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

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.

Physiotherapist-supervised exercises versus physiotherapist-prescribed home exercises for treating partial thickness rotator cuff tears: a randomized controlled trial

BACKGROUND

Partial thickness rotator cuff tears significantly affect physical and psychosocial well-being. This study aimed to compare the efficacy of physiotherapist-supervised exercise and physiotherapist-prescribed home exercise programs on physical and psychosocial health measures in partial thickness rotator cuff tears.

METHODS

Seventy patients with partial thickness rotator cuff tears (44 female; mean age, 50.1 ± 5.2 years) were divided into 2 groups. Both the physiotherapist-supervised exercise group (group 1, n = 35) and physiotherapist-prescribed home exercise group (group 2, n = 35) received a program consisting of glenohumeral joint range of motion, stretching, and strengthening exercises (twice a week for eight weeks). The primary outcome measures were the modified Constant-Murley Score (mCMS) and the Hospital Depression and Anxiety Scale. Secondary outcome measures were the visual analog scale, active range of motion (AROM), Pain Catastrophizing Scale, Pittsburg Sleep Quality Index, Short Form-12, and Global Rating of Change Scale. Patients were assessed at baseline and the end of the treatment. The significance level was adjusted to 0.025 after the Bonferroni correction.

RESULTS

Both groups showed significant improvements in all measures after treatment. There were no statistically significant group-by-time interactions for the mCMS (F = 12.47, P = .03) and the Hospital Depression and Anxiety Scale (F = 0.89, P = .14 for depression; F = 0.73, P = .44 for anxiety). However, the improvement in the mCMS was clinically meaningful in both groups. The overall group-by-time interaction was significant for the visual analog scale activity (P = .004), shoulder flexion (P = .01) and abduction (P = .02) AROM, and Pain Catastrophizing Scale (P = .005) in favor of group 1.

CONCLUSION

Exercise effectively improves physical and psychosocial health measures in partial thickness rotator cuff tears when delivered in the clinic or at home. However, exercise is more effective for activity pain, AROM, and pain catastrophizing when delivered in the clinic, highlighting the effectiveness of the physiotherapist-supervised exercise program.

Reverse shoulder arthroplasty following failed rotator cuff repair: A systematic review and meta-analysis

Background

Reverse shoulder arthroplasty (RSA) is an established operative treatment for failed rotator cuff repair (RCR) that may not be amenable to revision repair. The purpose of this meta-analysis is to evaluate the clinical outcomes for patients undergoing RSA following prior failed RCR compared with patients without prior RCR undergoing primary RSA.

Methods

A systematic search of articles in Pubmed, EMBASE and The Cochrane Library databases was carried out according to PRISMA guidelines. Comparative studies assessing outcomes of RSA after failed RCR versus primary RSA were included.

Results

Seven studies with 2149 total patients were included; 760 patients had a prior RCR and 1389 patients did not have a prior RCR. Prior failed RCR resulted in significantly lower postoperative ASES scores (mean difference [MD], -8.31 95% confidence interval [CI] -10.96, -5.66), less forward flexion (MD, -6.71 95%CI -11.75, -1.67), and higher VAS pain scores (MD; 0.85, 95% CI 0.47, 1.22) when compared to primary RSA. There were no significant differences in external rotation, complications rate, or rate of revision.

Conclusion

This study found that failed RCR prior to RSA was associated with lower functional outcomes scores, higher pain scores, and worse range of motion compared to primary RSA without prior RCR.

Predictive Factors for Poor Prognosis in Non-Surgical Treatment of Proximal Humerus Fractures in Elderly Patients

INTRODUCTION

Proximal humerus fractures (PHF) are common in the elderly, accounting for significant morbidity and mortality. Non-surgical treatment is a common option for low-demand elderly patients, but it can lead to unsatisfactory functional outcomes in some cases. The identification of predictive factors for poor prognosis in non-surgical management remains unclear. This study aimed to determine the predictive factors for poor prognosis in elderly patients treated non-surgically for displaced PHF and to assess associated complications.

METHODS

A retrospective cohort study was conducted involving patients aged 60 years or older with displaced PHF treated non-surgically from May 2020 to January 2023 at a reference hospital for orthopedic trauma. The primary outcome was functional assessment using the American Shoulder and Elbow Surgeons (ASES) scale at 12 months. Predictive factors such as metaphyseal fracture comminution, Pain Catastrophizing Scale (PCS) scores, and radiographic criteria were analyzed. Multivariate regression analyses were performed to identify independent predictors of poor outcomes.

RESULTS

Out of 140 initially selected patients, 103 met the inclusion criteria and completed the follow-up. The mean ASES score was 71.3±25.4 points. Multivariate analysis identified metaphyseal comminution (p < 0.001) and PCS scores ≥ 30 (p < 0.001) as significant predictors of poorer functional outcomes. Complications were observed in 17.4% of patients, including osteonecrosis (6.7%), nonunion (4.9%), and persistent pain and stiffness (5.8%).

CONCLUSION

Metaphyseal comminution and high PCS scores are significant predictors of poor prognosis in elderly patients undergoing non-surgical treatment for displaced PHF. These findings highlight the importance of considering both biomechanical and psychological factors when managing proximal humerus fractures in this population. Further studies with larger sample sizes and prospective designs are needed to validate these findings and refine treatment strategies.

Long-Term Association Between Patient-Reported Outcomes and Psychological Factors in Patients With a Distal Radius Fracture

Purpose

The outcome after a distal radius fracture (DRF) is often evaluated with radiography, clinical examination, and patient-reported outcome measures. However, research has identified associations between psychological factors and outcomes after a DRF. A knowledge gap exists about psychological factors and their potential implications for long-term outcomes after a DRF. The aim of this study was to examine the long-term association between psychological factors and patient-reported outcomes.

Methods

This multicenter investigation included patients aged 15-75 years with closed physes presenting with an acute DRF. Patients who completed a long-term follow-up (after 11-13 years) with patient-reported outcome measures were invited to participate in the study, and surveys measuring psychological factors were sent to the patients.

Results

Two hundred and four patients (70%) completed the follow-up (mean [range] age at injury, 56 [18-75] years; 154 were females [75%]). Multivariable analysis showed that higher age, injury to the dominant hand, and greater pain catastrophizing were associated with an increase in scores on the Disabilities of the Arm, Shoulder, and Hand questionnaire.

Conclusions

A decade after sustaining a DRF, patients with higher scores on the Pain Catastrophizing Scale reported inferior outcomes as measured by the Disabilities of the Arm, Shoulder, and Hand. The Pain Catastrophizing Scale accounts for 13% of the observed variance in Disabilities of the Arm, Shoulder, and Hand.

Type of study/level of evidence

Therapeutic level IIb.

Divine resilience: Unveiling the impact of religious coping mechanisms on pain endurance in arab older adults battling chronic pain

BACKGROUND

Chronic pain diminishes the quality of life for many Older Adults individuals. Identifying effective coping methods to enhance pain resilience is imperative as populations age. Older Adults commonly use religious faith and spiritual practices to endure pain, yet little research has explored their impact on pain tolerance.

METHODS

This cross-sectional study examined relationships between positive/negative religious coping styles and pain endurance in 200 Arab elders with chronic pain. Participants completed the Brief Arab Religious Coping Scale, Numeric Pain Rating Scale, WHOQOL-BREF, and demographic/medical history questionnaires.

RESULTS

Quantitative analysis demonstrated significant positive associations between positive religious reappraisal and active spiritual coping with higher self-reported pain endurance (p<.05). Negative religious coping styles lacked meaningful relationships with pain tolerance. Multiple regression confirmed the unique effects of reappraisal and spiritual practice on improving pain resilience, controlling for covariates.

CONCLUSIONS

Outcomes align with perspectives highlighting multidimensional neurocognitive, emotional, and psychosocial pain relief from religious coping. Findings underscore integrating positive faith-based resources in biopsychosocial paradigms for Older Adult's pain management. Additional research should investigate causal pathways and contextual factors influencing religious coping effects on diverse Older Adult subgroups.

Improved joint function when reaching behind the back is associated with patient reported outcomes in individuals with rotator cuff tears following exercise therapy

BACKGROUND

Reaching behind the back is painful for individuals with rotator cuff tears. The objectives of the study were to determine changes in glenohumeral kinematics when reaching behind the back, passive range of motion (RoM), patient reported outcomes and the relationships between kinematics and patient reported outcomes following exercise therapy.

METHODS

Eighty-four individuals with symptomatic isolated supraspinatus tears were recruited for this prospective observational study. Glenohumeral kinematics were measured using biplane radiography during a reaching behind the back movement. Passive glenohumeral internal rotation and patient reported outcome measures were collected. Depending on data normality, appropriate tests were utilized to determine changes in variables. Spearman's correlations were utilized for associations, and Stuart-Maxwell tests for changes in distributions.

FINDINGS

Maximum active glenohumeral internal rotation increased by 3.2° (P = 0.001), contact path length decreased by 5.5% glenoid size (P = 0.022), passive glenohumeral internal rotation RoM increased by 4.9° (P = 0.001), and Western Ontario Rotator Cuff Index and American Shoulder and Elbow Surgeons scores increased by 29.8 and 21.1 (P = 0.001), respectively. Changes in Western Ontario Rotator Cuff Index scores positively associated with changes in maximum active glenohumeral internal rotation and negatively associated with changes in contact path lengths (P = 0.008 and P = 0.006, respectively).

INTERPRETATION

The reaching behind the back movement was useful in elucidating in-vivo mechanistic changes associated with patient reported outcomes. Glenohumeral joint function and patient reported outcomes improved, where changes in Western Ontario Rotator Cuff Index scores were associated with kinematics. These findings inform clinicians of functional changes following exercise therapy and new targetable treatment factors.

A cross-sectional observational study comparing individuals with a symptomatic full-thickness rotator cuff tear with age-matched controls

Background

A full-thickness rotator cuff tear (FTRCT) is defined as a complete tear of one of the four rotator cuff muscle tendons (supraspinatus, infraspinatus, subscapularis or teres minor). This condition can lead to pain and reduced function. However, not all FTRCT are symptomatic. A better understanding of the characteristics that lead some individuals with FTRCT to experience pain is fundamental to improve strategies used to manage this condition. This level II descriptive study aimed to explore potential sociodemographic, anatomical, psychosocial, pain sensitivity, biomechanical and neuromuscular variables that may differ between individuals with symptomatic FTRCT and age-matched individuals with asymptomatic shoulders.

Methods

In this cross-sectional observational study, adults aged 50 to 80 years of age, either with symptomatic FTRCT or no shoulder pain, were recruited via convenience sampling. Participants filled out questionnaires on sociodemographic and psychosocial variables. Then, various tests were performed, including pain pressure threshold, shoulder range of motion, shoulder muscle strength, shoulder ultrasound and radiologic examination, and sensorimotor functions testing. Each variable was compared between groups using univariate analyses (independent t-tests, Mann-Whitney U tests, exact probability Fisher tests). Significance was set at 0.05.

Results

FTRCT (n = 30) and Control (n = 30) groups were comparable in terms of sex, age, and number of comorbidities. The symptomatic FTRCT group showed a higher proportion of smokers (P = .026) and more participants indicated consuming alcohol or drugs more than they meant to (P = .010). The FTRCT group had a significantly higher prevalence of glenohumeral osteophytes (48% vs. 17%; P = .012). Participants in the FTRCT group were significantly more stressed (P = .04), anxious (P = .003) and depressed (P = .002). The FTRCT group also showed significantly higher levels of pain catastrophisation (P < .001) and sleep disturbance (P < .001). The FTRCT group showed significantly lower range of motion for flexion (P < .001), and external rotation at 0° (P < .001) and 90° (P < .001) of abduction. Isometric strength in both abduction and external rotation were weaker (P = .005) for the FTRCT group.

Conclusion

Sociodemographic, anatomical, psychosocial and biomechanical variables showed statistically significant differences between the FTRCT and Control groups.

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.

Psychological, Pain, and Disability Factors Influencing the Perception of Improvement/Recovery from Physiotherapy in Patients with Chronic Musculoskeletal Pain: A Cross-Sectional Study

OBJECTIVES

The aim of this study was to identify the possible relationships between psychological, pain, and disability variables with respect to the perception of change/recovery from physiotherapy in patients with chronic musculoskeletal pain (CMP).

METHODS

A cross-sectional observational study was performed with 150 patients. All patients completed a series of self-administered questionnaires and a series of self-reports to quantify the perception of change with respect to the physiotherapy they underwent, the level of disability and pain intensity, the level of fear of movement, the level of catastrophism, the degree of self-efficacy, the level of therapeutic alliance and their adherence to the physiotherapy.

RESULTS

The strongest correlations were between the subjective perception of change and the number of sessions, treatment beliefs, self-efficacy, pain intensity, collaboration, and bonding. The linear regression model showed that the number of sessions, treatment beliefs, self-efficacy, compliance, pain intensity, and bonding were predictors of subjective perception of improvement, with 50% of the variance.

CONCLUSIONS

Treatment beliefs, therapeutic alliance, degree of self-efficacy, and pain intensity have been shown to be predictors of a subjective perception of improvement in patients with CMP. In turn, multimodal treatments had the greatest positive impact on the subjective perception of improvement.

Rotator cuff outcomes and mental health indices: Correlation or causation?

Background

Psychological factors such as catastrophizing, anxiety, and depression influence clinical outcomes in many conditions. Our purpose was to examine trends and associations between these and outcomes of rotator cuff surgery.

Methods

148 patients (76 W:72 M, 55.1 ± 8.2 years) with unilateral symptomatic rotator cuff syndrome were followed for 1 year after surgery. The Western Ontario Rotator Cuff Score (WORC), the Pain Catastrophizing Score (PCS), and the Hospital Anxiety and Depression Score (HADS) were administered. Evolution and associations of WORC, HADS and PCS scores were examined using uni- and multivariate analyzes.

Results

At 1 year, PCS, HADS-A, and HADS-D scores negatively correlated with WORC score (R = -0.6, -0.61, -0.69). The strength of correlation was lower between baseline PCS, HADS-A, and HADS-D scores and 1-year WORC score (R = -0.38, -0.43, -0.42). Prior anxiety diagnosis was associated with higher HADS-A scores at 2- and 6- weeks post-op (p = 0.013, 0.011). 106 participants experienced an improving HADS-D over the year of follow-up. Worse pre-op pain, WORC, PCS, HADS-A, HADS-D, cardiovascular disease and current smoking were associated with non-improving HADS-D.

Discussion

Patient-reported outcomes of rotator cuff surgery are associated with patient-reported anxiety, depression, and pain catastrophizing. In many, all outcome scores improved over time suggesting a two-way association between shoulder condition and psychological parameters.

Level of evidence

II.

Ischemic compression associated with joint mobilization does not promote additional clinical effects in individuals with rotator cuff related shoulder pain: A randomized clinical trial

OBJECTIVE

The objective of this study was to verify which are the additional effects of the ischemic compression (IC) technique associated with joint mobilization techniques on pain, morphological aspects of myofascial trigger points (MTrPs), function, and psychological aspects in individuals with rotator cuff-related shoulder pain (RCRSP).

METHODS

Sixty individuals with RCRSP were randomly allocated intervention sessions the Mobilization Group (MG, n = 20), only joint mobilizations of the shoulder complex; intervention sessions Compression Group (CG, n = 20), with the same mobilizations associated with the IC over MTrPs; and Placebo Group (PG, n = 20), with the same mobilizations associated with placebo of IC. All interventions performed 2 per week, for 6-weeks. Pain was assessed by Visual Analogue Scale and function by the Disabilities of the Arm, Shoulder and Hand questionnaire. The kinesiophobia, pain catastrophizing, perception of improvement, mobility, pain threshold and area the MTrPs were also evaluated at baseline (week-0), after 6-weeks and after 10-weeks.

RESULTS

There were no between-group difference in pain: CG-MG 0.8 (95% CI 0.4 to 1.2), CG-PG 0.5 (95% CI 0.0 to 0.9), MG-PG -0.3 (95% CI -0.8 to 0.1) after 6-weeks and CG-MG 0.1 (95% CI -0.2 to 0.5), CG-PG -0.7 (95% CI -0.9 to -0,4), MG-PG -0,8 (95% CI -1.07 to 0.5) at 10-weeks. Similar effects were observed on function, characteristics of MTrPs and psychological aspects.

CONCLUSION

The IC technique on the MTrPs of the upper trapezius muscle associated with joint mobilization techniques has no additional effect on pain in individuals with RCRSP.

TRIAL REGISTRATION

RBR-44v8y7.

Efficacy of combined strategies of physical activity, diet and sleep disorders as treatment in patients with chronic shoulder pain. A systematic review

Introduction: The objective of this systematic review was to analyze the existing scientific evidence on the influence of dietary strategies, exercise, and sleep disorders on the symptomatology of patients with chronic shoulder pain, as well as to assess the methodological quality of the literature collected. Methods: The selection criteria were as follows: we included randomized controlled clinical trials written in English that investigated the effects of such interventions in patients with chronic shoulder pain and excluded studies where pre-operative rehabilitation or rehabilitation combined with corticosteroid injections was performed. We searched six databases Pubmed, Cochrane Library, Web of Science, CINAHL, Sportdiscus and Scopus, using the keywords "shoulder pain," "fasting," "physical therapy modalities," "rehabilitation," "exercise," "circadian clocks," and "chronic pain" to select randomized controlled clinical trials conducted in humans and written in English. The last search was conducted on 24/01/2023. (PROSPERO:CRD42023379925). Results: We used the tool proposed by the Cochrane Handbook to assess the risk of bias in the included studies of the 17 studies included, nine had a high risk of bias, two studies had an unclear risk of bias, and the remaining six studies had a low risk of bias. A total of 17 articles were selected, including 10 studies that showed a positive influences of exercise on chronic shoulder pain and five studies that showed a negative influence of sleep disorders on this patient profile. The remaining two articles analyzed the influence of nutritional strategies and metabolic problems in patients with chronic shoulder pain. The total sample size of the 17 included articles amounted to 9,991 individuals. Discussion: Studies confirm that exercise generates a hypoalgesic effect that improves chronic shoulder pain, functionality, and quality of life. Although dietary strategies and sleep disorders are known to influence chronic shoulder pain, there is a lack of studies that conduct interventions on these problems to assess how chronic shoulder pain varies.

Social determinants of outcomes in nonoperatively treated proximal humerus fractures

Background

Proximal humerus fractures (PHFs) are common fractures especially in the elderly, with most fractures being managed nonoperatively. Traditional biomedical factors such as radiological alignment have not been able to meaningfully predict comfort and capability after PHFs. Conversely, recent literature has increasingly recognized the role of psychological factors in determining comfort and capability after PHFs. Nonetheless, less is known about the impact of social factors. Additional study of these potentially modifiable social factors as targets for enhancing recovery from injury is merited. Among people recovering from a nonoperatively- treated proximal humerus fracture (PHF) we studied the social factors associated with patient-reported outcomes at 6 months and 1 year.

Methods

One hundred seventy-one patients who received nonoperative management of a PHF completed baseline measures of sociodemographic characteristics (age, gender, race, employment status, household income, educational level, presence of domestic workers, housing type, and smoking status). Six and 12 months after fracture, participants completed the Oxford Shoulder Score (OSS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EuroQol-5-Dimensions (EQ5D) measures of comfort and capability. The relationship between capability and social factors was assessed using linear regression modelling, accounting for potential confounding from age, fracture severity assessed using Neer classification, premorbid comorbidities measured by Charlson Comorbidity Index, and premorbid functional status measured by Parker Mobility Index and Barthel Index.

Results

Lower capability (higher QuickDASH scores) 6 months and 1 year after fracture were associated with being unemployed (coef: -5.02 [95% CI: -9.96 to -0.07]; P = .047) and having domestic workers at home (coef: 8.63 [95% CI: 1.39 to 15.86]; P = .020), but not with Neer classification. Both greater shoulder discomfort and magnitude of incapability (lower OSS scores) and worse general quality of life (lower EQ5D scores) were associated with having domestic workers (coef: -4.07 [95% CI: -6.62 to -1.53]; P = .002 and coef: -0.18 [95% CI: -0.29 to -0.07]; P = .001 respectively) or living in an assisted care facility (coef: -14.82 [95% CI: -22.24 to -7.39]; P < .001 and coef: -0.59 [95% CI: -0.90 to -0.29] P < .001).

Conclusions

The finding that people recovering from PHF experience less incapability in proportion to their social independence (employment, absence of a caregiver such as domestic workers at home and living outside care facilities) emphasizes the important associations of social factors to musculoskeletal health, and the utility of accounting for social factors in the development and assessment of care strategies.

Trends in shoulder surgery patient-reported outcome measures

Patient-reported outcome measures (PROMs) are a vital part of the toolkit for the current practice of orthopedic surgery. We are witnessing the expansion of the use of PROMs in clinical practice and in research; the ultimate direction of this expansion is unclear. The purpose of this systematic review was to identify the trends in the use of PROMs in major upper limb publications over a 7-year period. We retrospectively reviewed all articles published in 6 of the most influential upper limb orthopedic journals based on impact factor from January 2013 to January 2020. PubMed, Medline, and Embase were used to access the abstracts for all articles published for this period. We included all articles related to shoulder arthroplasty, shoulder instability, rotator cuff surgery, and involving the use of PROMs. There were 4175 articles identified from the selected journals over the chosen time period, of which 607 were eligible for inclusion in the study. The number of articles reporting PROMs increased from 57 in 2013 to 115 in 2019, which was a 102% increase. The total number of PROM usages recorded was 1593 which was comprised of 63 different scoring systems, with each article using a median of 3 different PROMs. The most commonly used score in articles originating from North America was the American Shoulder and Elbow Surgeons score (216 uses in 273 articles; 78.1%), from Europe it was the Constant-Murley Score (129 uses in 183 articles; 70.4%), and from Asia it was the American Shoulder and Elbow Surgeons score (80 uses in 126 articles; 63.4%). The use of PROMs is evolving with an increasing prevalence of and diversity of PROMs being used in upper limb surgery. There is geographical variation in the use of PROMs, and a variety of systems used, with only 3 of the top 10 most used PROMs reporting on patient satisfaction or wellbeing. Given that a diverse range of PROMs study a diverse range of conditions and procedures, there may not be a need for a consensus on the best overall use of PROMs, but there may be ideal PROMs suited to answer specific questions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Athletes and Nonathletes Show No Difference in Symptoms or Function Prior to Knee Surgery, but Those With Chronic Symptoms Show Increased Pain Catastrophizing and Kinesiophobia

PURPOSE

To determine whether preoperative psychological status before outpatient knee surgery is influenced by athletic status, symptom chronicity, or prior surgical history.

METHODS

International Knee Documentation Committee subjective scores (IKDC-S), Tegner Activity Scale scores, and Marx Activity Rating Scale scores were collected. Psychological and pain surveys included the McGill pain scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia 11, Patient Health Questionnaire 9, Perceived Stress Scale, New General Self-Efficacy Scale, and Life Orientation Test-Revised for optimism. Linear regression was used to determine the effects of athlete status, symptom chronicity (>6 months or ≤6 months), and history of prior surgery on preoperative knee function, pain, and psychological status after matching for age, sex, and surgical procedure.

RESULTS

In total, 497 knee surgery patients (247 athletes, 250 nonathletes) completed a preoperative electronic survey. All patients were age 14 years and older and had knee pathology requiring surgical treatment. Athletes were younger than nonathletes on average (mean [SD], 27.7 [11.4] vs 41.6 [13.5] years; P < .001). The most frequently reported level of play among athletes was intramural or recreational (n = 110, 44.5%). Athletes had higher preoperative IKDC-S scores (mean [SE], 2.5 [1.0] points higher; P = .015) and lower McGill pain scores compared to nonathletes (mean [SE] 2.0 [0.85] points lower; P = .017). After matching for age, sex, athlete status, prior surgery, and procedure type, having chronic symptoms resulted in higher preoperative IKDC-S (P < .001), pain catastrophizing (P < .001), and kinesiophobia scores (P = .044).

CONCLUSIONS

Athletes demonstrate no difference in symptom/pain and function scores preoperatively when compared to nonathletes of similar age, sex, and knee pathology, as well as no difference in multiple psychological distress outcomes measures. Patients with chronic symptoms have more pain catastrophizing and kinesiophobia, while those who have had prior knee surgeries have slightly higher preoperative McGill pain score.

LEVEL OF EVIDENCE

Level III, cross-sectional analysis of prospective cohort study data.

Prolonged Opioid Usage Following Hip Fracture Surgery in Opioid-Naïve Older Patients

BACKGROUND

While the risk of long-term dependence following the opioid treatment of musculoskeletal injury is often studied in younger populations, studies in older patients have centered on short-term risks such as oversedation and delirium. This study investigated prolonged opioid usage after hip fracture in older individuals, focusing on prevalence, risk factors, and changes over time.

METHODS

In this retrospective cohort study of 47,309 opioid-naïve patients aged ≥ 60 years who underwent hip fracture surgery (2009 to 2020), outpatient opioid use was evaluated in 3 postoperative time periods: P1 (day 0 to 30 postsurgery); P2 (day 31 to 90); and P3 (day 91 to 180). The primary outcome was prolonged outpatient opioid use, defined as having one or more opioid prescriptions dispensed in all 3 time periods.

RESULTS

The incidence of prolonged opioid usage among patients surviving to P3 was 6.3% (2,834 of 44,850). Initial prescription quantities decreased over time, as did the risk of prolonged opioid usage (from 8.0% in 2009 to 3.9% in 2019). In the multivariable analyses, risk factors for prolonged opioid usage included younger age, women, current/former smoking, fracture fixation (as compared to hemiarthroplasty), and anxiety. Prolonged opioid usage was less common among patients who were Asian or had a history of dementia.

CONCLUSIONS

While prior research on the hazards of opioids in the elderly has focused on short-term risks such as oversedation and delirium, these findings suggest that prolonged opioid usage may be a risk for this older population as well. As initial prescription amounts have decreased, declines in prolonged opioid medication usage have also been observed.

Biopsychosocial Approach in Identifying Risk Factors of Kinesiophobia in Persons with Subacromial Pain Syndrome and Developing a Clinical Prediction Tool

Introduction

Although the negative effects of kinesiophobia on functional status in subacromial pain syndrome (SAPS) patients are clearly demonstrated, no study examines the risk factors of kinesiophobia in individuals with SAPS from a biopsychosocial perspective. The present study aims to determine the risk factors of kinesiophobia in individuals with SAPS using a biopsychosocial approach. This study also aims to explore the compounding effects of multiple associative risk factors by developing a clinical prediction tool to identify SAPS patients at higher risk for kinesiophobia.

Materials and methods

This cross-sectional study included 549 patients who were diagnosed with SAPS. The Tampa-Scale of Kinesiophobia (TSK) was used to assess kinesiophobia. Visual analog scale (VAS), The Shoulder Pain and Disability Index (SPADI), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the presence of metabolic syndrome, using any non-steroidal anti-inflammatory drugs, Pain Catastrophizing Scale (PCS), Illness Perception Questionnaire-revised (IPQ-R), Hospital Anxiety and Depression Scale (HADS), behavioral pattern of the patient, sociodemographic characteristics, and treatment expectancy were outcome measures.

Results

Thirteen significant risk factors of having kinesiophobia were: VASat rest (≥ 5.2), VASduring activity (≥ 7.1), DASH (≥ 72.1), presence of metabolic syndrome, PCShelplessness (≥ 16.1), IPQ-Rpersonal control (≤ 17.1), IPQ-Rtreatment control (≤ 16.3), HADSdepression (≥ 7.9), avoidance behavior type, being female, educational level (≤ high school), average hours of sleep (≤ 6.8), and treatment expectancy (≤ 6.6). The presence of seven or more risk factors increased the probability of having high level of kinesiophobia from 34.3 to 51%.

Conclusions

It seems necessary to address these factors, increase awareness of health practitioners and individuals.

Level of evidence

Level IV.

Pain Catastrophizing Scale Associated With Other Patient-Reported Outcome Measures in Plantar Fasciitis and Chronic Ankle Instability Patients

BACKGROUND

The Pain Catastrophizing Scale (PCS) is a measure of how patients emotionally respond to pain. It is composed of 3 subscales-rumination, magnification, and helplessness-which address intrusive thoughts of pain, expectations of negative outcomes, and inability to cope with pain. Our purpose is to compare baseline PCS scores with other baseline patient-reported outcome measures (PROMs) in patients with plantar fasciitis (PF) or chronic ankle instability (CAI).

METHODS

We retrospectively reviewed 201 patients who reported at least 1 pretreatment PCS subscore and were diagnosed with PF or CAI between 2015 and 2020 in a single fellowship-trained foot and ankle surgeon's clinic. Demographics, comorbidities, treatments, other baseline PROMs (i.e., visual analog scale [VAS], Pain Disability Index [PDI], 12-Item Short Form Survey [SF-12], 8-Item Somatic Symptom Scale [SSS-8]), and postoperative outcomes were recorded.

RESULTS

The PCS total score and its subscores significantly correlated with the total score and/or subscores of each PROM. Higher PCS total score significantly correlated with worse VAS (P<.001), SF-12 mental (P=.007), PDI total (P<.001), and SSS-8 (P<.001) scores. Only the PCS magnification subscore was significantly greater among patients who did (n=41) undergo surgery (P=.043). Those who had previously undergone foot and/or ankle surgery had significantly higher PCS rumination (P=.012), magnification (P=.006), helplessness (P=.008), and total (P=.003) scores. Likewise, those with a history of substance abuse also had significantly higher PCS scores (P=.005; P=.003; P=.006; P=.003).

CONCLUSION

The correlations between PCS scores and other baseline PROMs indicate that strong pain catastrophizers with PF or CAI may be at risk for poor treatment outcomes. PCS scores could be used to help with treatment for such high-risk patients.

The Unhappy Shoulder: A Conceptual Review of the Psychosomatics of Shoulder Pain

INTRODUCTION

Chronic pain is a multifaceted disorder genuinely entangled with psychic and psychosomatic symptoms, which are typically involved in the processes of chronification. The impingement syndrome of the shoulder is no exception to this rule, but several studies have shown respective peculiarities among those with pain and impingement of the shoulder. Notably, chronic pain is a lateralized experience, and, similarly, its psychosomatic correlates may be attached to the hemispheres functionally.

AIM

The present review therefore gives an overview of the respective findings, with regard not only to psychopathology, but also to personality factors and psychologic trauma, since the latter are reportedly associated with chronic pain. Moreover, we acknowledge symmetry as a possible pathogenic factor.

METHODS

This narrative review followed the current standards for conducting narrative studies. Based on prior findings, our research strategy included the relevance of psychotraumatologic and symmetrical aspects, as well as comorbidity. We retrieved the relevant literature reporting on the impact of psychopathology as well as personality features on shoulder pain, as published up to January 2022 from the Medline database (1966-2022). Study selecton: We included numerous studies, and considered the contextual relevance of studies referring to the neuropsychosomatics of chronic pain.

RESULTS

Pain-specific fears, depression, and anxiety are important predictors of shoulder pain, and the latter is generally overrepresented in those with trauma and PTSD. Moreover, associations of shoulder pain with psychological variables are stronger as regards surgical therapies as compared to conservative ones. This may point to a specific and possibly trauma-related vulnerability for perioperative maladaptation. Additionally, functional hemispheric lateralization may explain some of those results given that limb pain is a naturally lateralized experience. Not least, psychosocial risk factors are shared between shoulder pain and its physical comorbidities (e.g., hypertension), and the incapacitated state of the shoulder is a massive threat to the function of the human body as a whole.

CONCLUSIONS

This review suggests the involvement of psychosomatic and psychotraumatologic factors in shoulder impingement-related chronic pain, but the inconclusiveness and heterogeneity of the literature in the field is possibly suggestive of other determinants such as laterality.

Assessing Pain Research: A Narrative Review of Emerging Pain Methods, Their Technosocial Implications, and Opportunities for Multidisciplinary Approaches

Pain research traverses many disciplines and methodologies. Yet, despite our understanding and field-wide acceptance of the multifactorial essence of pain as a sensory perception, emotional experience, and biopsychosocial condition, pain scientists and practitioners often remain siloed within their domain expertise and associated techniques. The context in which the field finds itself today-with increasing reliance on digital technologies, an on-going pandemic, and continued disparities in pain care-requires new collaborations and different approaches to measuring pain. Here, we review the state-of-the-art in human pain research, summarizing emerging practices and cutting-edge techniques across multiple methods and technologies. For each, we outline foreseeable technosocial considerations, reflecting on implications for standards of care, pain management, research, and societal impact. Through overviewing alternative data sources and varied ways of measuring pain and by reflecting on the concerns, limitations, and challenges facing the field, we hope to create critical dialogues, inspire more collaborations, and foster new ideas for future pain research methods.

Efficient Screening for Fear of Movement in Outpatient Settings: Short Form and Computer Adaptive Tests for Fear Avoidance and Negative Pain Coping

OBJECTIVE

The purpose of this study was to develop screening measures using item response theory (IRT) for 2 factors highly relevant to fear of movement (FoM): fear avoidance and negative pain coping.

METHODS

A total of 431 patients with neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) conditions seeking physical therapy completed 8 validated psychological questionnaires measuring fear avoidance and negative pain coping, resulting in 97 candidate items for IRT analysis. Unidimensionality and local independence were assessed using exploratory factor analyses followed by confirmatory factor analyses. Items were assessed for model fit to the graded response model for ordinal items. Using the final item bank, a computer adaptive test (CAT) administration mode was constructed, and reduced item sets were selected to create short forms (SFs), including items with highest information (reliability) at the different levels of the trait being measured while also considering clinical content.

RESULTS

The results supported a 28-item bank for fear avoidance and 16-item bank for negative pain coping. A 10-item and 8-item SF were developed for fear avoidance and negative pain coping, respectively. Additionally, 4-item form versions were created to provide options with lower administrative burden. CAT administration used a mean (median) of 7.7 (8) and 7.0 (7) items for fear avoidance and negative pain coping, respectively. All factors demonstrated construct validity by discriminating patient groups in expected clinical patterns.

CONCLUSION

These newly derived SFs and CAT administration modes provide reliable, valid, and efficient options to screen for fear avoidance and negative pain coping in populations with musculoskeletal pain.

IMPACT

These tools, collectively referred to as the Screening for Pain Vulnerability and Resilience tools, address a critical need for standard FoM screening processes that aid in clinical decision-making to identify who might benefit from psychologically informed approaches.

Asynchronous and Tailored Digital Rehabilitation of Chronic Shoulder Pain: A Prospective Longitudinal Cohort Study

Background

Chronic shoulder pain (SP) is responsible for significant morbidity, decreased quality of life and impaired work ability, resulting in high socioeconomic burden. Successful SP management is dependent on adherence and compliance with effective evidence-based interventions. Digital solutions may improve accessibility to such treatments, increasing convenience, while reducing healthcare-related costs.

Purpose

Present the results of a fully remote digital care program (DCP) for chronic SP.

Patients and Methods

Interventional, single-arm, cohort study of individuals with chronic SP applying for a digital care program. Primary outcome was the mean change between baseline and 12 weeks on the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Secondary outcomes were change in pain (NPRS), analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.

Results

From 296 patients at program start, 234 (79.1%) completed the intervention. Changes in QuickDASH between baseline and end-of-program were both statistically (p < 0.001) and clinically significant, with a mean reduction of 51.6% (mean −13.45 points, 95% CI: 11.99; 14.92). Marked reductions were also observed in all secondary outcomes: 54.8% in NPRS, 44.1% ceased analgesics consumption, 55.5% in surgery intent, 37.7% in FABQ-PA, 50.3% in anxiety, 63.6% in depression and 66.5% in WPAI overall. Higher engagement was associated with higher improvements in disability. Mean patient satisfaction score was 8.7/10.0 (SD 1.6).

Conclusion

This is the first real-world cohort study reporting the results of a multimodal remote digital approach for chronic SP rehabilitation. High completion and engagement rates were observed, which were associated with clinically significant improvement in all health-related outcomes, as well as marked productivity recovery. These promising results support the potential of digital modalities to address the global burden of chronic musculoskeletal pain.

The Influence of Chronic Pain and Catastrophizing on Patient Outcomes in an Athletic Therapy Setting

CONTEXT

Chronic pain is a challenge for Athletic Trainers and Athletic Therapists working in a clinical or university setting. The fear avoidance model, including catastrophizing, is well established in other health professions but is not established in Athletic Training and Athletic Therapy and may affect rehabilitation outcomes.

OBJECTIVE

To measure the influence of catastrophizing on rehabilitation outcomes of patients being treated in an Athletic Therapy setting.

DESIGN

Prospective single group pre-post design.

SETTING

Student Athletic Therapy clinic.

PATIENTS

A total of 92 patients were evaluated at initial assessment, and 49 were evaluated at follow-up.

INTERVENTION

All participants completed self-reported function questionnaires to assess level of injury and then received individualized treatments for a variety of musculoskeletal injuries. All measures were completed at initial assessment and at follow-up approximately 6 weeks later.

MAIN OUTCOME MEASURES

The authors measured function using a variety of patient self-reported functional questionnaires: the Disability of the Arm, Shoulder, and Hand; Lower Extremity Functional Scale; the Neck Disability Index; and the Oswestry Disability Index depending on injury site. Catastrophizing was measured using the Pain Catastrophizing Scale.

RESULTS

Function significantly improved from the initial assessment to the follow-up (P > .001). Patients with acute pain experienced a significantly greater improvement in function between the initial assessment and follow-up compared with participants with chronic pain (P = .050). Those with high catastrophizing presented with lower levels of function at initial assessment (66.8%) and follow-up (72.1%) compared with those with low catastrophizing (80.8% and 87.0%, respectively).

CONCLUSION

Similar to other studies in other professions, the function of patients with chronic pain does not improve as much compared with patients recovering from acute pain in an Athletic Therapy setting. It is important to measure patient-reported outcomes to evaluate patient rehabilitation progress. Rehabilitating patients with chronic pain is a challenge, and pain catastrophizing should be evaluated at the initial assessment since catastrophizing is associated with worse function.

Determination of Perceived Levels of Physical Work Demand Thresholds, and Reliability and Responsiveness of the Modified-Spinal Function Sort Questionnaire in a Multidisciplinary Occupational Rehabilitation Setting

PURPOSE

To determine the levels of perceived work demand capacity corresponding to the Modified Spinal Function Sort (M-SFS) score and precise reliability validity and responsiveness.

METHODS

This prospective validation study included patients with chronic musculoskeletal impairments who underwent multidisciplinary occupational rehabilitation. After determining the percentiles of the work demand thresholds corresponding to the spinal function sort (SFS), the percentiles were transposed to the M-SFS. Reliability was assessed using the intraclass correlation coefficient and limits of agreement. Correlations with other questionnaires and a lifting task were measured to assess validity. Responsiveness was determined using anchor- and distribution-based approaches.

RESULTS

288 patients were included. The following thresholds were obtained for the M-SFS: 0-43 points, minimal; 44-50, very light; 51-58, light; 59-64, light to medium; 65-70, medium; 71-76, heavy; and 77-80, very heavy. Reliability was confirmed. The correlation between the M-SFS and SFS scores was good at 0.89 (95% CI, 0.86-0.91) and moderate according to the PILE-test result of 0.60 (95% CI, 0.50-0.67). We could not calculate a valid anchor-based minimal clinically important difference. The standard error of measurement was 3.9 points, and the smallest detectable change was 10.8 points.

CONCLUSIONS

On the basis of the comparison of the M-SFS and SFS scores, the M-SFS score can be interpreted in relation to the levels of work demand. This study confirms the good reliability and validity of the M-SFS questionnaire in assessing perceived physical capacity. Further studies are needed to determine its responsiveness.

The relationship of fear of movement with pain, range of motion and function in patients with shoulder pathologies

Background

The pain, fear of movement, and disability are interrelated parameters that may adversely affect the individual in terms of medical and social aspects. This relationship has not been well studied in shoulder pathologies. We carried out a single-center cross-sectional study in the Orthopaedics and Traumatology Clinic. The aim of the study was to investigate the relationship between pain, function range of motion (ROM), and fear of movement in patients with shoulder pain.

Results

The mean age of the participants was 53.7 ± 11.2 years. Symptom duration was 11.65 ± 23.39 months. Most of the subjects (66.7%) had impingement syndrome. There was a weak to moderate negative correlation between both visual analog scale (VAS) and Oxford Shoulder Score (OSS) with flexion, abduction, external rotation ROM values (r1 = − 0.293, r2 = − 0.348, r3 = − 0.330, p < 0.001). In addition, there was a weak negative correlation between Tampa Kinesiophobia Score (TKS) and ROM values of abduction, internal rotation, and external rotation (r1 = − 0.273, r2 = − 0.207, r3 = − 0.250, p < 0.05). Pain was weakly and positively correlated with OSS (r = 0.209, p < 0.05).

Conclusions

According to our results, shoulder pain was associated with functionality, but fear of movement was not associated with shoulder pain or functionality. ROM was associated with both pain, functionality, and fear of movement.

The relationship of fear of movement with pain, range of motion and function in patients with shoulder pathologies

Background

The pain, fear of movement, and disability are interrelated parameters that may adversely affect the individual in terms of medical and social aspects. This relationship has not been well studied in shoulder pathologies. We carried out a single-center cross-sectional study in the Orthopaedics and Traumatology Clinic. The aim of the study was to investigate the relationship between pain, function range of motion (ROM), and fear of movement in patients with shoulder pain.

Results

The mean age of the participants was 53.7 ± 11.2 years. Symptom duration was 11.65 ± 23.39 months. Most of the subjects (66.7%) had impingement syndrome. There was a weak to moderate negative correlation between both visual analog scale (VAS) and Oxford Shoulder Score (OSS) with flexion, abduction, external rotation ROM values (r1 = − 0.293, r2 = − 0.348, r3 = − 0.330, p < 0.001). In addition, there was a weak negative correlation between Tampa Kinesiophobia Score (TKS) and ROM values of abduction, internal rotation, and external rotation (r1 = − 0.273, r2 = − 0.207, r3 = − 0.250, p < 0.05). Pain was weakly and positively correlated with OSS (r = 0.209, p < 0.05).

Conclusions

According to our results, shoulder pain was associated with functionality, but fear of movement was not associated with shoulder pain or functionality. ROM was associated with both pain, functionality, and fear of movement.

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.

Pain-related fear phenotypes are associated with function of the upper limbs in individuals with shoulder pain

OBJECTIVE

To identify and describe phenotypes related to kinesiophobia, fear-avoidance, and pain catastrophizing, and determine clinical and demographic characteristics related to each phenotype as a function of self-reported function of the upper limbs in individuals with shoulder pain.

METHODS

One hundred and seventy-seven individuals with shoulder pain participated in this study. Tampa Scale of Kinesiophobia, Fear-Avoidance Beliefs Questionnaire, Pain Catastrophizing Scale, Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), Numerical Pain of Rating Scale, and the angular onset of pain during the elevation of the arm were measured in all participants. A cluster analysis was performed considering kinesiophobia, fear-avoidance, and pain catastrophizing, then clinical and demographic characteristics of clusters were used to model individual's chance to belong to one of the clusters as a function of DASH.

RESULTS

Two clusters were identified based on kinesiophobia, fear-avoidance, and pain catastrophizing. The cluster with worse pain-related fear profile presented (p < 0.05) higher age, worse function, and higher pain intensity. This same cluster was also associated with involvement of the dominant side (OR = 2.10, 95% CI = 1.03, 4.41) and worse function (OR = 0.96, 95% CI = 0.94, 0.98).

CONCLUSION

This study identified that individuals with worse pain-related fear profile were older, with worse function, and higher pain intensity. Worse function and involvement of the dominant side were associated with the phenotype with a worse pain-related fear condition.

The outcome of hydrodilation in frozen shoulder patients and the relationship with kinesiophobia, depression, and anxiety

Purpose

The aims of this study were to (1) investigate the effect of hydrodilatation in frozen shoulder patients on objective indices of shoulder functionality and subjective outcomes of pain, mobility, kinesiophobia, depression, and anxiety, and (2) progress knowledge about the reciprocal temporal relationship between psychological parameters at baseline and objective and subjective outcomes at 3-month follow-up.

Methods

We evaluated the clinical and psychological status of 72 patients with a frozen shoulder before and after hydrodilatation, using the Constant Murley score, the Visual Analogue score, the Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, and the Shoulder Pain And Disability Index.

Results

We noted a significant improvement in functionality, pain and disability (p < .001). Depression and anxiety improved significantly (p < .001) between baseline and 3-month follow-up. Prospective analyses demonstrated that psychological factors are more likely to predict outcomes of hydrodilatation than vice versa.

Conclusion

Hydrodilatation followed by physiotherapy is an excellent way to treat patients with recalcitrant frozen shoulder, resulting in a continuous improvement of ROM and pain. Physiotherapists and physicians should be aware that psychological factors might have an impact on the treatment outcome.

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.

Patient-Reported Outcome Measures (PROMs): Influence of Motor Tasks and Psychosocial Factors on FAAM Scores in Foot and Ankle Trauma Patients

Patient-reported outcome measures (PROMS) are being increasingly used as a quality of care metric. However, the validity and consistency of PROMS remain undefined. The study sought to determine whether Foot and Ankle Ability Measure (FAAM) scores improve after patients complete motor tasks evaluated on the survey and to examine the relationship between depression and self-efficacy and FAAM scores or change in scores. We conducted a prospective comparison study of adults with isolated foot, ankle, or distal tibia fractures treated operatively at level I trauma center. Twenty-seven patients completed the FAAM survey at the first clinic visit after being made weightbearing as tolerated (mean 3 months). Patients then completed 6 motor tasks queried on FAAM (standing, walking without shoes, squatting, stairs, up to toes), followed by a repeat FAAM and General Self-Efficacy scale (GSE) and Patient Health Questionnaire-2 (PHQ-2) instruments. FAAM scores before and after intervention; GSE and PHQ-2 scores compared with baseline FAAM and change in FAAM scores. Performing motor tasks significantly improved postintervention scores for squatting (P = .044) and coming up to toes (P = .012), the 2 most strenuous tasks. No difference was found for the remaining tasks. Higher depression ratings correlated with worse FAAM scores overall (P < .05). Higher self-efficacy ratings correlated with increase in FAAM Sports subscale postintervention (P = .020). FAAM scores are influenced by performing motor tasks. Self-reported depression influences baseline FAAM scores and self-efficacy may influence change in FAAM scores. Context and patient factors (modifiable and nonmodifiable) affect PROM implementation, with implications for clinical care, reimbursement models, and use of quality measure.

Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review

Background

Psychological factors may impact recovery in patients undergoing treatment for shoulder complaints. The aim of this review is to systematically analyse the evidence for the effect of modifiable psychological factors (MPF) on outcome, for patients with musculoskeletal shoulder disorders undergoing conservative or surgical treatment. MPF refers to factors that may change with intervention.

Methods

This is a systematic literature review. Five databases searched (MEDLINE, CINAHL, Cochrane Library, Embase and PsycInfo), for longitudinal studies investigating the influence of MPF on prognosis of patients with shoulder disorders, all diagnoses, undergoing clinical interventions (conservative or surgical). Level of evidence was determined using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Moderate and high quality evidence was included. We extracted all MPF, categorized constructs into the following domains: beliefs (self-efficacy, expectation of recovery), coping (catastrophizing, avoidant coping), and affect (depression, anxiety). We evaluated constructs for its predictive value of at least one outcome. Outcomes were informed by this review. Evidence was classified into three categories: evidence for, inconclusive evidence, and evidence against.

Results

Of 1170 references, 40 distinct publications based on 35 datasets were included (intervention type: 20 surgical; 20 conservative). Overall, 22 studies (20 cohort studies and 2 RCTs) were classified as high quality and 18 studies (16 cohort studies, 2 RCTs) were classified as moderate quality. Outcomes reported included pain, disability/function, perceived recovery, physical and mental health, and work status. Based on the review, of the psychological constructs explored, these data would suggest that expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety may predict outcome for patients managed surgically. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome.

Conclusions

Five constructs were predictive of outcome for surgically managed patients. This suggests that implementing the biopsychosocial approach (i.e., preoperative screening, intervention by a trained clinician) may be advantageous for patients recommended for shoulder surgery,,. The same is not indicated for conservatively managed patients as no conclusive association of MPF with outcomes was noted. The importance of other MPF on outcome requires further investigation.

BMI Course Over 10 Years After Bariatric Surgery and Biopsychosocial Complexity Assessed with the INTERMED: a Retrospective Study

Background

While bariatric surgery is an effective therapy for patients with severe obesity, not all patients benefit equally. An explanation might be that psychosocial risk factors hamper outcome. The study aimed to evaluate if biopsychosocial case complexity predicts evolution of BMI over 10 years after bariatric surgery.

Methods

Charts of patients (N = 236) of the Cohort of Obesity Lausanne (COOL) were retrospectively reviewed and rated with the INTERMED, a reliable and validated instrument, which assesses biopsychosocial case complexity and has been proven to predict outcome of medical treatments in different patient populations. The sample was stratified into BMI quartiles, computed from the patients’ baseline BMI. For each quartile, BMI evolution was analyzed using individual growth curve analysis.

Results

Growth curve analyses showed that in quartiles 1, 2, and 3, none of the INTERMED domain scores significantly predicted the BMI evolution after surgery. However, in the fourth quartile—including patients with the highest pre-surgical BMI—the social domain score of the INTERMED significantly predicted BMI evolution: patients with more social complexity showed higher increase in BMI.

Conclusion

Effectiveness of interventions targeted at social complexity, especially when patients suffer from severe obesity, may therefore be evaluated in future studies.

Graphical abstract

Risk factors for symptomatic retears after arthroscopic repair of full-thickness rotator cuff tears

BACKGROUND

Factors affecting a rotator cuff symptomatic retear after arthroscopic repair have yet to be clearly identified, since they usually influence the surgical decisions.

METHODS

Consecutive patients with full-thickness tear of the supraspinatus who underwent arthroscopic repair were retrospectively analyzed. Cases of symptomatic retear, defined as Sugaya type IV and V on magnetic resonance imaging, associated with intensive pain and/or functional impairment were identified at follow-up. The patients with no symptomatic retear were selected as the control group. Information from potential risk factors of symptomatic retear, including depression and subacromial corticosteroid injections, was extracted from the medical records. The statistical analysis included multivariant logistic regression.

RESULTS

The symptomatic retear rate was 9.5% in 158 patients. Patients in the symptomatic retear group were more likely to be smoking, to have massive tears, a short acromiohumeral distance, and moderate to severe fatty infiltration. They also had had more frequently subacromial corticosteroid injections and depression. However, following the multiple logistic regression analysis, only massive tears and moderate to severe fatty infiltration remained significantly associated. Similarly, in relation to the study hypothesis, both corticosteroid injections (odds ratio [OR] 6.66, 95% confidence interval [CI] 1.49, 29.81; P = .013) and depression (OR 8.26, IC 1.04, 65.62; P = .046) were significantly associated with symptomatic retear risk.

CONCLUSIONS

This study found support for the hypothesis that both depression and corticosteroid infiltration before surgery are independent risk factors for symptomatic retear after arthroscopic repair of rotator cuff.

Kinesiophobia Is Associated With Pain Intensity and Disability in Chronic Shoulder Pain: A Cross-Sectional Study

OBJECTIVE

Kinesiophobia is a clinically relevant factor in the management of chronic musculoskeletal pain. The aim of this study was to explore the cross-sectional association between kinesiophobia and both pain intensity and disability among individuals with chronic shoulder pain.

METHODS

A total of 65 participants with chronic unilateral subacromial shoulder pain were recruited from 3 primary care centers. The Shoulder Pain and Disability Index assessed pain intensity and disability. The Tampa Scale for Kinesiophobia short form assessed the presence of kinesiophobia. A linear multivariable regression analysis evaluated the potential association between kinesiophobia and range of movement free of pain with pain intensity and disability. The analysis was adjusted for sex and age.

RESULTS

In the linear multivariable regression analysis, only greater kinesiophobia (standardized β = 0.35, P < .01) and sex (standardized β = -0.29, P < .01) contributed to explain 19% of the variance in shoulder pain and disability scores.

CONCLUSION

This cross-sectional study provides preliminary evidence about the association between kinesiophobia and pain intensity and disability among individuals with chronic shoulder pain. However, our findings only contributed to explain 19% of the variance in shoulder pain and disability scores.

Physiotherapists' ability to diagnose and manage shoulder disorders in an outpatient orthopedic clinic: results from a concordance study

BACKGROUND

Advanced practice physiotherapy has emerged as a promising solution to improve health care access because access to orthopedic care is limited in several countries. However, evidence supporting advanced practice physiotherapy models for the management of shoulder pain remains scarce. The purpose of this study was to establish diagnostic, surgical triage, and medical imaging agreement between advanced practice physiotherapists (APPs) and orthopedic surgeons (OSs) for the management of patients with shoulder disorders in an outpatient orthopedic clinic.

METHODS

Patients referred to an OS for shoulder complaints were recruited and independently assessed by an OS and an APP. Each provider completed a standardized form indicating diagnosis, imaging test requests, and triage of surgical candidates. Patient satisfaction with care was recorded with the 9-item Visit-Specific Satisfaction Questionnaire (VSQ-9). Inter-rater concordance was calculated with the Cohen κ, prevalence-adjusted bias-adjusted κ, and associated 95% confidence interval (CI). We used χ² tests to compare differences between providers in terms of treatment plan options and Student t tests to compare patient satisfaction between providers.

RESULTS

Fifty participants were evaluated. Good diagnostic agreement was observed between providers (κ, 0.80; 95% CI, 0.67-0.93). Agreement for triage of surgical candidates was moderate (κ, 0.46; 95% CI, 0.21-0.71) as APPs tended to refer patients more often to OSs for further evaluation. Imaging test request agreement was moderate as well (κ, 0.42; 95% CI, 0.19-0.66). Patient satisfaction with care was high, with no significant differences found between providers (P = .70).

CONCLUSION

APPs could improve access to orthopedic care for shoulder disorders by safely initiating patient care without compromising satisfaction. These results support further development and evaluation of APP care for orthopedic patients presenting with shoulder disorders.

Early Psychological and Social Factors Explain the Recovery Trajectory After Distal Radial Fracture

BACKGROUND

This prospective study identified the association of demographic, injury, psychological, and social variables, measured early during recovery, with limitations in function (measured by the Patient-Reported Outcomes Measurement Information System Upper Extremity Physical Function Computer Adaptive Test [PROMIS UE]) at 6 to 9 months after a distal radial fracture. Additionally, we assessed variables associated with the PROMIS UE; the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH); the Patient-Rated Wrist Evaluation (PRWE); and the 3-Level EuroQol 5 Dimensions Index (EQ-5D-3L) over time.

METHODS

A total of 364 adult patients (73% female), with a median age of 65 years (interquartile range, 45.5 to 77 years), who sustained an isolated distal radial fracture completed questionnaires at 3 time periods after the fracture: within 1 week, between 2 and 4 weeks, and between 6 and 9 months. We created a multivariable regression model and a generalized least squares random effects model, accounting for multicollinearity using correlation matrices, the variable inflation factor, and the partial R.

RESULTS

Multiple variables within a week of the injury correlated with 6 to 9-month limitations in bivariate analysis. Being retired (partial R = 0.19; p < 0.001), using opioids after the fracture (partial R = 0.04; p < 0.001), using antidepressants (partial R = 0.11; p < 0.001), greater pain interference (partial R = 0.03; p = 0.001), and greater pain catastrophization (partial R = 0.04; p = 0.002) within 1 week of the injury were strong predictors of greater limitations (PROMIS UE) at 6 to 9 months in multivariable analysis. Longitudinal analysis of variables over time demonstrated greater pain interference, greater fear of movement, lower self-efficacy, older age, and female sex as strong predictors of limitations.

CONCLUSIONS

Recovery from a distal radial fracture is influenced by a series of demographic, psychological, and social variables. Of these factors, being retired, using opioids, using antidepressants, greater pain interference, and greater pain catastrophization within a week of the injury explain the largest amounts of unique variance in self-perceived upper-extremity physical function. Evaluating the impact of change in variables over time underlined the influence of pain interference as well as the influence of fear of movement and self-efficacy (or resiliency) on limitations in physical function and general health. These findings have important implications for identifying individuals who can benefit from behavioral interventions for these psychological factors to optimize recovery.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Is rotator cuff related shoulder pain a multidimensional disorder? An exploratory study

Background and aims

Rotator cuff related shoulder pain has been associated with factors from multiple dimensions such as strength changes, psychosocial measures, comorbidities and level of education. However, to date little research has been undertaken to evaluate which factors explain the greatest variance in pain and disability levels in people with rotator cuff related shoulder pain. The objective of this study was therefore to evaluate which multidimensional examination findings were associated with higher pain and disability in a primary care cohort with rotator cuff related shoulder pain.

Methods

This was an exploratory cross-sectional cohort study. Sixty-seven participants with rotator cuff related shoulder pain were assessed for: pain intensity, disability; demographic, psychological, social and lifestyle characteristics, and isometric strength of shoulder internal and external rotator muscles. Univariable associations between pain intensity/disability and each variable were assessed using linear regression. Variables with univariable associations (p < 0.1) were entered into backwards stepwise multivariable regression models.

Results

The multivariable model for pain intensity included sleep and perceived persistence and explained 46.5% of the variance (37.6% uniquely by sleep, 5.4% uniquely by perceived persistence). The multivariable model for disability included sleep and sex and explained 26.8% of the variance (4.5% shared by predictors, 16.4% uniquely by sleep, 5.9% uniquely by sex).

Conclusions

Rotator cuff-related shoulder pain and disability are associated with sleep disturbance, perceived symptom persistence and sex. Rotator cuff related shoulder pain may be considered a multidimensional disorder.

Implications

Clinicians need to evaluate sleep and perceived symptom persistence in people with rotator cuff related shoulder pain. Future research may examine whether management strategies for RCRSP directed towards these factors afford improved treatment outcomes.

Influence of Anxiety and Depression, Self-Rated Return-to-Work Problems, and Unemployment on the Outcome of Outpatient Rehabilitation After Shoulder Arthroscopy

OBJECTIVE

The aim of this study was to research the influence of psychosocial confounders on outpatient rehabilitation after arthroscopic shoulder surgery.

DESIGN

This retrospective study included patients who underwent such rehabilitation in a single center between January 2014 and October 2016. Shoulder function (Constant Shoulder Score) and pain (visual analog scale), improvements in these scores, and patient satisfaction were evaluated with regard to anxiety and depression (Hospital Anxiety and Depression Scale), self-rated return-to-work problems (Würzburg screening), and employment status.

RESULTS

The analysis included 176 patients. The mean (SD) Constant Shoulder Score and visual analog scale improved from 53.9 (18) to 75.4 (16.5) and 4.6 (2.1) to 2.9 (2.4) cm, respectively. A total of 84.1% of the patients were satisfied with the outcome. Unemployed patients (P = 0.001) and Hospital Anxiety and Depression Scale-positive ones (P = 0.014) were less satisfied than their counterparts. Patients with a Würzburg screening-positive screening showed less improvement in pain (P = 0.015), function (P = 0.016), and satisfaction (P = 0.002) than those without. Unemployed reported more pain (P = 0.008) than employed patients when starting rehabilitation. At the end of rehabilitation, all psychosocial scores (Hospital Anxiety and Depression Scale, P = 0.002; Würzburg screening, P = 0.001; unemployment, P < 0.001) negatively influenced pain, Würzburg screening (P = 0.007), and unemployment (P = 0.008) function.

CONCLUSIONS

Because we identified psychosocial factors that influence the success of outpatient shoulder rehabilitation, rehabilitation setup should be adjusted in patients with such problems.

Correlation of PROMIS Physical Function, Pain Interference, and Depression in Pediatric and Adolescent Patients in the Ambulatory Sports Medicine Clinic

Background:

Recently, interest has increased in incorporating the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes into clinical and research applications in sports medicine. The PROMIS forms have not been studied in pediatric and adolescent sports medicine patients.

Purpose/Hypothesis:

The goal of this study was to determine the correlation between PROMIS Computer Adaptive Test (CAT) forms measuring physical function, pain interference, and depression in pediatric and adolescent patients seen in the ambulatory sports medicine clinic. We hypothesized that there would be a negative correlation between physical function and pain interference as well as depression, as has been demonstrated in adult patient populations.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

All patients aged 8 to 17 years seen by 3 shoulder and sports medicine providers were included in this study. Patients completed a series of PROMIS CAT forms at clinic visits, including the PROMIS-PF and PROMIS-UE (Physical Function and Upper Extremity; depending on the nature of the complaint), PROMIS-PI (Pain Interference), and PROMIS-Depression subscales. Pearson correlation coefficients were calculated between the PROMIS forms as well as with other patient demographic data.

Results:

A total of 236 patient visits (152 patients) were included in the study, comprising 712 total PROMIS CAT forms. A negative correlation was found between PROMIS-PF and both PROMIS-Depression (R = –0.34) and PROMIS-PI (R = –0.76). These correlations with PROMIS-Depression and PROMIS-PI were –0.21 and –0.75, respectively, when considering the PROMIS-UE CAT. Patient demographic information had minimal impact on PROMIS scores as well as on correlations between scores.

Conclusion:

Correlations between physical function, pain interference, and depression were found to be similar in pediatric patients as they are in adult patients, as measured by PROMIS CAT forms.

Factors associated with the magnitude of limitations during recovery from a fracture of the proximal humerus

Aims

The purpose of this study was to identify factors associated with limitations in function, measured by patient-reported outcome measures (PROMs), six to nine months after a proximal humeral fracture, from a range of demographic, injury, psychological, and social variables measured within a week and two to four weeks after injury.

Patients and Methods

We enrolled 177 adult patients who sustained an isolated proximal humeral fracture into the study and invited them to complete PROMs at their initial outpatient visit within one week of injury, between two and four weeks, and between six to nine months after injury. There were 128 women and 49 men; the mean age was 66 years (sd 16; 18 to 95). In all, 173 patients completed the final assessment. Bivariate analysis was performed followed by multivariable regression analysis accounting for multicollinearity using partial R2, correlation matrices, and variable inflation factor.

Results

Many variables within a week of injury and between two and four weeks after injury correlated with six- to nine-month PROMs in bivariate analysis. Kinesiophobia measured within a week of injury (Tampa Scale for Kinesiophobia-11: partial R2 = 0.14; p = 0.000) and self-efficacy measured between two and four weeks (Pain Self-efficacy Questionnaire-2: partial R2 = 0.266; p < 0.001) were the strongest predictors of limitations (measured by Patient Reported Outcome Measurement Information System Upper Extremity Physical Function Computer Adaptive Test (PROMIS UE)) at six to nine months in multivariable analysis. Similar findings were observed with other types of PROM. Regression models accounted for a substantial amount of variance in all PROMs at both timepoints (e.g. 66% of the overall variance within one week, and 70% within two to four weeks for PROMIS UE at six to nine months).

Conclusion

Recovery from a proximal humeral fracture appears to be enhanced by overcoming fears of movement or reinjury within a week after injury and greater self-efficacy (developing resilience and more effective coping strategies) within a month. Such factors are modifiable using enhanced communication skills and cognitive behavioural treatments. These findings could be a catalyst for the routine assessment and treatment of psychological and social factors in the management of patients with fractures. Cite this article: Bone Joint J 2019;101-B:715–723.