were treated with corticosteroid injection were recruited. We initially measured pain sensitization by assessing the patients' pressure pain thresholds in the mid-dorsal forearm and by administering a Pain Sensitivity Questionnaire. The pain score using a visual analogue scale, the result of Eichhoff's test, and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire were assessed at baseline and at 6 and 24 weeks after the injection. The DASH scores at 6 weeks correlated slightly with higher Pain Sensitization Questionnaire scores, and the DASH scores at 24 weeks correlated moderately with higher Pain Sensitization Questionnaire scores and lower pressure pain thresholds. Lower pressure pain thresholds, higher Pain Sensitization Questionnaire scores, and heavy manual work were independently associated with a higher likelihood of persistent symptoms and signs after a local corticosteroid injection for de Quervain's tenovaginosis. Level of evidence: III.

The Prognostic Value of Pain Sensitization in Patients With Lateral Epicondylitis

PURPOSE

Pain sensitization is a contributing factor to conditions of chronic pain. The aim of this study was to evaluate the influence of pain sensitization on the prognosis of lateral epicondylitis (LE) treated by self-stretching exercises and the use of a counterforce brace.

METHODS

We enrolled 131 patients who presented with isolated LE symptoms for less than 6 months. We initially measured pain sensitization by assessing patients' pressure pain thresholds (PPTs) in the contralateral middorsal forearm and administering a pain sensitization questionnaire (PSQ). For outcome assessments, we assessed the self-administered, patient-reported Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire at 6 and 12 months' follow-up.

RESULTS

Initial PSQ scores correlated moderately with baseline DASH scores and slightly with symptom duration; PPTs correlated slightly with baseline DASH scores. After we accounted for confounding variables, patient-reported disability was associated with lower PPTs, higher PSQ scores, and manual labor at 6 months. These 3 factors accounted for 36% of variance in the DASH scores; however, at 12 months only the PSQ score was associated with higher DASH scores, accounting for 14% of variance.

CONCLUSIONS

Pain sensitization during the early stages of LE correlated with initial symptom severity and duration and was associated with persistently increasing disability after 1 year of nonsurgical treatment. More research is needed to show whether early identification and treatment of pain sensitization will enhance LE treatment outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Psychological symptoms and the MCID of the DASH score in shoulder surgery

BACKGROUND

Psychological symptoms are frequently present in patients scheduled for shoulder surgery. The perception of functional disability, activity level and pain in the shoulder is negatively influenced by psychological symptoms, which leads to higher scores of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The aim of this study was to determine the influence of psychological symptoms on the minimal clinically important difference (MCID) of the DASH score in patients after shoulder surgery.

METHODS

In this prospective longitudinal cohort study, 176 patients were included. Group 1 (32 patients) had symptoms of psychological disorders before and after surgery; group 2 had no symptoms of psychological disorders (110 patients). In the remaining patients (34 patients), psychological disorders changed after surgery. Clinical outcome was measured with the change of DASH score and anchor questions for perceived improvement of pain and function after surgery. Symptoms of psychological disorders were identified with the Four-Dimensional Symptom Questionnaire. An anchor-based mean change score technique was used to determine the MCID of the DASH score.

RESULTS

DASH scores before and 12 months after shoulder surgery were significantly higher in patients with symptoms of psychological disorders; change of DASH score was not different between the two groups. The MCID of the DASH score was 13.0 [SD 20.7] in the group with symptoms of psychological disorders and 12.7 [SD 17.6] in the group with no symptoms of psychological disorders. We observed no difference (p = 0.559) in the MCID between the group with and the group without symptoms of psychological disorders.

CONCLUSION

Symptoms of psychological disorders had a negative effect on the DASH score but no influence on the MCID of the DASH score. The DASH score could be used in future studies to assess the influence of psychological factors on the clinical outcome of treatment.

Treated Versus Untreated Depression in Total Joint Arthroplasty Impacts Outcomes

BACKGROUND

To determine if there was a difference in the change in patient-reported physical function (PF) between nondepressed and medically treated depressed or untreated depressed total joint arthroplasty (TJA) patients.

METHODS

This is an Institutional Review Board exempt retrospective review of 280 TJA cases from March 2014 to May 2016. Patient-reported PF was measured as part of the routine care via the Patient Reported Outcomes Measurement Information System PF computerized adaptive test. Linear generalized estimating equation regression analyses were used.

RESULTS

Untreated depressed cases demonstrated much smaller gains in PF scores compared to nondepressed patients (P = .020). Additionally, although treated and untreated depressed patients had statistically similar preoperative and postoperative PF scores (P > .05), untreated depressed cases experienced a lower magnitude of change (P = .015).

CONCLUSION

Medically treated depressed patients may have similar PF gains as nondepressed patients. Larger prospective studies may help identify whether screening for untreated depression and subsequent treatment leads to improved outcomes.

Self-reported Mental Disorders Negatively Influence Surgical Outcomes After Arthroscopic Treatment of Femoroacetabular Impingement

Background

Femoroacetabular impingement (FAI) is responsible for hip pain and dysfunction, and surgical outcomes depend on multiple factors. The presence of mental disorders negatively influences outcomes of multiple orthopaedic conditions, although the impact on FAI surgery is unclear.

Hypothesis

The authors hypothesized that a preoperative self-reported history of mental disorders would negatively influence patient-reported outcome measures after FAI surgery.

Study Design

Cohort study; Level of evidence, 3.

Methods

A matched-cohort study was performed by reviewing a prospectively collected database of cases of arthroscopic management of FAI with a single surgeon over a 2-year period. Demographics and radiographic parameters were recorded for all patients. Patients completed the Hip Outcome Score-Activity of Daily Living Subscale (HOS-ADL), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and modified Harris Hip Score (mHHS) prior to surgery and 2 years after surgery. Unpaired and paired t tests were used to compare results between and within cohorts at baseline and follow-up. Statistical significance was defined as P < .05.

Results

The cohort included 301 patients, with 75 and 226 patients reporting and not reporting a history of mental disorders, respectively. Before treatment, all patient-reported outcome measures were significantly lower among patients reporting a history of mental disorders (P < .01 for HOS-ADL, HOS-SSS, and mHHS). Patients in both groups demonstrated significant improvements (P < .0001) in HOS-ADL, HOS-SSS, and mHHS when preoperative outcome measures were compared with follow-up. Patients with reported mental disorders had significantly lower scores after surgery as compared with patients without mental disorders (P < .0001 for HOS-ADL, HOS-SSS, and mHHS).

Conclusion

The presence of a reported mental disorder is associated with lower patient-reported outcomes before and after surgical management of FAI. Statistically significant and clinically relevant improvements were observed for patients who reported mental disorders. The magnitude of these improvements was not as large as that for an age- and sex-matched control group without a self-reported mental disorder.

Preoperative Pain Sensitization Is Associated With Postoperative Pillar Pain After Open Carpal Tunnel Release

BACKGROUND

Postoperative pillar pain (deep-seated wrist pain worsened by leaning on the heel of the hand) sometimes occurs after carpal tunnel release (CTR), leading to weakness in the hand and delayed return to work. Increased pain sensitivity has been found to be associated with worse symptoms and poorer treatment response in a number of chronic musculoskeletal conditions, but few studies have investigated the association of pain sensitization with pillar pain after CTR.

QUESTIONS/PURPOSES

(1) Is preoperative pain sensitization in patients with carpal tunnel syndrome (CTS) associated with increased severity of pillar pain after open CTR? (2) What other demographic, electrophysiological, or preoperative clinical characteristics are associated with pillar pain after CTR?

METHODS

Over a 35-month period, one surgeon performed 162 open carpal tunnel releases. Patients were eligible if they had sufficient cognitive and language function to provide informed consent and completed a self-reported questionnaire; they were not eligible if they had nerve entrapment other than CTR or if the surgery was covered by workers compensation insurance. Based on these criteria, 148 (91%) were approached for this study. Of those, 17 (9%) were lost to followup before 12 months, leaving 131 for analysis. Their mean age was 54 years (range, 32-78 years), and 81% (106 of 131) were women; 34% (45 of 131) had less than a high school education. We preoperatively measured pain sensitization by assessing the patients' pressure pain thresholds by stimulating pressure-induced pain in the pain-free volar forearm and administering a self-reported Pain Sensitivity Questionnaire minor subscale, an instrument that assesses pain intensity in daily life situations. We evaluated postoperative pillar pain using the "table test" (having the patient lean on a table with their weight on their hands placed on the table's edge with elbows straight) with an 11-point ordinal scale at 3, 6, and 12 months after their surgical procedures. We conducted bivariate and multivariable analyses to determine whether the patients' clinical, demographic, and pain sensitization factors were associated with their postoperative pillar pain severity after CTR.

RESULTS

After controlling for relevant confounding variables such as age, education level, and functional states, we found that increased pillar pain severity was associated with the pressure pain threshold (β = -1.02 [-1.43 to -0.61], partial R = 11%, p = 0.021) and Pain Sensitivity Questionnaire minor (β = 1.22 [0.73-1.71], partial R = 17%, p = 0.013) at 3 months, but by 6 months, only Pain Sensitivity Questionnaire minor (β = 0.92 [0.63-1.21], partial R = 13%, p = 0.018) remained an associated variable for pillar pain. Additionally, gender (women) was associated with increased pain severity at 3 (β = 0.78 [0.52-1.04], partial R = 9%, p = 0.023) and 6 months (β = 0.72 [0.41-1.01], partial R = 8%, p = 0.027). At 3 months, pressure pain threshold, Pain Sensitivity Questionnaire minor, and gender (women) collectively accounted for 37% of the variance in pillar pain severity; at 6 months, Pain Sensitivity Questionnaire minor and gender (women) accounted for 21% of the variance, but no relationship between those factors and pillar pain was observed at 12 months.

CONCLUSIONS

Gender (women) and preoperative pain sensitization measured by pressure pain threshold and self-reported Pain Sensitivity Questionnaire were associated with pillar pain severity up to 3 and 6 months after CTR, respectively. However, the influence of pain sensitization on pillar pain was diminished at 6 months and it did not show persistent effects beyond 12 months. Pain sensitization seems to be more important in the context of recovery from surgical intervention (in the presence of a pain condition) than in healthy states, and clinicians should understand the role of pain sensitization in the postoperative management of CTS. Future research may be needed to determine if therapeutic interventions to reduce sensitization will decrease the risk of pillar pain.

LEVEL OF EVIDENCE

Level III, prognostic study.

Psychological Factors Affecting Outcomes After Elective Shoulder Surgery

To optimize outcomes following elective shoulder surgery, it is important to address not only the injury or pathology itself, but also the cognitive and emotional factors that may influence a patient's recovery. Depression, anxiety, catastrophic thinking, distress, somatization, and decreased self-efficacy are among the most common psychological factors associated with adverse perioperative events and poor postoperative outcomes. Such factors may manifest at any point during recovery. Validated questionnaires can be used to measure psychological factors preoperatively, thereby enabling earlier intervention that may mitigate any potential negative effect of these factors on the patient's overall outcome. Orthopaedic surgeons must be sensitive to the influence of stress, distress, and limited coping strategies on patients and should learn how best to mitigate the detrimental effects of these factors on outcomes after elective shoulder surgery.

Agreement between patient-based and clinician-based assessment of the shoulder

BACKGROUND

Patient home-based self-assessments after shoulder surgery have the potential to aid clinicians in reducing clinic time and decreasing follow-up requirements. The purpose of this systematic review was to determine the correlation between patient-based and physician-assessed outcome measures for range of motion (ROM), strength, and shoulder function.

METHODS

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases were searched. All studies comparing patient-reported and clinician-based assessments of shoulder ROM, strength, and function were eligible for inclusion. Studies that included patient or clinician assessment only, description of shoulder diseases or treatments only, and animal- or cadaveric-based studies were excluded. More than 250 abstracts were searched, and 4 studies were found eligible.

RESULTS

Patients assessed their shoulder ROM, strength, and function with moderate-to-high accuracy compared with clinical assessment. There was less agreement between patients and clinicians regarding the symptomatic shoulder compared with the contralateral shoulder. There was less agreement between patients and clinicians on rotation than forward elevation. Patients who were less satisfied with their shoulder had less agreement with clinicians.

CONCLUSION

There is moderate-to-high agreement between patients and clinicians in the assessment of the shoulder after surgery. Methods of assessment of rotation could be reviewed to create a more exact self-assessment tool.

The Influence of Preoperative and Postoperative Psychological Symptoms on Clinical Outcome after Shoulder Surgery: A Prospective Longitudinal Cohort Study

Background

Psychological symptoms are highly prevalent in patients with shoulder complaints. Psychological symptoms in patients with shoulder complaints might play a role in the aetiology, perceived disability and pain and clinical outcome of treatment. The aim of this study was to assess whether preoperative symptoms of distress, depression, anxiety and somatisation were associated with a change in function after shoulder surgery and postoperative patient perceived improvement of pain and function. In addition, the change of psychological symptoms after shoulder surgery was analyzed and the influence of postoperative symptoms of psychological disorders after surgery on the change in function after shoulder surgery and perceived postoperative improvement of pain and function.

Methods and Findings

A prospective longitudinal cohort study was performed in a general teaching hospital. 315 consecutive patients planned for elective shoulder surgery were included. Outcome measures included change of Disabilities of the Arm, Shoulder and Hand (DASH) score and anchor questions about improvement in pain and function after surgery. Psychological symptoms were identified before and 12 months after surgery with the validated Four-Dimensional Symptom Questionnaire (4DSQ). Psychological symptoms were encountered in all the various shoulder diagnoses. Preoperative symptoms of psychological disorders persisted after surgery in 56% of patients, 10% of patients with no symptoms of psychological disorders before surgery developed new psychological symptoms. Preoperative symptoms of psychological disorders were not associated with the change of DASH score and perceived improvement of pain and function after shoulder surgery. Patients with symptoms of psychological disorders after surgery were less likely to improve on the DASH score. Postoperative symptoms of distress and depression were associated with worse perceived improvement of pain. Postoperative symptoms of distress, depression and somatisation were associated with worse perceived improvement of function.

Conclusions

Preoperative symptoms of distress, depression, anxiety and somatisation were not associated with worse clinical outcome 12 months after shoulder surgery. Symptoms of psychological disorders before shoulder surgery persisted in 56% of patients after surgery. Postoperative symptoms of psychological disorders 12 months after shoulder surgery were strongly associated with worse clinical outcome.

Clinician and Patient-reported Outcomes Are Associated With Psychological Factors in Patients With Chronic Shoulder Pain

BACKGROUND

Validated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors.

QUESTIONS

We asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements?

METHODS

All new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months (interquartile range, 5.5-15 months), and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries (59%, 93 patients) and were followed for a mean of 31.6 days (SD, 7.5 days). Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment (physiotherapy, cognitive therapy and vocational training). The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes.

RESULTS

Greater disability on the DASH was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.64; 95% CI, 0.25-1.03; p = 0.002) and social factors (language, professional qualification combined coefficient, -6.15; 95% CI, -11.09 to -1.22; p = 0.015). Greater pain on the Brief Pain Inventory was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.076; 95% CI, 0.021-0.13; p = 0.006). Poorer impression of change was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia coefficient, 0.93; 95% CI, 0.87-0.99; p = 0.026) and social factors (education, language, and professional qualification coefficient, 6.67; 95% CI, 2.77-16.10; p < 0.001). Worse clinician-rated outcome was associated only with psychological factors (Hospital Anxiety and Depression Scale (depression only), Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, -0.35; 95% CI, -0.58 to -0.12; p = 0.003).

CONCLUSIONS

Depressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score.

LEVEL OF EVIDENCE

Level III, prognostic study.

Validation of the four-dimensional symptom questionnaire (4DSQ) and prevalence of psychological symptoms in orthopedic shoulder patients

Psychological problems are common in shoulder patients. A validated psychological questionnaire measuring clinically relevant psychological symptoms (including distress, depression, anxiety, and somatization) in shoulder patients is lacking. The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire to identify distress, depression, anxiety, and somatization which has been validated in primary care populations. The aim of this study was to validate the 4DSQ in orthopedic shoulder patients. We assessed whether the 4DSQ measures these four constructs the same way in an orthopedic population with shoulder problems compared to a general practice population. We also investigated the prevalence of psychological symptoms in shoulder patients. The shoulder group consisted of 200 consecutive patients and the general practice group comprised 368 patients, matched for gender and age. Differential item functioning analysis showed that the 4DSQ measures the different psychological symptoms in orthopedic shoulder patients the same way as in general practice patients. The shoulder patients tended to score higher on the somatization scale, resulting in a new cut-off point for somatization. The prevalence of distress, somatization, anxiety, and depression in the shoulder group was 23%, 14%, 10%, and 8%, respectively. It can be concluded from this study that the 4DSQ in orthopedic shoulder patients measures the same constructs as in general practice patients and can therefore be used in orthopedic practice to measure psychological symptoms in patients with shoulder complaints.

Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears

BACKGROUND

Patient-reported outcome measures have increasingly accompanied objective examination findings in the evaluation of orthopaedic interventions. Our objective was to determine whether a validated measure of mental health (Short Form-36 Mental Component Summary [SF-36 MCS]) or measures of tear severity on magnetic resonance imaging were more strongly associated with self-assessed shoulder pain and function in patients with symptomatic full-thickness rotator cuff tears.

METHODS

One hundred and sixty-nine patients with full-thickness rotator cuff tears were prospectively enrolled. Patients completed the Short Form-36, visual analog scales for shoulder pain and function, the Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons (ASES) instrument at the time of diagnosis. Shoulder magnetic resonance imaging examinations were reviewed to document the number of tendons involved, tear size, tendon retraction, and tear surface area. Age, sex, body mass index, number of medical comorbidities, smoking status, and Workers' Compensation status were recorded. Bivariate correlations and multivariate regression models were calculated to identify associations with baseline shoulder scores.

RESULTS

The SF-36 MCS had the strongest correlation with the visual analog scale for shoulder pain (Pearson correlation coefficient, -0.48; p < 0.001), the visual analog scale for shoulder function (Pearson correlation coefficient, -0.33; p < 0.001), the SST (Pearson correlation coefficient, 0.37; p < 0.001), and the ASES score (Pearson correlation coefficient, 0.51; p < 0.001). Tear severity only correlated with the visual analog scale for shoulder function; the Pearson correlation coefficient was 0.19 for tear size (p = 0.018), 0.18 for tendon retraction (p = 0.025), 0.18 for tear area (p = 0.022), and 0.20 for the number of tendons involved (p = 0.011). Tear severity did not correlate with other scores in bivariate correlations (all p > 0.05). In all multivariate models, the SF-36 MCS had the strongest association with the visual analog scale for shoulder pain, the visual analog scale for shoulder function, the SST, and the ASES score (all p < 0.001).

CONCLUSIONS

Patient mental health may play an influential role in patient-reported pain and function in patients with full-thickness rotator cuff tears. Further studies are needed to determine its effect on the outcome of the treatment of rotator cuff disease.

The Relationship Between Catastrophic Thinking and Hand Diagram Areas

PURPOSE

To evaluate the relationship between the total area marked on pain and numbness diagrams and psychosocial factors (depression, pain catastrophic thinking, and health anxiety).

METHODS

A total of 155 patients marked painful and numb areas on separate hand diagrams. Patients also completed demographic, condition-related, and psychosocial (Pain Catastrophizing Scale, Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test, and Short Health Anxiety Inventory) questionnaires. Bivariate and multivariable analyses were used to determine factors associated with total area marked on the pain and numbness diagrams.

RESULTS

The total area marked on the pain diagram correlated with catastrophic thinking, symptoms of depression, and health anxiety. In multivariable analysis, catastrophic thinking was the sole predictor of marked pain area, accounting for 10% of variance in the hand pain diagram. The total area marked on the numbness diagram correlated with the interval between onset and visit, diagnosis, catastrophic thinking, and symptoms of depression. In multivariable analysis, the interval between onset and visit, a diagnosis of carpal tunnel syndrome, and catastrophic thinking were independently associated with total area marked on the hand numbness diagram.

CONCLUSIONS

Catastrophic thinking was independently associated with larger pain and numbness areas on a hand diagram. This suggests that larger symptom markings on hand diagrams may indicate less effective coping strategies. Hand diagrams might be used as a basis for discussion of coping strategies and illness behavior in patients with upper extremity conditions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

One-year Patient-reported Outcomes After Arthroscopic Rotator Cuff Repair Do Not Correlate With Mild to Moderate Psychological Distress

BACKGROUND

Patients with shoulder and rotator cuff pathology who exhibit greater levels of psychological distress report inferior preoperative self-assessments of pain and function. In several other areas of orthopaedics, higher levels of distress correlate with a higher likelihood of persistent pain and disability after recovery from surgery. To our knowledge, the relationship between psychological distress and outcomes after arthroscopic rotator cuff repair has not been similarly investigated.

QUESTIONS/PURPOSES

(1) Are higher levels of preoperative psychological distress associated with differences in outcome scores (visual analog scale [VAS] for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) 1 year after arthroscopic rotator cuff repair? (2) Are higher levels of preoperative psychological distress associated with less improvement in outcome scores (VAS for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) 1 year after arthroscopic rotator cuff repair? (3) Does the prevalence of psychological distress in a population with full-thickness rotator cuff tears change when assessed preoperatively and 1 year after arthroscopic rotator cuff repair?

METHODS

Eighty-five patients with full-thickness rotator cuff tears were prospectively enrolled; 70 patients (82%) were assessed at 1-year followup. During the study period, the three participating surgeons performed 269 rotator cuff repairs; in large part, the low overall rate of enrollment was related to two surgeons enrolling only two patients total in the initial 14 months of the study. Psychological distress was quantified using the Distress Risk Assessment Method questionnaire, and patients completed self-assessments including the VAS for pain, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score preoperatively and 1 year after arthroscopic rotator cuff repair. Fifty of 85 patients (59%) had normal levels of distress, 26 of 85 (31%) had moderate levels of distress, and nine of 85 (11%) had severe levels of distress. Statistical models were used to assess the effect of psychological distress on patient self-assessment of shoulder pain and function at 1 year after surgery.

RESULTS

With the numbers available, distressed patients were not different from nondistressed patients in terms of postoperative VAS for pain (1.9 [95% confidence interval {CI}, 1.0-2.8] versus 1.0 [95% CI, 0.5-1.4], p = 0.10), Simple Shoulder Test (9 [95% CI, 8.1-10.4] versus 11 [95% CI, 10.0-11.0], p = 0.06), or American Shoulder and Elbow Surgeons scores (80 [95% CI, 72-88] versus 88 [95% CI, 84-92], p = 0.08) 1 year after arthroscopic rotator cuff repair. With the numbers available, distressed patients also were not different from nondistressed patients in terms of the amount of improvement in scores between preoperative assessment and 1-year followup on the VAS for pain (3 [95% CI, 2.2-4.1] versus 2 [95% CI, 1.4-2.9], p = 0.10), Simple Shoulder Test (5.2 [95% CI, 3.7-6.6] versus 5.0 [95% CI, 4.2-5.8], p = 0.86), or American Shoulder and Elbow Surgeons scale (38 [95% CI, 29-47] versus 30 [95% CI, 25-36], p = 0.16). The prevalence of psychological distress in our patient population was lower at 1 year after surgery 14 of 70 (20%) versus 35 of 85 (41%) preoperatively (odds ratio, 0.36; 95% CI, 0.17-0.74; p = 0.005).

CONCLUSIONS

Mild to moderate levels of distress did not diminish patient-reported outcomes to a clinically important degree in this small series of patients with rotator cuff tears. This contrasts with reports from other areas of orthopaedic surgery and may be related to a more self-limited course of symptoms in patients with rotator cuff disease or possibly to a beneficial effect of rotator cuff repair on sleep quality or other unrecognized determinants of psychosocial status.

LEVEL OF EVIDENCE

Level I, prognostic study.

The effect of feedback regarding coping strategies and illness behavior on hand surgery patient satisfaction and communication: a randomized controlled trial

BACKGROUND

Patients and surgeons can feel uncomfortable discussing coping strategies, psychological distress, and stressful circumstances. It has been suggested that patient-reported outcome measures (PROMs) facilitate the discussion of factors associated with increased symptoms and disability. This study assessed the effect of providing feedback to patients regarding their coping strategy and illness behavior on patient satisfaction and patient-physician communication in orthopedic surgery.

METHODS

In a prospective study, 136 orthopedic patients were randomly assigned to either receive feedback about the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference computer-adaptive test (CAT) prior to the visit with the hand surgeon or not. The primary outcome was patient satisfaction with the consultation and secondary outcomes involved patient-physician communication. Bivariate and multivariable analyses were performed to determine the influence of the feedback on patient satisfaction and communication.

RESULTS

There was no significant difference in patient satisfaction between patients who received feedback and patients who did not (P = 0.70). Feedback was associated with more frequent discussion of coping strategies (P = 0.045) in bivariate analysis but was not independently associated: in multivariable analysis, only PROMIS Pain Interference CAT and age were identified as independent predictors (odds ratio (OR) 1.1; 95 % confidence interval (CI) 1.0-1.1, P = 0.013, and OR 0.97, 95 % CI 0.94-0.99, P = 0.032, respectively). No factors were associated with discussion of stressors. Discussion of circumstances was independently associated with increased PROMIS Pain Interference CAT, marital status, and work status.

CONCLUSION

We found that feedback regarding coping strategies and illness behavior using the PROMIS Pain Interference CAT did not affect patient satisfaction. Although feedback was associated with increased discussion of illness behavior in bivariate analysis, less effective coping strategies and personal factors (age, marital status, and work status) were more important factors.

A threshold disability score corresponds with an estimated diagnosis of clinical depression in patients with upper extremity disease

BACKGROUND

The purpose of this study was to assess whether there is a threshold Disability of Arm, Shoulder and Hand (DASH) score among patients with common hand diagnoses that corresponds with an estimated diagnosis of clinical depression.

METHODS

Two hundred sixty-nine patients with one of five common upper extremity disorders completed a measure of upper extremity-specific disability (QuickDASH or DASH) and a questionnaire assessing depressive symptoms (Patient Health Questionnaire (PHQ) or Center for Epidemiologic Studies Depression scale (CES-D). A receiver operating characteristic (ROC) analysis of the discriminatory value of a threshold DASH score for an estimated diagnosis of clinical depression was assessed. The threshold DASH score with the highest positive predictive value for an estimated diagnosis of clinical depression was selected. In bivariate analysis, the association between demographic factors, disease factors, and an estimated diagnosis of clinical depression was examined.

RESULTS

The area under the ROC curve for a threshold DASH value diagnostic of an estimated diagnosis of clinical depression was 0.75, indicating clinical usefulness for a threshold DASH score as a screening test for depression. The highest positive predictive value of 72 % occurred at a threshold QuickDASH/DASH score of 55. In bivariate analysis, only diagnosis and years of education were significantly different between patients with and without an estimated diagnosis of clinical depression.

CONCLUSION

A DASH score of 55 or greater in patients with common upper extremity disorders has an acceptable area under the curve and positive predictive value for an estimated diagnosis of clinical depression.

LEVEL OF EVIDENCE

Level 3, diagnostic study.

Association between patient-reported measures of psychological distress and patient satisfaction scores after spine surgery

BACKGROUND

Patient satisfaction has become an important component of the delivery of health care in the United States. Previous studies have shown that patient satisfaction is influenced by patient-specific characteristics. The goal of this study was to determine whether psychological distress influences outpatient satisfaction scores following spine surgery.

METHODS

We retrospectively reviewed the records from all outpatient clinical encounters at a single academic spine surgery center between February 2011 and January 2013. Any patient who completed both a patient satisfaction survey and a Distress and Risk Assessment Method (DRAM) questionnaire for the same clinical encounter was included in the study. Statistical analysis was performed to determine whether patient satisfaction scores were influenced by psychological distress.

RESULTS

During the study period, 103 patients who met the inclusion criteria were identified. On the basis of their responses to the DRAM questionnaire, fifty-six were classified as normal (no evidence of distress), twenty-two as at risk, thirteen as distressed depressive, and twelve as distressed somatic. The mean overall patient satisfaction scores (and standard deviation) were 90.2 ± 10.9 in the normal group, 94.7 ± 8.2 in the at-risk group, 87.5 ± 16.2 in the distressed-depressive group, and 75.7 ± 22.4 in the distressed-somatic group (p = 0.003). The mean score for the patients' satisfaction with their provider was 94.2 ± 12.0 in the normal group, 94.2 ± 9.5 in the at-risk group, 90.6 ± 24.0 in the distressed-depressive group, and 74.9 ± 26.2 in the distressed-somatic group (p = 0.011).

CONCLUSIONS

These results indicate a significant association between patient satisfaction and psychological distress as measured with the DRAM questionnaire. "Distressed" patients gave significantly lower scores for overall satisfaction and satisfaction with their provider compared with patients categorized as "normal." These results suggest that psychological factors may influence patients' perception of the medical care provided to them.

The Dutch Shoulder Pain and Disability Index (SPADI): a reliability and validation study

PURPOSE

To evaluate the reliability and validity of the Dutch Shoulder Pain and Disability Index (SPADI-D).

BACKGROUND

The SPADI is recommended and frequently used. However, the validity and reliability of the SPADI-D are unknown.

METHODS

The study population consisted of patients consulting a physical therapist for shoulder pain. We assessed construct validity, using known groups, convergent validity (SDQ) and divergent validity (EQ5D) for which the mean difference or Spearman correlations coefficients were calculated. The factor structure was assessed using principal component factor analysis, and we calculated Cronbach's alpha and the ICC to assess the reliability.

RESULTS

A total of 356 patients and a randomly selected group of 74 subjects for the reliability analysis were included. There was a significant difference between extreme groups (a high/low level of pain and work absence/presence) in SPADI score. The correlation between the SPADI and the SDQ was 0.69, with the EQ5D mobility-item 0.25 and with the depression-item 0.14. The SPADI consisted of one factor according to principal component factor analysis, which showed high internal consistency (Cronbach's alpha = 0.94 for the total score), and the test-retest reliability was good (ICC = 0.89).

CONCLUSION

The Dutch SPADI is a valid and reliable questionnaire for patients in primary care in assessing functional disability.

Psychological distress negatively affects self-assessment of shoulder function in patients with rotator cuff tears

BACKGROUND

In many areas of orthopaedics, patients with greater levels of psychological distress report inferior self-assessments of pain and function. This effect can lead to lower-than-expected baseline scores on common patient-reported outcome scales, even those not traditionally considered to have a psychological component.

QUESTIONS/PURPOSES

This study attempts to answer the following questions: (1) Are higher levels of psychological distress associated with clinically important differences in baseline scores on the VAS for pain, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score in patients undergoing arthroscopic rotator cuff repair? (2) Does psychological distress remain a negative predictor of baseline shoulder scores when other clinical variables are controlled?

METHODS

Eighty-five patients with full-thickness rotator cuff tears were prospectively enrolled. Psychological distress was quantified using the Distress Risk Assessment Method questionnaire. Patients completed baseline self-assessments including the VAS for pain, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score. Age, sex, BMI, smoking status, American Society of Anesthesiologists classification, tear size, and tear retraction were recorded for each patient. Bivariate correlations and multivariate regression models were used to assess the effect of psychological distress on patient self-assessment of shoulder pain and function.

RESULTS

Distressed patients reported higher baseline VAS scores (6.7 [95% CI, 4.4-9.0] versus 2.9 [95% CI, 2.3-3.6], p = 0.001) and lower baseline Simple Shoulder Test (3.7 [95% CI, 2.9-4.5] versus 5.7 [95% CI 5.0-6.4], p = 0.001) and American Shoulder and Elbow Surgeons scores (39 [95% CI, 34-45] versus 58 [95% CI, 53-63], p < 0.001). Distress remained associated with higher VAS scores (p = 0.001) and lower Simple Shoulder Test (p < 0.001) and American Shoulder and Elbow Surgeons scores (p < 0.001) when age, sex, BMI, American Society of Anesthesiologists classification, smoking status, tear size, and tear retraction were controlled.

CONCLUSIONS

Higher levels of psychological distress are associated with inferior baseline patient self-assessment of shoulder pain and function using the VAS, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score. Longitudinal followup is warranted to clarify the relationship between distress and self-perceived disability and the effect of distress on postoperative outcomes after arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Level I, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Effect of anxiety and catastrophic pain ideation on early recovery after surgery for distal radius fractures

PURPOSE

To evaluate the effects of preoperative anxiety and catastrophic pain ideation on perceived disability and objective measures after distal radius fracture surgery.

METHODS

A total of 121 patients with distal radius fractures treated with volar plate fixation were enrolled. The wrist range of motion (ROM), grip strength, and perceived disability as measured by the Michigan Hand Questionnaire (MHQ) score were assessed 4, 12, and 24 weeks after surgery. To evaluate psychological factors related to pain, catastrophic pain ideation was measured using the Pain Catastrophizing Scale (PCS) and pain anxiety was measured using the Pain Anxiety Symptom Scale (PASS). Then relative contributions of pain anxiety and catastrophic pain ideation and other clinical parameters to functional recovery in terms of grip strength, ROM, and MHQ score were assessed.

RESULTS

An increase in the PCS score was associated with the wrist ROM and grip strength only at week 4, whereas an increase in the PASS score was associated with the wrist ROM at week 4 and grip strength at weeks 4 and 12. According to a multivariate regression analysis, an increase in the PCS score was associated with a decrease in grip strength, ROM, and MHQ score at week 4; and an increase in the PASS score was associated with a decrease in grip strength, ROM, and MHQ score at week 4 and grip strength and MHQ score at week 12. At week 24, only age and fracture severity were associated with the MHQ score. In addition, age was associated with grip strength and fracture type was associated with ROM.

CONCLUSIONS

Preoperative PCS and PASS were significantly associated with delayed recovery as evidenced by scores on both objective and subjective measures of function. Given these relationships, it becomes important to assess preoperative PCS and PASS and address issues for patients at risk with brief psychosocial intervention early in the recovery process.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Psychologic distress reduces preoperative self-assessment scores in femoroacetabular impingement patients

BACKGROUND

In several areas of orthopaedics, including spine and upper extremity surgery, patients with greater levels of psychologic distress report worse self-assessments of pain and function than patients who are not distressed. This effect can lead to lower than expected baseline scores on common patient-reported outcome scales, even those not traditionally considered to have a psychologic component.

QUESTIONS/PURPOSES

The purposes of this study were to determine (1) the association of psychologic distress and baseline modified Harris hip scores and Hip Outcome Scores in patients undergoing hip arthroscopy; and (2) whether psychologic distress would remain a significant negative predictor of baseline hip scores when other clinical variables such as age, sex, BMI, smoking status, and American Society of Anesthesiologists (ASA) classification were controlled.

METHODS

One hundred forty-seven patients at one center were prospectively enrolled when they scheduled hip arthroscopy to treat painful femoroacetabular impingement. Before surgery, psychologic distress was quantified using the Distress Risk Assessment Method questionnaire. Patients also completed baseline self-assessments of hip pain and function including the modified Harris hip score and the Hip Outcome Score. Age, sex, BMI, smoking status, and ASA classification were recorded for each patient. Bivariate correlations and multivariate regression models were used to assess the effect of psychologic distress on patient self-assessment of hip pain and function.

RESULTS

Patients with distress reported significantly lower baseline modified Harris hip scores (58 versus 67, p = 0.001), Hip Outcome Score-Activities of Daily Living scores (62 versus 72, p = 0.002), and Hip Outcome Score-Sports scores (36 versus 47, p = 0.02). Distress remained significantly associated with lower baseline modified Harris hip (p = 0.006), Hip Outcome Score-Activities of Daily Living (p = 0.005), and Hip Outcome Score-Sports scores (p = 0.017) when age, sex, BMI, smoking status, and ASA classification were controlled for in the multivariate model.

CONCLUSIONS

Practitioners should recognize that psychologic distress has a negative correlation with baseline patient self-assessment using the modified Harris hip score and the Hip Outcome Scores, scales not previously described to correlate with psychologic distress. Longitudinal followup is warranted to clarify the relationship between distress and self-perceived disability and the effect of distress on postoperative outcomes in patients having hip arthroscopy.

LEVEL OF EVIDENCE

Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Clinical evaluation of upper limb function: Patient's impairment, disability and health-related quality of life

Musculoskeletal disorders substantially impacts physical activity, mental state, and quality of life (QOL). Generally, comprehensive assessment of upper limb function requires measures of impairment or disability as well as health-related quality of life. A growing number of outcome instrument have been introduced to evaluate upper limb function and disability, and these measures can be categorized as patient- or clinician-based, and as condition specific or general health-related QOL evaluations. The upper limb outcome instruments reviewed in this article assess different aspect of upper limb conditions, and the measures are affected by differences in cultural, psychological, and gender aspect of illness perception and behavior. Therefore, physician should select/interpret the outcome instruments addressing their primary purpose of research. Information about regional instruments for upper limb condition and health-related QOL in upper limb disorder may help us in decision-making for treatment priority or in interpretation of the treatment outcomes.

Correlational analysis of neck/shoulder pain and low back pain with the use of digital products, physical activity and psychological status among adolescents in Shanghai

Purpose

This study investigates the neck/shoulder pain (NSP) and low back pain (LBP) among current high school students in Shanghai and explores the relationship between these pains and their possible influences, including digital products, physical activity, and psychological status.

Methods

An anonymous self-assessment was administered to 3,600 students across 30 high schools in Shanghai. This questionnaire examined the prevalence of NSP and LBP and the level of physical activity as well as the use of mobile phones, personal computers (PC) and tablet computers (Tablet). The CES-D (Center for Epidemiological Studies Depression) scale was also included in the survey. The survey data were analyzed using the chi-square test, univariate logistic analyses and a multivariate logistic regression model.

Results

Three thousand sixteen valid questionnaires were received including 1,460 (48.41%) from male respondents and 1,556 (51.59%) from female respondents. The high school students in this study showed NSP and LBP rates of 40.8% and 33.1%, respectively, and the prevalence of both influenced by the student’s grade, use of digital products, and mental status; these factors affected the rates of NSP and LBP to varying degrees. The multivariate logistic regression analysis revealed that Gender, grade, soreness after exercise, PC using habits, tablet use, sitting time after school and academic stress entered the final model of NSP, while the final model of LBP consisted of gender, grade, soreness after exercise, PC using habits, mobile phone use, sitting time after school, academic stress and CES-D score.

Conclusions

High school students in Shanghai showed high prevalence of NSP and LBP that were closely related to multiple factors. Appropriate interventions should be implemented to reduce the occurrences of NSP and LBP.