Psychological Distress Is Associated with Greater Perceived Disability and Pain in Patients Presenting to a Shoulder Clinic

Menendez, Mariano E. MD; Baker, Dustin K. BS; Oladeji, Lasun O. MS; Fryberger, Charles T. BS; McGwin, Gerald PhD; Ponce, Brent A. MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.O.00387
Scientific Articles

Background: Shoulder disorders are a common cause of disability and pain. The Shoulder Pain and Disability Index (SPADI) is a frequently employed and previously validated measure of shoulder pain and disability. Although the SPADI has high reliability and construct validity, greater differences between individual patients are often observed than would be expected on the basis of diagnosis and pathophysiology alone. This study aims to determine how psychological factors (namely depression, catastrophic thinking, and self-efficacy) affect pain and perceived disability in the shoulder.

Methods: A cohort of 139 patients completed a sociodemographic survey and elements from the SPADI, Pain Self-Efficacy Questionnaire (PSEQ), Pain Catastrophizing Scale (PCS), and Patient Health Questionnaire Depression Scale (PHQ-2). Bivariate and multivariate analyses were performed to determine the association of psychosocial factors, demographic characteristics, and specific diagnosis with shoulder pain and disability.

Results: The SPADI score showed medium correlation with the PCS (r = 0.43; p < 0.001), PHQ-2 (r = 0.39; p < 0.001), and PSEQ (r = −0.45; p < 0.001). Current work status (F = 4.35; p = 0.006) and body mass index (r = 0.27; p = 0.002) were also associated with the SPADI score. In the multivariate analysis, greater catastrophic thinking (estimate, 0.003; p = 0.029), lower self-efficacy (estimate, −0.005; p = 0.001), higher body mass index (estimate, 0.006; p = 0.048), and being disabled (estimate, 0.15; p = 0.017) or retired (estimate, 0.16; p < 0.001) compared with being employed were associated with worse SPADI scores. The primary diagnosis did not have a significant relationship (p > 0.05) with the SPADI.

Conclusions: Catastrophic thinking and decreased self-efficacy are associated with greater shoulder pain and disability. Our data support the notion that patient-to-patient variation in symptom intensity and magnitude of disability is more strongly related to psychological distress than to the specific shoulder diagnosis.

Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Author Information

1Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114

2Division of Orthopaedic Surgery, University of Alabama at Birmingham, 1313 13th Street South, Suite 203, Birmingham, AL 35205. E-mail address for B. Ponce:

3University of Illinois College of Medicine at Peoria, 1 Illini Drive, Peoria, IL 61605

Article Outline

Symptomatic shoulder disorders are common in primary health care1. In general, symptom intensity and magnitude of disability seem to be influenced by a variety of factors unrelated to the physical diagnosis, including socioeconomic, emotional, and occupational status2-4. These factors have been shown to have a greater impact on symptoms and disability than the severity of the patient’s diagnosis5. The majority of studies on psychosocial determinants of pain and disability in orthopaedics have come from the spine, hand, and hip and knee reconstruction subspecialties6-12. Research evaluating the impact of psychological factors on shoulder pain and disability is more limited, with a single study being performed in patients scheduled for rotator cuff repair5.

The Shoulder Pain and Disability Index (SPADI) was developed in 1991 as a thirteen-item test used to quantify pain and disability associated with disorders of the shoulder13. The SPADI has been verified in multiple studies showing high reliability and internal consistency, as well as good construct validity and responsiveness to change over time14-19. Because of these advantages, the SPADI is often used as a primary patient-reported outcome measure in shoulder illness. The purpose of this study was to determine the association of depression, catastrophic thinking, and self-efficacy with shoulder pain and disability. Our hypothesis was that psychological factors would influence patient-reported pain and disability as measured by the SPADI.

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Methods and Materials

Study Design

After approval from our institutional review board, 139 patients presenting to an academic hospital-based shoulder surgeon were asked to enroll in this prospective cross-sectional study. Patients were considered eligible for this study if they had shoulder pain and no history of shoulder surgery. We excluded patients who were younger than eighteen years of age or pregnant. Enrollment took place from November 2013 to November 2014.

A research fellow asked all consenting patients to complete a sociodemographic survey and the following questionnaires: the SPADI13, Patient Health Questionnaire Depression Scale (PHQ-2)20, Pain Catastrophizing Scale (PCS)21, and Pain Self-Efficacy Questionnaire (PSEQ)22. Sociodemographic variables included age, sex, marital status, current work status, handedness, smoking, and duration of symptoms. Patient charts were reviewed to determine the patient’s diagnosis (determined by the treating surgeon) as well as height and weight.

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The PHQ-2 is a brief screening test for unipolar depression and includes two items inquiring about the frequency of depressed mood and anhedonia20. The two questions are scored on a scale from 0 to 3, with a total score ranging from 0 to 6 points. A score of 1 point indicates a 36.9% chance of any depressive disorder, but a score of 6 points indicates a 92.9% chance of any depressive disorder20.

The PCS contains thirteen items aimed at assessing the patients’ perception of their own pain by measuring the domains of rumination, magnification, and helplessness21. Items are scored on a scale from 0 to 4, with a maximum possible score of 52 points.

The PSEQ contains ten questions that measure a patient’s confidence in performing certain activities in spite of pain22. Items are scored on a scale from 0 to 6, with a maximum possible score of 60 points. Lower scores indicate less self-efficacy.

These psychological questionnaires were chosen as they have all been previously studied and have been validated as outcome measures in patients with musculoskeletal conditions13,20-23.

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Statistical Analysis

Continuous variables were presented in terms of the mean, standard deviation, and range; for categorical variables, frequencies and percentages were presented.

Bivariate analyses were performed to identify factors associated with increased SPADI scores using the Pearson correlation coefficient for all continuous variables, including age, body mass index (BMI), duration of symptoms, PHQ-2, PSEQ, and PCS; one-way analysis of variance (ANOVA) was used for categorical variables, including smoking status, handedness, sex, diagnosis, marital status, and current work status. Following bivariate analysis, all variables with p values of <0.10 were entered into a multivariate analysis using backward stepwise multinomial logistic regression. Significance was considered to be p < 0.05 (two-sided).

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Source of Funding

There was no source of external funding for this study.

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The mean age of patients (and standard deviation) was 58.1 ± 14.3 years. The patients had a mean BMI of 31.0 ± 7.2 kg/m2 and a mean duration of symptoms of 18.7 ± 26.8 months. A total of seventy-four patients (53%) of those with data were female, and sixty-five patients (47%) were male. Smokers made up 14% of the population. Married patients made up 56% of the population, followed by single patients (19%), divorced or separated patients (14%), and widowed patients (9%). With regard to work status, 34% of patients were employed, 24% were not employed, 9% were disabled, and 31% were retired. Demographic information is summarized in Table I.

The most common diagnosis was rotator cuff tear (27%), followed by osteoarthritis (17%), impingement (17%), and adhesive capsulitis (13%). Although not significant (p > 0.05), SPADI scores by diagnosis ranged from 43.6 points for acute acromioclavicular joint separation to 80.5 points for shoulder contusion. Full SPADI scores by diagnosis are seen in Table II.

The SPADI was scored on a scale from 0 to 100, with a mean score of 61.4 ± 23.2 points (range, 91.7 points [minimum to maximum, 8.3 to 100 points]). The PCS was scored on a scale from 0 to 52 points, with a mean score of 20.8 ± 15.1 points (range, 49.0 points [minimum to maximum, 0 to 49 points]). The PSEQ was scored on a scale from 0 to 60 points, with a mean score of 37.4 ± 15.4 points. The PHQ-2 was scored on a scale from 0 to 6 points, with a mean score of 2.1 ± 2.1 points (Table III).

In the bivariate analysis (Table IV), the SPADI score showed medium correlation with the PCS (r = 0.43; p < 0.001), PHQ-2 (r = 0.39; p < 0.001), and PSEQ (r = −0.45; p < 0.001). Work status (F = 4.35; p = 0.006) and BMI (r = 0.27; p = 0.002) were also associated with the SPADI score and met the threshold for inclusion in the multivariate analysis. In the multivariate analysis (Table V), greater catastrophic thinking (estimate, 0.003; p = 0.029), lower self-efficacy (estimate, −0.005; p = 0.001), higher BMI (estimate, 0.006; p = 0.048), and being disabled (estimate, 0.15; p = 0.017) or retired (estimate, 0.16; p < 0.001) compared with being employed were associated with worse SPADI scores.

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Shoulder disorders are a common cause of disability and pain. How a patient experiences pain is greatly influenced by psychosocial factors, which often lead to variations within the same diagnosis2-5. To our knowledge, this study is the first to examine these factors specifically in patients with shoulder pain. We found that disabled and retired work status, higher BMI, pain catastrophizing, and lower pain self-efficacy (ineffective coping strategies) were associated with greater symptom intensity and magnitude of disability.

The traditional biomedical model of illness assumes a direct relationship between nociception and pain, and the biopsychosocial model acknowledges the influence of biological, psychological, cultural, and social factors on a patient’s experience with his or her own pain24. The results of this study appear to support the latter. Biological (BMI), psychological (pain catastrophizing and ineffective coping strategies), and social (work status) factors were independently associated with symptom intensity and magnitude of disability. However, the primary diagnosis, although borderline significant (p = 0.061), did not independently predict the SPADI, even though one would expect variation in pain and disability between different shoulder conditions. A similar effect has been seen previously in the shoulder, as one study found that tear size, retraction, or humeral head migration did not predict functional scores in patients with rotator cuff abnormalities25. In the current study, the lack of significance between diagnoses may be partially explained by the low numbers for certain diagnoses (i.e., only two patients with acromioclavicular joint separation).

The PCS focuses on three aspects of a patient’s psychological response to pain: rumination, magnification, and helplessness26. The utility of this scale has previously been shown in the general orthopaedic population. One study demonstrated that high PCS scores predicted future pain at rest, pain during activity, and disability in patients who received operative treatment for musculoskeletal trauma27. Furthermore, the PCS has been identified as a predictor of continued opioid use one to two months after the surgical procedure for musculoskeletal injuries, which may indicate a predilection for misuse and dependence28. In patients with chronic pain, the link between opioid misuse and catastrophic thinking has already been firmly established, with a previous study showing a strong correlation between the PCS and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R)29. Although the effect of catastrophic thinking on postoperative outcomes specific to the shoulder is unknown, the current study establishes the relationship between this pathologic behavior and poor baseline function.

The PSEQ22 was developed under the principle, first proposed by Bandura30, that “efficacy expectations determine how much effort people will expend and how long they will persist in the face of obstacles and aversive experiences.” The inverse relationship between the PSEQ and SPADI in the current study is a logical finding, as those who report greater confidence in their ability to function in spite of pain would be expected to report less pain and disability. Self-efficacy scores have been shown to correlate well with scores on the shortened version of the Disabilities of the Arm, Shoulder and Hand outcome measure (QuickDASH) in a population of patients with a variety of hand and upper-extremity conditions31. However, studies on the predictive value of PSEQ scores on postoperative outcomes in orthopaedics have been limited, with a single study in the knee replacement literature showing preoperative self-efficacy to be a predictor of postoperative functional status32.

Much of the previous literature on the effect of occupational status on outcomes in orthopaedics has focused on the issue of Workers’ Compensation. The effects of Workers’ Compensation status on outcomes of shoulder and upper-extremity surgery have been extensively studied, with Workers’ Compensation patients having less favorable outcomes in return to maximal function, final functional status, and return to work33-37. However, the relationship between retired or disabled work status classifications and SPADI scores is a novel finding. Retirement as a negative influence on pain and disability reporting is a surprising finding, considering that retirement has been shown to have a positive effect on well-being38.

BMI was the sole biological influence on pain and disability scores, as age, sex, smoking status, duration of symptoms, and even primary diagnosis were not independent predictors. Higher BMI has been shown to contribute to pain in knee osteoarthritis, and obesity is a well-established risk factor for osteoarthritis of the knee, with a stepwise progression in prevalence and severity as BMI increases39,40. However, the relationship between BMI and pain in the shoulder is less clear. There have been reported associations between BMI and psychological well-being, with obesity identified as a risk factor for depression and anxiety41,42.

There were several limitations to this study. The study used baseline pain and disability scores at the first clinic visit for its primary measurement. Because of the cross-sectional nature of this study, we were unable to determine whether or not psychological distress predated the shoulder condition. Furthermore, no conclusions can be drawn as to how the identified psychological factors affect disease progression. Future research should identify factors that affect postoperative pain and response to treatment. Such studies would allow surgeons to identify patients who are at risk for a treatment-refractory course. Our findings might have been different if we had enrolled patients presenting with a single condition or a group of similar conditions, although inclusion of patients with the usual spectrum of illnesses in our clinic could also be considered a strength. Also, our survey was not all-encompassing of the patient’s biopsychosocial condition. Factors such as income, education level, medical and psychiatric comorbidities, and Workers’ Compensation status were not surveyed, although these factors could potentially influence the patient’s perception of pain. Specifically, patients’ psychiatric medications such as antidepressants were not surveyed. Future studies may be aimed at analyzing the effect of these medications on the perception of pain. Indicators of disease severity, such as the size of a rotator cuff tear or extent of glenoid wear, were not collected. Therefore, only limited conclusions were able to be drawn with regard to the patients’ specific diagnoses. Finally, although all of our survey components have been validated, no studies have determined the reading level required for them, and patient comprehension may be lacking.

In spite of these limitations, this study presents very useful information for clinicians. Our data suggest that patient-to-patient variation in shoulder pain and disability is primarily mediated by psychological distress. Interventions to decrease catastrophic thinking and to optimize self-efficacy during treatment and before scheduling shoulder surgery hold potential to ameliorate symptom intensity and the magnitude of disability and merit additional study.

Investigation performed at the Division of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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