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.
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
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