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

Psychosocial Factors, Sleep, and Central Pain Processing for Making a Prognosis About Recovery of Pain, Function, and Quality of Life After Rotator Cuff Repair: An Exploratory Longitudinal Study

OBJECTIVE: To explore modifiable psychosocial factors, sleep-related variables, indices of central pain processing and patients' characteristics as potential prognostic factors for pain, shoulder function, and quality of life (QoL) 1 year after rotator cuff repair. DESIGN: This observational longitudinal study included 142 patients who were undergoing rotator cuff repair. All measures took place pre-rotator cuff repair (T0), and 12 weeks (T1) and 12 months (T2) after rotator cuff repair. METHODS: Mixed-effects linear regression modeled relationships between the Western Ontario Rotator Cuff Index (WORC, model A), the Subjective Shoulder Value (SSV, model B), and EuroQol's EQ-5D-5L for QoL (model C), and potential prognostic factors over time. Factors included psychosocial variables, sleep-related indices, and proxies of central pain processing. Patients' age, sex, and body mass index complemented the analyses. RESULTS: At follow-up (T2), data from 124 participants were available for analysis. Five prognostic factors were identified for the 1-year outcome. Better expectations for symptom reduction (P<.0001, -1.4 mm) and an increase in Douleur Neuropathique 4 score (P = .0481, -0.9 mm) affected the evolution of WORC over time (model A). An increase in injury perception subscale consequence (P = .0035, 0.04%) influenced the SSV trajectory (model B). In addition, when sleep quality (P = .0011, -0.13%) and sleep efficiency (P = .0002, 0.005%) improved, the EQ-5D-5L slope was affected (model C). CONCLUSION: Addressing cognitions, pain mechanisms and sleep behavior prior to rotator cuff repair can identify people who are at risk of a poor outcome after surgery. J Orthop Sports Phys Ther 2024;54(8):530-540. Epub 4 July 2024. doi:10.2519/jospt.2024.12398.

The impact of social deprivation on rotator cuff repair outcomes

BACKGROUND

Rotator cuff tears are a common orthopedic injury, and the role of social determinants of health (SDoH) in surgical outcomes remains underexplored. The goal of this study was to investigate the correlation between social deprivation, measured by the Area Deprivation Index (ADI), and outcomes following arthroscopic rotator cuff repair.

METHODS

We conducted a retrospective chart review on patients undergoing primary arthroscopic rotator cuff repair at a level 1 academic center between 2006 and 2019. Patient demographics (age, gender, race), comorbidities, ADIs, range of motion, visual analog pain scores, and patient-reported outcomes (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire [QuickDASH]) were collected. Patients were stratified into terciles based on their relative level of deprivation. Statistical analysis was performed using analysis of variance, t tests, χ2 tests, and univariate or multivariate logistic regression.

RESULTS

A total of 322 patients were included in this study. The most deprived group had a higher prevalence of diabetes compared to the least and intermediately deprived group (P < .001). Massive tear occurrence was greater in the least deprived group (P = .003) compared to the most deprived group. There was no difference in objective outcomes between groups. Patient-reported outcomes (SST, ASES, and QuickDASH scores) were worse in the most deprived group compared with the least and intermediate deprived groups.

CONCLUSION

Social deprivation significantly affects patient-reported outcomes in rotator cuff repair surgery. Although clinician-reported outcomes were consistent, patients' perceptions varied based on social determinants. Integrating SDoH considerations in orthopedic care is a promising next step in securing equitable approaches. However, more research is needed to validate and expand these findings.

Increased patient resilience scores are related to positive postoperative outcomes in rotator cuff repairs

HYPOTHESIS

We sought to determine whether patients' preoperative resilience scores predict postoperative outcomes in arthroscopic rotator cuff repair surgery.

METHODS

Patients were prospectively enrolled and underwent data collection preoperatively and at 3, 6, 12, and 24 months postoperatively. Data collected included demographic characteristics and the Brief Resilience Scale (BRS) score, visual analog scale score, Veterans RAND 12-Item Health Survey scores (mental component [VR-12M] and physical component [VR-12P]), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Single Assessment Numeric Evaluation score, and Simple Shoulder Test (SST) score.

RESULTS

In total, 131 patients had complete 1- or 2-year postoperative outcome measures. Female patients comprised 56.5% of our sample, and the average age was 57.6 years. Between the low, normal, and high resilience groups, there were significant differences in the VR-12M scores at 0, 12, and 24 months postoperatively (P < .01 for all). The VR-12P scores at 12 months were 44.2, 47.4, and 49.8 in the low, normal, and high resilience groups, respectively, showing a trend upward, but this failed to reach the level of significance (P = .08). The SST scores of the low, normal, and high resilience groups at 12 months were 69.1, 79.9, and 85.1, respectively, again showing a trend upward, but this failed to reach the level of significance (P = .07). The SST scores at 0 and 24 months did not differ between groups. There were no significant differences in American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores at 0, 12, or 24 months postoperatively. We found a significant positive correlation between the BRS score and SST score at 12 months (R = 0.18), VR-12M score at 12 months (R = 0.38), VR-12M score at 24 months (R = 0.31), and VR-12P score at 12 months (R = 0.21).

CONCLUSIONS

Our study provides evidence that BRS scores in patients undergoing arthroscopic rotator cuff repair are related to postoperative outcomes, measured through the VR-12M and SST scores at 2-year follow-up.

Predictors of pain development for contralateral asymptomatic degenerative rotator cuff tears based on features of an ipsilateral painful cuff tear: a prospective longitudinal cohort study

BACKGROUND

Prior rotator cuff disease natural history studies have focused on tear-related factors that predict disease progression within a given shoulder. The purpose of this study was to examine both patient- and tear-related characteristics of a painful rotator cuff tear that predict future pain development and functional impairment in a shoulder with a contralateral asymptomatic cuff tear.

METHODS

This was a prospective longitudinal cohort study of patients aged ≤65 years who underwent surgery for a painful degenerative rotator cuff tear and possessed an asymptomatic contralateral tear. Patients were followed up prospectively by shoulder ultrasound, physical examination, and functional score assessment. The primary outcome was change in the American Shoulder and Elbow Surgeons (ASES) score at 2 years. Secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, Patient-Reported Outcomes Measurement Information System (PROMIS) score, Hospital Anxiety Depression Scale (HADS) depression and anxiety scores, and Veterans RAND-12 (VR-12) mental component score (MCS).

RESULTS

Sixty-five patients were included, with a mean follow-up period of 37 months (range, 24-42 months). In 17 patients (26%), contralateral shoulder pain developed at a median of 15.2 months (interquartile range [IQR], 10.5 months). No difference in age, sex, Charlson Comorbidity Index, or occupational demand was noted between patients in whom pain developed and those in whom pain did not develop. In the presenting painful shoulder, there was no difference in baseline tear size, muscle degeneration, or biceps pathology between groups. The mean baseline tear length (8.6 mm vs. 3.8 mm, P = .0008) and width (8.4 mm vs. 3.2 mm, P = .0004) were larger in asymptomatic shoulders in which pain subsequently developed compared with those in which pain did not develop. However, there was no difference in mean tear enlargement (P = .51 for length and P = .90 for width). There were no differences in baseline ASES, WORC, Patient-Reported Outcomes Measurement Information System (PROMIS), or HADS depression and anxiety scores between shoulders in which pain developed and those in which pain did not develop; however, patients in whom pain developed reported a lower baseline VR-12 MCS (53.3 vs. 57.6, P = .04). Shoulders in which pain developed had higher visual analog scale pain scores (2.9 [standard deviation (SD), 2.5] vs. 0.6 [SD, 1.0]; P = .016), lower ASES scores 75 [SD, 33] vs. 100 [SD, 11.6]; P = .001), and significant changes in all WORC scales with pain onset compared with those that remained asymptomatic. The study showed no significant difference in changes in the HADS anxiety and depression scores but found a significant increase in the VR-12 MCS in patients in whom pain developed (7.1 [interquartile range, 12.6] vs. -1.9 [interquartile range, 8.7]; P = .036).

CONCLUSION

In one-quarter of patients with painful cuff tears, pain developed in a contralateral asymptomatic cuff tear that resulted in a measurable decline in function within 3 years. Our analysis showed that only the baseline tear size of the asymptomatic shoulder was predictive of pain development. There were no tear-related features of the presenting painful rotator cuff tear or indices of mental health and physical function or occupational demand that were predictive of future pain development at short-term follow-up.

Patients with rotator cuff tears present a psychological impairment, not only a functional deficit: a systematic review

INTRODUCTION

Psychological factors impact patients with rotator cuff tears (RCT) in terms of pain level, shoulder function, sleep disturbance, and quality of life (QoL). The aim of this study was to quantify the prevalence of psychological factors in those patients, evaluate their influence on patient-reported outcomes (PROMs), and assess the possible improvement with surgical treatment.

METHODS

The literature search was performed on PubMed, Web of Science, Wiley Cochrane Library up to January, 2023.

INCLUSION CRITERIA

RCT treated with arthroscopic rotator cuff reconstruction (ARCR), description of psychological variables evaluated with validated questionnaires, descriptions of PROMs.

RESULTS

Thirty-nine studies included 7021 patients. Depression was found in eight studies (19.2%), anxiety in 6 (13.0%), sleep disturbance in seven (71.3%), and distress in three studies (26.4%). Studies evaluating the relationship between psychological impairment and pain documented more pain and impaired shoulder function before and after ARCR in patients with altered psychological status.

DISCUSSION

An impaired psychological status has an important impact on patients' perception of their disease. RCT patients with psychological alterations often experience more pain and reduced shoulder function, thus having worse QoL.

CONCLUSION

This study underlines that psychological impairment largely affects RCT patient condition and treatment outcome, which underlines the importance of a multidisciplinary biopsychosocial intervention to achieve better results.

Patients With Depression and/or Anxiety Having Arthroscopic Rotator Cuff Repair Show Decreased Number of Prescriptions and Number of Psychotherapy Sessions in the Year After Surgery

PURPOSE

To determine whether the utilization of psychological treatments changes after arthroscopic rotator cuff repair (RCR) for patients with preoperative depression and/or anxiety.

METHODS

The Truven Healthcare Marketscan database was used to identify patients who underwent arthroscopic RCR between January 2009 and December 2016. We included all patients with diagnosis codes associated with either depression or anxiety before RCR. Patients were excluded if they did not have complete insurance coverage for 1 year before or after surgery, or if they had arthroscopic RCR in the year before the index surgical procedure. We compared the proportion of patients with preoperative depression or anxiety who filled a prescription and had psychotherapy procedural codes in the year before and the year after arthroscopic RCR.

RESULTS

A total of 170,406 patients who underwent RCR were identified, of which depression and/or anxiety was found in 46,737 patients (43.7% male). Of the 46,737 patients, 19.6% filled a prescription for a depression/anxiety medication at least once in the year before surgery. Of this subset of patients, 41.5% did not fill a prescription for depression or anxiety medication after surgery, whereas 32.6% continued medication use but demonstrated a median 30-day reduction in the number of days' worth of medication. Similarly, 13.1% of patients were attending psychotherapy sessions preoperatively, but 76.6% of those patients either stopped or reduced the amount of psychotherapy sessions in the year following RCR.

CONCLUSIONS

The number of prescriptions and psychotherapy sessions decreased in the year after RCR for patients with preoperative diagnoses of depression and/or anxiety.

LEVEL OF EVIDENCE

Level IV, case series.

A systematic review of biopsychosocial prognostic factors of recovery after a proximal humerus fracture

BACKGROUND

Proximal humerus fracture (PHF) is a common upper extremity injury. PHF often causes prolonged disability and interferes with independent function.

PURPOSE

This study reviewed and summarized prognostic factors of recovery following PHF and classified them within the International Classification of Functioning, Disability and Health (ICF) with each domain sub-categorized by modifiability.

STUDY DESIGN

Systematic review.

METHODS

We searched MEDLINE, CINAHL, EMBASE, and PsychINFO from the date of database inception to March 2019 and updated searches in December 2021. Studies included examining an association between prognostic factors and recovery with at least a 6-month follow-up. Two independent reviewers used the Quality in Prognosis Studies tool for methodological bias and levels of evidence. Designs showed wide variability in terms of characteristics of the included population, definition of recovery, assessment of prognostic factors, and outcome measures used. This prevented pooled estimates from being produced. Prognostic factors linked to ICF domains were possible.

RESULTS

Twenty-three studies including 4323 participants aged ≥18 met inclusion criteria. The risk of bias was low (35%), moderate (30%), and high (35%) across the included studies. Moderate evidence showed a significant association between pre-fracture functional independence and post-fracture complications with recovery. Fracture type, structural deformity, medication use, age, and gender were prognostic factors with inconclusive evidence. We assigned a weak level of evidence to the remaining 20 factors due to limited data. Immediate rehabilitation, compliance to post-fracture rehabilitation exercise, task-oriented exercise, and pain self-efficacy (i.e., coping behavior) are modifiable and are tapped into the ICF contextual factors.

CONCLUSIONS

An array of factors that fit within an ICF biopsychosocial framework have been investigated as potential mediators of outcomes after PHF. The evidence is incomplete conceptually and in terms of research design quality. Preoperative functional status is predictive of functional recovery emphasizing the importance of healthy aging.

Central sensitization syndrome in patients with rotator cuff tear: prevalence and associated factors

INTRODUCTION

A significant number of rotator cuff tear (RCT) patients developed chronic shoulder pain that did not correspond to physiological changes. Central sensitization syndrome (CSS) is a neurophysiological adaptation process that can result in hypersensitivity to peripheral stimuli. Although there is evidence of an association between CSS and musculoskeletal problems, no studies have focused on the association between CSS and RCT. The primary purpose of this study was to examine the prevalence of CSS in patients with RCT. The secondary purpose was to document the associated conditions and comorbidity that were associated with the CSS.

METHODS

This was a cross-sectional study of patients with RCT who completed the Central Sensitization Inventory (CSI). Patients with score of ≥ 40/100 were considered positive for CSS. Demographic and clinical data and CSI results were collected to analyze the prevalence and associated factors of CSS in RCT patients.

RESULTS

A total of 404 RCT patients were included, and the CSS prevalence was 39.4%. Compared to the non-CSS group, the CSS group had an odds ratio of 4.13 (95% CI, 2.70-6.32; p＜0.001) for ages 51-60, 3.07 (95% CI, 2.00-4.69; p＜0.001) for symptoms lasting more than 6 months, 6.08 (95% CI, 3.90-9.47; p＜0.001) for nonphysical laborers, 3.69 (95%CI, 2.42-5.61; p＜0.001) for long head of biceps (LHB) abnormality, 2.93 (95% CI, 1.93-4.45; p＜0.001) for concurrent shoulder stiffness, 4.82 (95% CI, 2.55-9.10; p＜0.001) for anxiety or panic episodes, and 2.11 (95% CI, 1.12, 4.00; p＜0.001) for depression.

CONCLUSIONS

The prevalence of CSS in patients with RCT was relatively high at 39.4%. The CSS was associated with higher age, female gender, and clinical findings of symptoms lasting over six months, nonphysical laborers, abnormal LHB, concurrent shoulder stiffness, anxiety, and depression.

One-year patient-reported outcomes following primary arthroscopic rotator cuff repair vary little by surgeon

Background

This study's purpose was to investigate the extent to which differences among operating surgeons may influence 1-year patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair (RCR) surgery, after controlling for general and disease-specific patient factors. We hypothesized that surgeon would be additionally associated with 1-year PROMs, specifically the baseline to 1-year improvement in Penn Shoulder Score (PSS).

Methods

We used mixed multivariable statistical modeling to assess the influence of surgeon (and alternatively surgical case volume) on 1-year PSS improvement in patients undergoing RCR at a single health system in 2018, controlling for eight patient- and six disease-specific preoperative factors as possible confounders. Contributions of predictors to explaining variation in 1-year PSS improvement were measured and compared using Akaike's Information Criterion.

Results

518 cases performed by 28 surgeons met inclusion criteria, with median (quartiles) baseline PSS of 41.9 (31.9, 53.9) and 1-year PSS improvement of 42 (29.1, 55.3) points. Contrary to expectation, surgeon and surgical case volume were neither statistically significantly nor clinically meaningfully associated with 1-year PSS improvement. Baseline PSS and mental health status (VR-12 MCS) were the dominant and only statistically significant predictors of 1-year PSS improvement, with lower baseline PSS and higher VR-12 MCS predicting larger 1-year PSS improvement.

Conclusion

Patients generally reported excellent 1-year outcomes following primary RCR. This study did not find evidence that the individual surgeon or surgeon case volume influences 1-year PROMs, independently of case-mix factors, following primary RCR in a large employed hospital system.

Psychosocial factors play a greater role in preoperative symptoms for patients with atraumatic shoulder instability: data from the MOON-Shoulder Instability group

BACKGROUND

Previous studies have demonstrated that psychosocial factors and comorbid depression are associated with worse preoperative baseline measures, clinical outcomes, and recovery in patients undergoing shoulder surgery. It is unknown whether this potential link would differ between those with traumatic vs. atraumatic shoulder instability, as symptoms may persist longer in atraumatic instability prior to surgical intervention. The purpose of this study was to determine if psychosocial factors and/or comorbid depression more heavily influence preoperative symptoms for patients with traumatic vs. atraumatic shoulder instability.

METHODS

Prospective baseline data from 1552 patients in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort were analyzed based on mechanism of injury while controlling for age, sex, and direction of instability. Multivariable linear regressions were performed to determine whether psychological factors (RAND 36 Mental Component Score [MCS], depression diagnosis, Personality Assessment Screener-22) were predictive of preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Western Ontario Shoulder Instability Index (WOSI) scores in the atraumatic group. The same model was repeated for the traumatic instability group, and the model fit was compared between groups, with P < .05 considered statistically significant.

RESULTS

Female sex and lower MCS were significantly associated with worse preoperative ASES and WOSI scores for the group with atraumatic instability (ASES R2 = 0.15, P < .001; WOSI R2 = 0.17, P < .001). The same model performed significantly worse (P < .05) for both ASES and WOSI scores in the group with traumatic instability (ASES R2 = 0.07, WOSI R2 = 0.08).

CONCLUSIONS

Worse preoperative psychosocial factors were found to be more strongly associated with shoulder-related pain and function for patients with atraumatic instability. Across multiple orthopedic conditions, depression and emotional well-being have been associated with worse preoperative symptoms and inferior postoperative patient-reported outcomes. Despite the stronger and significant association in atraumatic patients, worse psychosocial factors did not have as large an impact as has been seen in other, more chronic conditions such as osteoarthritis or rotator cuff tears. In addition to medically optimizing patients prior to surgery, the current findings identify a subset of shoulder instability patients that may benefit from a behavioral health intervention either prior to surgery or early in the postoperative period to potentially improve postoperative outcomes.

Psychiatric Disorders Are Predictive of Worse Pain Severity and Functional Outcomes After Fasciotomy for Chronic Exertional Compartment Syndrome of the Leg

OBJECTIVE

To determine whether concomitant psychiatric diagnoses and medication use were associated with postfasciotomy outcomes in patients with chronic exertional compartment syndrome (CECS).

DESIGN

Retrospective comparative cohort study.

SETTING

Single academic medical center from 2010 to 2020.

PATIENTS

All patients above 18 years old who underwent fasciotomy for CECS.

ASSESSMENT OF RISK FACTORS/INDEPENDENT VARIABLES

Psychiatric history was recorded from electronic health records including disease diagnosis and medications.

MAIN OUTCOME MEASURES

The 3 main outcome measures were postoperative pain using the Visual Analog Scale, functional outcomes using the Tegner Activity Scale, and return to sport.

RESULTS

Eighty one subjects (legs), 54% male, with an average age of 30 years and follow-up of 52 months were included. 24 subjects (30%) had at least one psychiatric diagnosis at the time of surgery. Regression analysis found psychiatric history to be an independent predictor of worse postoperative pain severity and postoperative Tegner scores (P < 0.05). Furthermore, subjects with psychiatric disorders not on medication had worse pain severity (P < 0.001) and Tegner scores (P < 0.01) versus controls, whereas subjects with a psychiatric disorder on medication had better pain severity (P < 0.05) versus controls.

CONCLUSIONS

History of psychiatric disorder was predictive of worse postoperative pain and activity outcomes after fasciotomy for CECS. Use of psychiatric medication was associated with improvement in pain severity in some domains.

Rotator cuff tendinopathy: magnitude of incapability is associated with greater symptoms of depression rather than pathology severity

BACKGROUND

Population-based studies have established that rotator cuff tendinopathy develops in most persons during their lifetimes, it is often accommodated, and there is limited correspondence between symptom intensity and pathology severity. To test the relationship between effective accommodation and mental health on its continuum, we studied the relative association of magnitude of capability with symptoms of anxiety or depression compared with quantifications of rotator cuff pathology such as defect size, degree of retraction, and muscle atrophy among patients presenting for specialty care.

METHODS

We analyzed a retrospective cohort of 71 adults seeking specialty care for symptoms of rotator cuff tendinopathy who underwent a recent magnetic resonance imaging scan of the shoulder and completed the following questionnaires: Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health questionnaire (a measure of symptom intensity and magnitude of capability, consisting of mental and physical health subscores), Generalized Anxiety Disorder questionnaire (measuring symptoms of anxiety), and Patient Health Questionnaire (measuring symptoms of depression). Two independent reviewers measured the sagittal length of the rotator cuff defect and tendon retraction in millimeters on magnetic resonance imaging scans (excellent reliability) and rated rotator cuff muscle atrophy and fatty infiltration (more limited reliability), and we used the average measurement or rating for each patient. Multivariable statistical models were used to identify factors associated with the PROMIS Global Health score and mental and physical health subscores.

RESULTS

Accounting for potential confounding in multivariable analysis, lower PROMIS Global Health total scores and physical health subscale scores were independently associated with greater symptoms of depression but not with measures of pathology. Lower PROMIS mental health subscale scores were independently associated with greater symptoms of anxiety and greater muscle atrophy.

CONCLUSIONS

The observation that magnitude of incapability among patients seeking care for symptoms of rotator cuff pathology is associated with symptoms of depression but not with measures of the severity of the rotator cuff pathology suggests that treatment strategies for patients who seek care for symptoms of rotator cuff tendinopathy may be incomplete if they do not anticipate and address mental health.

Prognostic factors for improvement of shoulder function after arthroscopic rotator cuff repair: a systematic review

Background

The identification of factors that specify prognostic models for postoperative results should be based on the best scientific evidence and expert assessment. We aimed to identify, map, and evaluate potential prognostic factors for the improvement of shoulder function in patients undergoing arthroscopic rotator cuff repair.

Methods

Longitudinal primary studies of arthroscopic rotator cuff repair reporting any multivariable factor analyses for shoulder function improvement with an endpoint assessment of at least 6 months were included. We systematically searched EMBASE, Medline, and Scopus for articles published between January 2014 and June 2021. The risk of bias of included studies and the quality of evidence were assessed using the Quality in Prognosis Studies tool and an adapted Grading of Recommendations, Assessment, Development, and Evaluations framework.

Results

Overall, 24 studies including 73 outcome analyses were included. We classified younger age and smaller tear size as probably prognostic for a greater improvement in objective outcomes. Shorter symptom duration, absence of a worker compensation claim, low preoperative level of functional status, and high preoperative pain level were classified as probably prognostic for greater improvement in patient-reported outcome measures. The quality of the synthesized evidence was low. Twenty-one studies had an overall high risk of bias.

Conclusion

Six potential prognostic factors for shoulder function after arthroscopic rotator cuff repair were identified. Along with ongoing expert opinion assessments, they will feed into a prognostic model-building process.

Association between changes in pain or function scores and changes in scapular rotations in patients with subacromial shoulder pain: a prospective cohort study

Background

Scapular dyskinesis is reported as one of the potential factors contributing to the presentation of pain in subacromial shoulder pain. In clinical practice, the evaluation and control of scapular dyskinesis is considered important for managing the subacromial shoulder pain. The aim is to determine the association between changes in pain or function and changes in scapular rotations in participants with subacromial shoulder pain.

Method

Pain, function and scapular rotations were measured in 25 participants with subacromial shoulder pain at baseline and after 8 weeks. Pain was measured with Numeric Pain Rating Scale (NPRS) and function was measured with Patient Specific Functional Scale (PSFS). Scapular rotations were measured with a scapular locator at 60°, 90° and 120° of scapular arm elevation. Spearman rank correlations (r_s) were used to assess the association between variables.

Findings

No association was observed between changes in pain or function scores with changes in scapular upward/downward rotations (r_s = 0.03 to 0.27 for pain and − 0.13 to 0.23 for function) and scapular anterior/posterior tilt (r_s = − 0.01 to 0.23 for pain and − 0.13 to 0.08 for function) of arm at 60°, 90° and 120° elevation. Data associated with scapular internal/external rotation was not reported due to low reliability.

Conclusion

These findings reject associations between changes in pain or function scores and scapular rotations. Future observational study is warranted using a multifactorial approach to understand potential factors that contribute to the presentation of subacromial shoulder pain.

Are psychosocial variables, sleep characteristics or central pain processing prognostic factors for outcome following rotator cuff repair? A protocol for a prospective longitudinal cohort study

INTRODUCTION

Prognosis following surgical rotator cuff repair (RCR) is often established through the assessment of non-modifiable biomedical factors such as tear size. This understates the complex nature of recovery following RCR. There is a need to identify modifiable psychosocial and sleep-related variables, and to find out whether changes in central pain processing influence prognosis after RCR. This will improve our knowledge on how to optimise recovery, using a holistic rehabilitation approach.

METHODS AND ANALYSIS

This longitudinal study will analyse 141 participants undergoing usual care for first time RCR. Data will be collected 1-21 days preoperatively (T1), then 11-14 weeks (T2) and 12-14 months (T3) postoperatively. We will use mixed-effects linear regression to assess relationships between potential prognostic factors and our primary and secondary outcome measures-the Western Ontario Rotator Cuff Index; the Constant-Murley Score; the Subjective Shoulder Value; Maximal Pain (Numeric Rating Scale); and Quality of Life (European Quality of Life, 5 dimensions, 5 levels). Potential prognostic factors include: four psychosocial variables; pain catastrophising, perceived stress, injury perceptions and patients' expectations for RCR; sleep; and four factors related to central pain processing (central sensitisation inventory, temporal summation, cold hyperalgesia and pressure pain threshold). Intercorrelations will be assessed to determine the strength of relationships between all potential prognostic indicators.Our aim is to explore whether modifiable psychosocial factors, sleep-related variables and altered central pain processing are associated with outcomes pre-RCR and post-RCR and to identify them as potential prognostic factors.

ETHICS AND DISSEMINATION

The results of the study will be disseminated at conferences such as the European Pain Congress. One or more manuscripts will be published in a peer-reviewed SCI-ranked journal. Findings will be reported in accordance with the STROBE statement and PROGRESS framework. Ethical approval is granted by the Ethical commission of Canton of Zurich, Switzerland, No: ID_2018-02089 TRIAL REGISTRATION NUMBER: NCT04946149.

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.

Impact of patient resilience on early recovery from rotator cuff repair

AIMS

We sought to evaluate early recovery from rotator cuff repair by assessing the correlation between patient resilience and postoperative shoulder pain and function, and physical and mental health.

METHODS

Patients scheduled to undergo arthroscopic rotator cuff repair were prospectively enrolled. Resilience was assessed using the Brief Resilience Scale (BRS), pain and function was measured by American Society of Shoulder and Elbow Surgeons (ASES) shoulder scores, and physical and mental health was measured by the Patient-Reported Outcome Measurement Information System Global Health-10 (PROMIS-10). All scores were obtained preoperatively and postoperatively at three- and six months. Spearman correlation coefficient (r) was used to assess the relationship between variables.

RESULTS

Ninety-eight patients ultimately underwent rotator cuff repair; 76 and 68 patients provided three- and six-month follow-up, respectively. There was no statistically significant correlation between preoperative BRS and three- and six-month ASES. However, there was a statistically significant correlation between preoperative BRS and three-month PROMIS-10 (r = 0.3763, p = 0.009) and concurrent BRS and PROMIS-10 at three months (r = 0.5657, p = 0.0025) and six months (r = 0.5308, p = 0.0025).

DISCUSSION

Resilience appears to be more predictive of global physical and mental health than shoulder pain and function in early recovery from rotator cuff repair.

Minimum 2-year outcomes of reverse total shoulder arthroplasty for fracture: how does acute arthroplasty compare with salvage?

BACKGROUND

The objective of our study was to compare patient-reported outcome measures, range of motion (ROM), complication rates, and reoperation rates after reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures between patients treated acutely (≤30 days after injury), those treated after initial nonoperative treatment (>30 days after injury), and those treated after failed open reduction-internal fixation. Secondarily, we aimed to identify any patient-, injury-, or surgery-related factors independently associated with our response variables.

METHODS

We identified 576 patients who sustained a proximal humeral fracture treated with primary or revision shoulder arthroplasty between January 2003 and August 2018. The final cohort included 153 patients. Multivariable analysis was used to assess whether explanatory variables were associated with our response variables.

RESULTS

Initial nonoperative treatment compared with acute rTSA was associated with worse Shoulder Subjective Value (P = .04), Shoulder Pain and Disability Index score (P = .03), and Shoulder Pain and Disability Index disability subscale score (P = .03). Only depression was independently associated with worse visual analog scale pain score (P = .04). There was no significant difference in postoperative ROM between the initial treatment groups. Older age was associated with decreased ROM in all planes. Additionally, ipsilateral upper-extremity injury was associated with decreased active abduction (P = .03), and cemented humeral stems were associated with decreased passive abduction (P = .03). Initial nonoperative treatment was associated with increased complication rates (odds ratio, 3.65; 95% confidence interval, 1.11-12.01), and male sex was associated with higher rates of reoperation (odds ratio, 3.53; 95% confidence interval, 1.31-9.51).

CONCLUSIONS

Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. Patients who undergo rTSA after failed open reduction-internal fixation show no difference in patient-reported outcomes compared with those who undergo acute rTSA. In addition, male patients are at higher risk of reoperation, whereas older patients are at risk of decreased ROM. Patients with preoperative depression are at risk of increased pain at 2 years after surgery.

Rotator cuff repair vs. nonoperative treatment: a systematic review with meta-analysis

BACKGROUND

Rotator cuff (RC) tears have been widely studied as many treatment strategies have been recommended. However, optimal management for patients with RC tears is still unclear.

PURPOSE

The main aim of this systematic review was to analyze randomized controlled trials using meta-analysis to compare repair to conservative treatments for patients with any type of RC tear.

METHODS

MEDLINE, Cochrane Library (CENTRAL database), PEDro, and Scopus databases were used. Two independent reviewers selected randomized controlled trials that compared surgical to conservative treatments for RC tear patients. The studies included were assessed using Cochrane Risk of Bias 2 tools, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and to summarize the study conclusions.

RESULTS

Six trials were included. Pooled results showed improvement in function and pain perception in favor of the repair group at 6 months (mean difference 1.26, 95% CI -2.34, 4.85, P = .49; and -0.59, 95% CI -0.84, -0.33, P < .001, respectively), at 12 months (mean difference 5.25, 95% CI 1.55, 8.95, P = .005, for function; and -0.41, 95% CI -0.70, -0.12, P = .006, for pain) and at 24 months (mean difference 5.57, 95% CI 1.86, 9.29, P = .003, for function; and -0.92, 95% CI -1.31, -0.52, P < .001, for pain) in RC tear patients. However, these differences did not reach the minimum clinically important difference. The certainty of evidence ranged from low to moderate because of imprecision in the studies included.

CONCLUSIONS

Overall analysis showed that in patients with RC tear, repair compared with conservative treatment could result in increased pain reduction and functional improvement at 6, 12, and 24 months. Even if these effects were often statistically significant, their clinical relevance was limited. Moreover, the certainty of body of evidence ranged from low to moderate.

Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation

Purpose

Although baseline biopsychosocial factors are associated with short-term patient-reported outcomes following distal radius fracture open reduction internal fixation (ORIF), their effect on mid-term outcomes is unclear. We aimed to evaluate the effect of social deprivation, previously established as a surrogate for depression, pain interference, and anxiety, on quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores >1 year following distal radius ORIF.

Methods

Adult patients (≥18 years) with an isolated distal radius fracture treated with ORIF by orthopedic trauma and hand surgeons at a single tertiary academic center over a 3-year period were included. Outcomes at ≥1 year postoperatively were evaluated using QuickDASH. Age, follow-up duration, area deprivation index (ADI; a measure of social deprivation), subspecialty (hand vs trauma), and postoperative alignment were assessed using linear regression with 95% confidence intervals after bootstrapping and a permutation test for P values to test for their association with the final QuickDASH score.

Results

Follow-up data were obtained for 98 of 220 (44.5%) patients at a mean of 3.1 ± 1.0 years after surgery. Mean age and ADI were 53.2 ± 15.4 years and 26.8 ± 18.7, respectively. Most fractures were intra-articular (67.3%), and 72.4% had acceptable postoperative alignment parameters, as defined by the American Academy of Orthopaedic Surgeons clinical practice guidelines. The mean QuickDASH score was 13.0 ± 16.5. There were no significant associations between the final QuickDASH score and any studied factor, including ADI, as determined using univariable analysis. Multivariable analysis showed no association between ADI and the final QuickDASH score, independent of age, sex, treating service, follow-up duration, and fracture alignment or pattern.

Conclusions

At mid-term follow up after distal radius ORIF, ADI did not correlate with QuickDASH scores, and the QuickDASH scores of the patients did not differ from those of the general population. However, our cohort mostly comprised patients with levels of deprivation below the national median. Although studies have shown that the short-term outcomes of distal radius ORIF are influenced by biopsychosocial factors, outcomes at the time of final recovery may not be associated with social deprivation.

Type of study/level of evidence

Prognostic IV.

Prior mood disorder diagnoses do not relate to current mood disorder symptoms or patient-reported disease severity in rotator cuff patients

BACKGROUND

Surgery for rotator cuff syndrome does not always produce symptom improvement. Biological factors may explain some symptoms, but mood disorder symptoms may also contribute. The purpose of this study is to examine the interaction between disease severity, prevalence of mood disorder diagnoses, and current mood disorder symptoms in preoperative rotator cuff patients.

METHODS

A prospective cohort of patients aged 35-75 years with unilateral rotator cuff disease awaiting surgery participated. Demographics, psychiatric history, the Hospital Anxiety & Depression Scale, and the Western Ontario Rotator Cuff index were collected. Descriptive and univariate statistical testing was performed.

RESULTS

Of 140 participants (75M:65W) aged 55 ± 8 years, 34 reported a prior diagnosis of a mood disorder. There was a moderate positive relationship between disease severity and current depression and anxiety scores. Women were more likely to carry a diagnosis of a mood disorder, but there were no differences in current symptom levels between genders. No differences were found in patient-reported outcome measure scores between patients with and without a mood disorder diagnosis.

DISCUSSION

Current mood disorder symptoms were associated with greater disease severity, whereas the presence of a past mood disorder diagnosis was not. Awareness of this relationship may reduce bias about past mood disorder diagnoses during decision-making.

Which Risk Factors Are Associated with Pain and Patient-reported Function in Patients with a Rotator Cuff Tear?

BACKGROUND

Patient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores.

QUESTION/PURPOSE

After controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?

METHODS

Fifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05.

RESULTS

This model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r2 = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.65; p < 0.001).

CONCLUSION

Our results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan.

LEVEL OF EVIDENCE

Level II, prognostic study.

Analysis of Functional Recovery and Subjective Well-Being after Arthroscopic Rotator Cuff Repair

Background: Rotator cuff tears are common causes of functional shoulder instability and often lead to arthroscopic rotator cuff repair. A well-programmed rehabilitation leads to successful tendon healing, positive functional recovery and subjective well-being (SWB). Objective: To evaluate the changes in shoulder functioning and SWB pre-, post-outpatient rehabilitation and after one-month follow-up. Materials and Methods: A total of 44 patients were assessed three times: at the beginning (six weeks’ post-surgery), at the end of outpatient rehabilitation (2–3 weeks) and one month after rehabilitation. The outcome measures were the Disabilities of the Arm, Shoulder and Hand score (DASH), active range of motion (ROM), manual muscle testing (MMT), hand dynamometry (HD) and pain level by a Visual Analogue Scale (VAS). SWB was assessed by Rosenberg self-esteem scale (RSES), Positive and Negative Affect Schedule (PANAS) and the Lithuanian Psychological Well-Being Scale (LPWBS). Results are presented as a difference between periods. Results: Affected shoulder motor function (MMT, HD and ROM) significantly improved in three periods (p < 0.05); however, major recovery was observed in the follow-up period. VAS scores meaningfully decreased over all stages and negatively correlated with motor function recovery (p < 0.05). DASH rates exhibited significant retrieval in all phases, especially in follow-up. SWB results demonstrated the larger effects of self-evaluation in follow-up, improved daily functions and psychological wellness, then negative emotions significantly decreased (p < 0.05). Conclusions: The experienced pain and psychosocial factors significantly influence functional recovery of the shoulder during rehabilitation. The improvement in motor function, ability and pain relief during rehabilitation increases level of SWB, psychological wellness and positive emotional affect in long-term context.

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.

Establishing Clinically Significant Outcomes for Patient-Reported Outcomes Measurement Information System After Biceps Tenodesis

PURPOSE

To establish thresholds for improvement in patient-reported outcome scores that correspond with clinically significant outcomes (CSOs) including the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive testing (CAT) and pain interference (PIF) CAT after biceps tenodesis (BT) and to assess patient variables that are associated with achieving these outcomes.

METHODS

After institutional review board approval was obtained, a prospectively maintained institutional database was queried for patients undergoing BT between December 2017 and August 2019. Patients undergoing BT in isolation or BT in conjunction with rotator cuff debridement, SLAP repair, subacromial decompression, or distal clavicle excision were included in the analysis. Anchor- and distribution-based methods were used to calculate the MCID whereas an anchor-based method was used to calculate SCB and the PASS for PROMIS UE CAT and PIF CAT.

RESULTS

A total of 112 patients (86.8% follow-up) who underwent BT were included for analysis. The MCID, net SCB, absolute SCB, and PASS for PROMIS UE CAT were 4.02, 9.25, 43.4, and 41.1, respectively. The MCID, net SCB, absolute SCB, and PASS for PROMIS PIF CAT were -4.12, -10.7, 52.4, and 52.4, respectively. Higher preoperative UE CAT and PIF CAT scores, preoperative opioid use, depression, and living alone were negative predictors of CSO achievement. Male sex and regular participation in exercise were positive predictors of CSO achievement.

CONCLUSIONS

Patients with higher preoperative UE scores were less likely to achieve the MCID (odds ratio [OR], 0.84), whereas patients with higher preoperative PIF scores were less likely to achieve absolute SCB and the PASS (OR, 0.83-0.89). Most patients achieved the MCID for PIF CAT (70.5%) and UE CAT (62.5%) at final follow-up. Male sex (OR, 4.38-9.15) and regular exercise participation (OR, 6.45-18.94) positively predicted CSO achievement, whereas preoperative opioid use (OR, 0.06), depression (OR, 0.23), and living alone (OR, 0.90) were negative predictors of CSO achievement.

LEVEL OF EVIDENCE

Level IV, case series.

The Effect of Patient and Surgical Factors on Opioid Prescription Requests Following Arthroscopic Rotator Cuff Repair

Purpose

To determine whether differences in total morphine equivalent doses (MEDs) prescribed after arthroscopic rotator cuff repair (RCR) existed because of age younger than or older than 55 years and sex and to characterize potential risk factors for needing an opioid medication refill, visiting a provider other than the surgeon (either in the emergency department or ambulatory settings), and postoperative pain control requiring opioids approximately 6 weeks from the date of surgery.

Methods

A retrospective cohort study of 100 patients who underwent arthroscopic RCR between July 1, 2018, to November 30, 2018, in a single institution was performed. Data including demographics, perioperative treatments, and postoperative opioid prescriptions were recorded. Our primary hypotheses were evaluated with the Wilcoxon-Mann-Whitney test. Univariate and multivariate analyses assessed potential risk factors for the 3 outcomes of interest. Results were given in adjusted odds ratios (aORs), 95% confidence intervals (CIs), and P values.

Results

There was a difference (P = .038) in total MEDs used (in 5 mg oxycodone tablets) between males (median 56 tablets; interquartile range, 50-98 tablets) and females (median 78 tablets; interquartile range, 56-116 tablets). Age younger than 55 years was a risk factor for seeking an opioid refill (OR = 2.51; CI, 1.11-5.66; P = .026). A significant risk factor for visiting another provider was preoperative opiate use (OR = 15.0; CI, 1.79-125.8; P = .013). Age younger than than 55 years (aOR = 2.51; CI, 1.01-6.02; P = .047), body mass index (aOR = 1.08; CI, 1.01-1.17; P = .046), and shorter surgical duration (aOR = 0.97; CI, 0.95-0.99, P =.007) were independent predictive factors for requiring opioids for pain control 6 weeks after surgery.

Conclusions

After arthroscopic RCR, MED prescription is higher for females than males. The risk factors for requesting opioid prescription refill for pain control 6 weeks after surgery were age younger than 55 years and shorter surgical duration.

Level of Evidence

Level III, retrospective comparative study.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study

INTRODUCTION

In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective.

METHODS AND ANALYSIS

A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.

ETHICS AND DISSEMINATION

This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.

TRIAL REGISTRATION NUMBER

NCT04321005.

PROTOCOL VERSION

Version 2 (13 December 2019).

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.

Associations of preoperative patient mental health status and sociodemographic and clinical characteristics with baseline pain, function, and satisfaction in patients undergoing primary shoulder arthroplasty

HYPOTHESIS AND BACKGROUND

Shoulder pain and dysfunction are common indications for shoulder arthroplasty, yet the factors that are associated with these symptoms are not fully understood. This study aimed to investigate the associations of patient and disease-specific factors with preoperative patient-reported outcome measures (PROMs) in patients undergoing primary shoulder arthroplasty. We hypothesized that worse mental health status assessed by the Veterans RAND 12-Item Health Survey (VR-12) mental component score (MCS), glenoid bone loss, and increasing rotator cuff tear severity would be associated with lower values for the preoperative total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscores.

METHODS

We prospectively identified 12 patient factors and 4 disease-specific factors as possible statistical predictors of preoperative PROMs in patients undergoing primary shoulder arthroplasty at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in the preoperative PSS and its subscores.

RESULTS

A total of 788 cases performed by 12 surgeons met the inclusion criteria, with a preoperative median total PSS of 31 points (pain, 10 points; function, 18 points; and satisfaction, 1 point). As hypothesized, a lower VR-12 MCS was associated with lower preoperative PSS pain, function, and total scores, but patients with intact status or small to medium rotator cuff tears had modestly lower PSS pain subscores (ie, more pain) than patients with large to massive superior-posterior rotator cuff tears. Glenoid bone loss was not associated with the preoperative PSS. Female sex and fewer years of education (for all 4 outcomes), lower VR-12 MCS and preoperative opioid use (for all outcomes but satisfaction), and rotator cuff tear severity (for pain only) were the factors most prominently associated with preoperative PROMs.

CONCLUSION

In addition to mental health status and rotator cuff tear status, patient sex, years of education, and preoperative opioid use were most prominently associated with preoperative PROMs in patients undergoing shoulder arthroplasty. Further studies are needed to investigate whether these factors will also predict postoperative PROMs.

Resilience as a Predictor of Patient Satisfaction With Nonopioid Pain Management and Patient-Reported Outcome Measures After Knee Arthroscopy

PURPOSE

The purpose of this study was to evaluate the Brief Resilience Score (BRS) as a predictor for patient satisfaction with nonopioid pain management and patient-reported outcome measures (PROMs) after arthroscopic partial meniscectomy or chondroplasty.

METHODS

One hundred seventy-five patients undergoing arthroscopic partial meniscectomy and/or chondroplasty were recruited from a single clinic and were preoperatively stratified into low-to-normal resilience or high resilience groups as measured by the BRS. Satisfaction with nonopioid pain control was assessed at a 2-week follow-up visit using the Hospital Consumer Assessment of Healthcare Provider and Systems questionnaire, and various PROMs were measured at 3 and 6 months postoperatively. Statistical analysis was performed to assess for differences in satisfaction with pain control or PROMs between resilience groups.

RESULTS

Analysis revealed no statistically significant differences between the low-to-normal resilience group and the high resilience group with regard to satisfaction with nonopioid pain control or PROMs assessed at 3- or 6-month follow-ups. Outcome measures [visual analog scale pain, Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain, KOOS Activities of Daily Living, KOOS Quality of Life, Single Assessment Numerical Evaluation (SANE) Knee, and Veterans Rand 12-Item Health Survey Physical and Mental Component Scores] all followed expected trajectories after surgery, without a statistically significant difference between resilience groups.

CONCLUSION

This study provides evidence that preoperative resilience score, as measured by the BRS, does not correlate with postoperative patient-reported functional outcome or satisfaction with a nonopioid pain regimen after knee arthroscopy.

LEVEL OF EVIDENCE

II.

Mental health and tobacco use are correlated with PROMIS upper extremity and pain interference scores in patients with shoulder pathology

PURPOSE

To determine whether patient demographics have predictive influence on patient-reported outcomes measurement information system (PROMIS) domains of pain interference (PROMIS-PI), depression (PROMIS-D), and upper extremity (PROMIS-UE) for patients with shoulder pathology treated nonoperatively.

METHODS

Patients with partial rotator cuff tears, impingement, scapular dyskinesia, osteoarthritis, muscle strains, biceps tendonitis, instability, and acromioclavicular arthritis were retrospectively identified. Patients who underwent surgery were excluded. Demographic characteristics were documented, and PROMIS scores before and after nonoperative intervention were analyzed for correlations between each domain.

RESULTS

A total of 638 questionnaires (PROMIS-UE, PROMIS-PI, and PROMIS-D) were analyzed. PROMIS-UE had a strong negative correlation with PROMIS-PI (R = - 0.73, P < .001). PROMIS-PI and PROMIS-D demonstrated a positive correlation of moderate strength (R = 0.54, P < .001). Patients who never used tobacco, compared to current or former users, had significantly higher PROMIS-UE scores (34.5 vs. 30.6 and 31.9; P < .001), lower PROMIS-PI (59.7 vs. 63.1 and 60.9; P < .001), and lower PROMIS-D scores (47.3 vs. 52.1 and 49.3; P < .001). Patients with body mass index < 24.8 had significantly higher PROMIS-UE scores than those with > 24.8 (P < .05).

CONCLUSION

There is an inverse relationship between upper extremity physical function and pain and depression, as measured by PROMIS scores. Smoking and increased BMI are significant contributors to worse outcomes in patients with shoulder pathology, even in nonoperative populations. Counseling patients regarding prognosis and functional outcomes is important in managing their expectations in this patient population.

The effect of psychological factors on pain, function and quality of life in patients with rotator cuff tendinopathy: A systematic review

BACKGROUND

Psychological factors may affect the pain level, shoulder function and quality of life in patients with rotator cuff tendinopathy.

OBJECTIVE

To systematically review the prevalence of psychological factors reported in patients with rotator cuff tendinopathy; and to determine the association between psychological factors and pain, function and quality of life in patients with rotator cuff tendinopathy.

STUDY DESIGN

Systematic review METHODS: Pubmed, Embase, CINAHL and Web of Science were systematically searched from inception to June 2019. Studies that investigated patients with signs and symptoms suggestive of rotator cuff tendinopathy, and reported psychological variables and patient-reported outcome measures including pain, shoulder function or disability and quality of life.

RESULTS

A total of 14 studies were included. Our results showed that 22.8%-26.2% of patients with rotator cuff tendinopathy reported depression; 23% reported anxiety; and 70.2%-89% of patients reported sleep disturbance or insomnia. Overall, nine psychological factors were identified to be associated with pain, function and quality of life in patients with rotator cuff tendinopathy. Low-to-moderate quality of evidence suggests that various psychological factors are associated with pain, function and quality of life in patients with rotator cuff tendinopathy CONCLUSION: This review identified various psychological factors may affect the pain level, shoulder function and quality of life in patients with rotator cuff tendinopathy, and the causal relationship warrants future high-quality prospective studies.

Cost-Effectiveness of Supervised versus Unsupervised Rehabilitation for Rotator-Cuff Repair: Systematic Review and Meta-Analysis

Background: The objective of the present study was to compare the efficacy between supervised and unsupervised rehabilitation after rotator-cuff (RC) repair in terms of clinical outcomes, visual-analog-scale (VAS) score, range of motion (ROM), and risk of retear. Material: a comprehensive search of Pubmed, CINAHL, Cochrane, EMBASE, Ovid, and Google Scholar databases through a combination of the following keywords with logical Boolean operators: “informed”, “uninformed”, “unsupervised”, “supervised”, “rehabilitation”, “physical therapy”, “physical therapies”, “postoperative period”, “physical-therapy techniques”, “physical-therapy technique”, “exercise”, “exercise therapy”, “rotator cuff”, “rotator-cuff tear”, and “rotator-cuff repair”. For each article included in the study, the following data were extracted: authors, year, study design, sample size and demographic features, RC tear characteristics, clinical outcomes, ROM, VAS score, retear rate, and time of follow-up. Meta-analysis was performed in terms of VAS score. Results: Four randomized control trials with 132 patients were included. One study demonstrated significant improvement in VAS, active ROM, and the activity of the muscle’s motor units at stop and during maximal effort in supervised patients. Another one showed lower retear rates in the supervised group. The remaining two randomized controlled trials did not reveal any significant differences between supervised and unsupervised rehabilitation in terms of clinical outcomes. Moreover, higher costs were described for supervised rehabilitation. The VAS was not significantly different in the two groups (9.9 compared with 8.25, p = 0.23). Conclusions: although several publications address the problem of RC lacerations, there is a paucity of evidence in the literature regarding the effectiveness of supervised and unsupervised rehabilitation protocols. This systematic review and meta-analysis showed no significant differences between the two types of rehabilitation in terms of VAS scores, while outlining the pros and cons of each protocol.

Cross-cultural adaptation, reliability, and validity of the Italian version of the Shoulder Disability Questionnaire

BACKGROUND

The Shoulder Disability Questionnaire (SDQ) demonstrated promising psychometric properties, but currently there is no evidence of an Italian version.

OBJECTIVE

To cross-culturally adapt the Italian version of the SDQ (SDQ-I) and to explore its psychometric properties in patients with non-specific shoulder pain (SP).

METHODS

The SDQ-I was translated according to international guidelines and administered to 105 patients with SP. The SDQ-I scores were compared with Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), Numerical Pain Rating Scale (NPRS), and 36-item Short Form Health Survey (SF-36). Structural validity (Exploratory Factor Analysis [EFA]), internal consistency (Cronbach's alpha), test-retest reliability (Intraclass Correlation Coefficient [ICC]), measurement error (Standard Error of the Measurement [SEM], Minimal Detectable Change [MDC]), and construct validity (hypothesis testing with correlation of the DASH, NPRS, and SF-36) were explored.

RESULTS

The EFA identified two subscales (activity and participation-psychosocial factors). The internal consistency was supported for activity (α = 0.78), but not for participation-psychosocial subscales (α = 0.45). Both subscales demonstrated high test-retest reliability (ICC = 0.97 [95%CI = 0.96-0.98] and ICC = 0.95 [95%CI = 0.93-0.97]), a SEM of 5.8% and 7.0%, and a MDC of 15% and 19% for the first and second subscale, respectively. Construct validity was satisfactory, as >75% of the expected correlations were met for each subscale.

CONCLUSIONS

The SDQ-I was successfully cross-cultural adapted into Italian and proved to be valid for patients with non-specific SP, but its reliability should be further assessed, as internal consistency of the participation-psychosocial subscale showed some psychometric flaws. Further research is needed to refine the instrument.

Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs

BACKGROUND

Shoulder pain and dysfunction are common indications for rotator cuff repair surgery, yet the factors that are associated with these symptoms are not fully understood.

PURPOSE/HYPOTHESIS

This study aimed to investigate the associations of patient and disease-specific factors with baseline patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair. We hypothesized that tear size and mental health status, as assessed by the Veterans RAND 12-Item Health Survey mental component score (VR-12 MCS), would be associated with baseline total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscale scores.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We prospectively identified 12 patient factors and 12 disease-specific factors as possible statistical predictors for baseline PROMs in patients undergoing surgical repair of superior-posterior rotator cuff tears at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in baseline PSS and its subscale scores.

RESULTS

A total of 1442 patients who had undergone surgery by 23 surgeons met inclusion criteria, with a baseline median total PSS of 38.5 (pain, 12; function, 24.2; satisfaction, 2). Adjusted R² in multivariable models demonstrated that the 24 general patient and disease-specific factors accounted for 22% to 24% of the variability in total PSS and its pain and function subscale scores. Large/massive tear size was significantly associated with worse PSS total score and function score but not pain or satisfaction scores. Lower VR-12 MCS was significantly associated with worse total PSS and all 3 subscale scores. Among other factors significantly associated with baseline PROMs were sex, race, preoperative opioid use, years of education, employment status, acromion status, and adhesive capsulitis. Lower VR-12 MCS, preoperative opioid use, female sex, and black race were the factors most strongly associated with baseline PROMs.

CONCLUSION

Large/massive tear size, lower VR-12 MCS, and several additional patient and disease-specific factors are associated with baseline PROMs in patients undergoing rotator cuff repair. Further studies are needed to investigate whether these factors will also predict poor postoperative PROMs.

Factors associated with choice for surgery in newly symptomatic degenerative rotator cuff tears: a prospective cohort evaluation

BACKGROUND

The patient-related factors for the perceived need for surgery for degenerative rotator cuff tears are not known. The purpose of this study is to examine patient- and tear-specific factors leading to surgery in newly painful degenerative rotator cuff tears.

METHODS

Asymptomatic, degenerative rotator cuff tears were followed prospectively to identify the onset of pain and tear enlargement. Newly painful tears were continually monitored with a focus on identifying patient-specific (age, occupation, activity level) and tear-specific (tear type and size, tear progression, American Shoulder and Elbow Surgeons score, muscle degeneration) factors that are associated with surgical intervention.

RESULTS

Forty-eight of 169 newly painful shoulders were eventually managed surgically. Factors associated with surgical treatment included younger age (P = .0004), pain development earlier in surveillance (P = .0002), a greater increase in pain (P = .0001), a decline in American Shoulder and Elbow Surgeons score (P < .0001), and a history of contralateral shoulder surgery (P = .0006). Eighty-five of the 169 tears (50%) enlarged either before or within 2 years of pain development. Neither tear type (P = .13), tear enlargement (P = .67) nor tear size (P = .51) was associated with surgery. Neither the severity of muscle degeneration, occupational status, hand dominance, Shoulder Activity Score, nor changes in RAND-12 mental or physical scales differed between groups.

DISCUSSION

For newly painful rotator cuff tears, patient-specific factors such as younger age and prior surgery on the contralateral shoulder are more predictive of future surgery than tear-specific factors or changes in tear size over time.

Mental Health and Tobacco Use Are Correlated With Physical Function Outcomes in Patients With Knee Pain and Injury

PURPOSE

To examine the relation between the Patient-Reported Outcomes Measurement Information System (PROMIS) domains of Pain Interference (PROMIS-PI), Depression (PROMIS-D), and Physical Function (PROMIS-PF) for nonoperative patients presenting to our ambulatory sports orthopaedic clinic with knee complaints and to determine whether patient demographic characteristics influence PROMIS scores, particularly tobacco use.

METHODS

All patients treated nonoperatively for a primary complaint of knee pain were recruited for participation. Patients were included if they completed all 3 PROMIS questionnaires prior to their clinical evaluation. Patients were excluded if their treatment plan determined that surgical intervention was warranted. Survey results were compiled, and statistical correlations were run between PROMIS domains and patient demographic characteristics.

RESULTS

A total of 527 PROMIS questionnaire sets were included. PROMIS-PF had a strong negative correlation with PROMIS-PI (R = -0.75, P < .001) and a nearly moderate negative correlation with PROMIS-D (R = -0.47, P < .001). When evaluating patient demographic characteristics, we found a significant decrease in physical function scores and increases in pain and depression scores in both current and former tobacco users compared with nonsmokers. Differences in all PROMIS domains between smokers and nonsmokers exceeded minimal clinically important differences.

CONCLUSIONS

Our study showed an inverse correlation between PROMIS-PI and PROMIS-PF, as well as between PROMIS-D and PROMIS-PI, in patients seen in the ambulatory setting for knee complaints treated nonoperatively. A positive correlation was found between PROMIS-PI and PROMIS-D. Tobacco use was a patient demographic factor found to significantly impact PROMIS scores leading to minimal clinically important differences across all 3 PROMIS domains. The findings of this study may be used to identify patients at high risk of poor outcomes.

LEVEL OF EVIDENCE

Level III, observational study.

Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery

Background:

There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear.

Purpose/Hypothesis:

The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship–trained orthopaedic surgeons were included in the study. Preoperative PROMIS–Upper Extremity (PROMIS-UE), PROMIS–Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors.

Results:

Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI (R = –0.61; P < .001), and a negligible correlation was found between the PROMIS-UE and PROMIS-D (R = –0.28; P < .001). When stratified by patient demographic factors, the correlation between the PROMIS-UE and PROMIS-PI was stronger in female patients compared with male patients (R = –0.77 vs –0.46, respectively; P < .001 for both), stronger in black patients compared with white patients (R = –0.72 vs –0.56, respectively; P < .001 for both), and highest in current tobacco users (R = –0.80; P < .001).

Conclusion:

Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups.

The assessment of psychological factors on upper extremity disability: A scoping review

INTRODUCTION

The primary purpose of this scoping review was to describe the nature and extent of the published research that assesses the relationship between psychological features and patient-reported outcome following surgery or rehabilitation of upper extremity disease or injury.

METHODS

Twenty-two included studies were examined for quantitative study design, outcome measure, inclusion/exclusion criteria, follow-up and recruitment strategy. Patient population and psychological assessment tools were examined for validity.

RESULTS

Twenty-two studies met the inclusion criteria for this study. Only 7 of the 22 studies were longitudinal and the rest were cross sectional studies. Depression was the most common psychological status of interest and was included in 17 studies. Pain catastrophizing was the psychological status of interest in 5 of the studies. Four studies considered anxiety, 3 considered pain anxiety, 3 considered distress, 2 considered coping, 2 considered catastrophic thinking, and 2 considered fear avoidance beliefs.

DISCUSSION

The majority of studies in this review were cross-sectional studies. Cross-sectional studies may not provide conclusive information about cause-and-effect relationships. This review encourages clinicians to be mindful of the psychological implications found in rehabilitation of individuals with upper extremity disease or injury along with being cognizant of choosing appropriate measurement tools that best represent each patient's characteristics and diagnoses.

CONCLUSIONS

The nature of the research addressing psychological factors affecting outcomes after hand injury focus on negative traits and have limited strength to suggest causation as most have used cross-sectional designs. Stronger longitudinal designs and consideration of positive traits are needed in future studies.

Self-Perceived Pain in Chinese Patients With Cancer

Background

Pain is one of the most burdensome and prevalent symptoms cancer patient report and it has severe negative impact on patient's quality of life. The aim of this study is to estimate the prevalence of pain and to test the association between demographic, clinical, psychological factors, and self-assessed pain in Chinese cancer population.

Methods

A total of 553 cancer patients were recruited in this cross-sectional study. Patient's basic demographic data was collected by a study-designed information sheet, and patient's pain, sleep disturbance and psychological distress were assessed by several validated measurements (MPQ-SF, AIS, FoP-Q-SF, PHQ-9, and GAD-7). Descriptive statistics and hierarchical multiple regression analyses were performed.

Results

Of the 553 patients, 411 (74.32%) patients reported that they experience some degree of pain. Fear of progression, anxiety, insomnia, and depressive symptoms were significantly associated with different subscales and the overall pain score in bivariate correlation matrix. Insomnia, depressive symptoms, and fear of cancer progression were significant independent factors of cancer pain on multivariate analyses.

Conclusion

Psychological factors play a great role in the relationship between objective pathophysiology and patient's subjective experience of pain. It is important to evaluate each individual in detail with respect to psychological distress and pain severity when planning treatment and rehabilitation.

The Effect of Psychosocial Factors on Outcomes in Patients With Rotator Cuff Tears: A Systematic Review

PURPOSE

To determine whether psychosocial factors affect patient-reported outcomes in individuals with rotator cuff tears or after rotator cuff repair.

METHODS

A systematic review was conducted using a computerized search of the PubMed and Web of Science electronic databases in adherence with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Articles were then evaluated based on inclusion and exclusion criteria. The Newcastle-Ottawa Scale was used to assess study quality and risk of bias. Because of study heterogeneity and varied levels of evidence, meta-analysis was not possible.

RESULTS

Of 980 identified articles, 15 met the inclusion and exclusion criteria. In those reported, the visual analog scale correlation with distress scales ranged from -0.476 to 0.334, depending on outcome, with a trend toward increased pain in patients with distress. The depression subscale of the Hospital Anxiety and Depression Scale was negatively correlated with the American Shoulder and Elbow Surgeons score in 2 of 3 studies (-0.309 to 0.235). Six studies evaluated the presence of psychosocial factors and their correlation with patient-reported outcomes prior to surgery. These showed a significant correlation between rotator cuff pathology and psychological distress (i.e., depression or anxiety) as identified on standardized patient-reported outcome measures. Nine studies evaluated psychosocial factors either before and after surgery or only postoperatively. Of these 9 studies, 3 found no statistically significant differences in outcomes as related to psychosocial factors. In contrast, 6 of 9 reported an association between outcomes and psychosocial factors. Moreover, 2 of these 6 studies reported a direct relationship between patient expectations and outcomes, with 1 of these 2 studies finding that higher expectations improved baseline scores on the mental component summary of the Short Form 36 (r = 0.307). One study found significant differences in mental status in patients with rotator cuff tears based on age and sex.

CONCLUSIONS

This review found that most studies support that psychosocial factors do significantly influence the level of disability and pain experienced by patients preoperatively; however, 3 of 9 studies showed significant improvements in postoperative pain and function even with significant psychosocial confounders. These studies, however, do support that there is a direct relation between patient expectations and outcomes in rotator cuff surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Narcotic Use and Resiliency Scores Do Not Predict Changes in Sleep Quality 6 Months After Arthroscopic Rotator Cuff Repair

Background:

Patients with rotator cuff disease commonly complain of difficulty sleeping. Arthroscopic repair has been associated with improved sleep quality in many patients with rotator cuff tears; however, some individuals continue to suffer from sleep disturbance postoperatively.

Purpose:

To determine whether changes in sleep quality following rotator cuff repair are predicted by a patient’s narcotic use or ability to cope with stress (resilience).

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 48 patients undergoing arthroscopic rotator cuff repair were prospectively enrolled and completed the Connor-Davidson Resilience Scale (CD-RISC) preoperatively. The Pittsburgh Sleep Quality Index (PSQI) was administered preoperatively and at multiple intervals postoperatively for 6 months. Narcotic utilization was determined via a legal prescriber database. Pre- and postoperative sleep scores were compared using paired t tests and the McNemar test. Linear regression was used to determine whether narcotic use or CD-RISC score predicted changes in sleep quality.

Results:

An increased number of patients experienced good sleep at 6 months postoperatively (P < .01). Mean ± SD nocturnal pain frequency improved from 2.5 ± 1.0 at baseline to 0.9 ± 1.1 at 6 months. CD-RISC score had a positive predictive value on changes in PSQI score (R² = 0.09, P = .028) and nocturnal pain frequency (R² = 0.08, P = .041) at 2 weeks. Narcotic use did not significantly predict changes in PSQI score or nocturnal pain frequency (P > .05).

Conclusion:

Most patients with rotator cuff disease will experience improvement in sleep quality following arthroscopic repair. Patients demonstrated notable improvements in nocturnal pain frequency as soon as 6 weeks following surgery. CD-RISC resiliency scores had a significant positive predictive value on changes in sleep quality and nocturnal pain frequency at 2 weeks. Narcotic use was not associated with change in sleep quality.

Pain catastrophizing, anxiety, and depression in hip pathology

AIMS

Psychological factors play a critical role in patient presentation, satisfaction, and outcomes. Pain catastrophizing, anxiety, and depression are important to consider, as they are associated with poorer outcomes and are potentially modifiable. The aim of this study was to assess the level of pain catastrophizing, anxiety, and depression in patients with a range of hip pathology and to evaluate their relationship with patient-reported psychosocial and functional outcome measures.

PATIENTS AND METHODS

Patients presenting to a tertiary-centre specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, and depression. Validated assessments were undertaken such as: the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), and the 12-Item Short-Form Health Survey (SF-12). Patient characteristics and demographics were also recorded. Multiple linear regression modelling, with adaptive least absolute shrinkage and selection operator (LASSO) variable selection, was used for analysis.

RESULTS

A total of 328 patients were identified for inclusion, with diagnoses of hip dysplasia (DDH; n = 50), femoroacetabular impingement (FAI; n = 55), lateral trochanteric pain syndrome (LTP; n = 23), hip osteoarthrosis (OA; n = 184), and avascular necrosis of the hip (AVN; n = 16) with a mean age of 31.0 years (14 to 65), 38.5 years (18 to 64), 63.7 years (20 to 78), 63.5 years (18 to 91), and 39.4 years (18 to 71), respectively. The percentage of patients with abnormal levels of pain catastrophizing, anxiety, or depression was: 22.0%, 16.0%, and 12.0% for DDH, respectively; 9.1%, 10.9%, and 7.3% for FAI, respectively; 13.0%, 4.3%, and 4.3% for LTP, respectively; 21.7%, 11.4%, and 14.1% for OA, respectively; and 25.0%, 43.8%, and 6.3% for AVN, respectively. HADS Anxiety (HADSA) and Hip Disability Osteoarthritis Outcome Score Activities of Daily Living subscale (HOOS ADL) predicted the PCS total (adjusted R² = 0.4599). Age, HADS Depression (HADSD), and PCS total predicted HADSA (adjusted R² = 0.4985). Age, HADSA, patient's percentage of perceived function, PCS total, and HOOS Quality of Life subscale (HOOS QOL) predicted HADSD (adjusted R² = 0.5802).

CONCLUSION

Patients with hip pathology may exhibit significant pain catastrophizing, anxiety, and depression. Identifying these factors and understanding the impact of psychosocial function could help improve patient treatment outcomes. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care. Cite this article: Bone Joint J 2019;101-B:800-807.

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.

Do we really allow patient decision-making in rotator cuff surgery? A prospective randomized study

BACKGROUND

There is a growing patient interest in being involved in the decision-making process. However, little information is provided on how this information should be structured. Does it make a difference, in patient treatment decision-making, whether information is given based on the benefits or on the side effects in rotator cuff disorders?

METHODS

It is a prospective randomized study that includes patients diagnosed with rotator cuff tears. Patients were randomly allocated to either group A (benefit-inform) or group B (side effect-inform) and were asked to answer the following questions based on their assigned group: Group A: Your doctor informs you that you have a rotator cuff tear and states that if he/she surgically repairs your cuff tear you will improve and that the cuff remains healed at the 2-year follow-up in 71% of the cases where surgery is done. Would you choose surgery? Yes or No Group B: Your doctor informs you that you have a rotator cuff tear and that if he/she surgically repairs your cuff tear you will improve and that the cuff is torn again at 2-year follow-up in 29% of the cases where surgery is done. Would you choose surgery? Yes or No Age, gender, the shoulder affected and the functional status assessed through the Constant score were also recorded.

RESULTS

80 patients were randomized (43 to group A and 37 to group B). The patients assigned to group A (benefit) accepted surgery significantly more frequently than those assigned to group B (complication) (P = 0.000). In group A, 36 of 43 (84%) accepted surgery, compared to 17 of 37 (46%) in group B.

CONCLUSIONS

The way that information on rotator cuff disorders is provided strongly influences patients' treatment decisions.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03205852 . Registered 29 June 2017. Retrospectively registered.