Chronic painful musculoskeletal disorders are a common problem in older adults and are related to a general decline in health and reduced quality of life. After the knee, the shoulder joint is the most commonly cited painful appendicular joint in the United States, being reported in 18.3 million individuals older than 18 years.1 The prevalence of shoulder pain in the general adult population ranges from 6.9% to 31%.2 Although the consensus in the literature is that the peak prevalence of shoulder pain occurs in people aged 45 to 64 years,2 this varies by definition and duration of pain.
While some understanding of risk factors exists for shoulder pain (obesity, diabetes, statin use, activity level),3–5 it remains unclear how demographic trends and risk factors affect the prevalence of shoulder disease in older adults. In addition, little is known about the impact of shoulder pain and impaired function on older patients' quality of life, and the frequency with which they report this symptom to their health care provider. One wonders if older patients have come to accept shoulder pain as a long-standing symptom and thus underreport this condition to their providers. Another possible explanation is that pain is more likely to resolve over time and is thus not reported secondary to resolution of symptoms. The goal of this study was to describe shoulder pain and dysfunction and explore relationships among them, in a convenience sample of individuals older than 60 years drawn from a large, Veterans Affairs (VA) outpatient primary care clinic.
Subjects and Study Design
After approval by the local institutional review board, a cross-sectional survey, examination, and chart review of 93 individuals were performed. Clinic schedules were reviewed to solicit participation from individuals older than 60 years, and these were randomly approached in the waiting room of an outpatient primary care clinic at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin. After informed consent was obtained, individuals were screened for exclusion criteria, including major shoulder injuries, shoulder surgery, inflammatory arthritis, and upper extremity neuropathy or myopathy. If patients indicated that shoulder problems were a reason for the visit, they were excluded. If not excluded, individuals were asked a series of questions including whether they had had shoulder pain for more than 3 months in the last year, the location of their pain, and whether it interfered with sleep. Participants then completed the Stanford Modified Health Assessment Questionnaire (MHAQ), a global assessment of function based on reported amount of difficulty with daily activities that have been validated in aging populations.6,7 Categories include dressing and grooming, eating, and reaching, with each category scored separately. Each item was scored on a 4-point scale: 0 for no difficulty, 1 for some difficulty, 2 for much difficulty, and 3 for unable to perform. The use of a device or the need for assistance added 1 point to each category score. Higher scores on the 20-point scale indicate worse overall function. Participants rated their overall health as excellent, good, fair, or poor (self-assessed health [SAH],8 questions 7 and 8). Self-assessments of whether one's health is excellent, very good, good, fair, or poor have been valid and powerful predictors of mortality in community-dwelling adults in more than 300 studies over the past several decades.8 A primary chart review was completed on each individual to obtain background information, including demographics, medical history, and the number of prescription medications. In subjects with shoulder pain, a secondary chart review was performed, including a review of the problem list, progress notes, documented physical examination findings, referrals, and other management plans related to the shoulder complaint. A series of 3 simple physical maneuvers was used to assess shoulder mobility and pain with each movement (range of motion [ROM]). Active abduction, external rotation, and internal rotation were assessed by asking the participants to touch their hands to back of their neck, raise arms above their head and touch their upper, inner arms to their ears, and touch their thumbs to their shoulder blades. Each maneuver was assessed by observing and grading range of mobility on a 3-point scale (fully able, 3; partially able, 2; or unable, 1) and pain with movement (no pain, 1; some pain, 2; and lots of pain, 3). The right and left sides were scored separately. A sum score for all 3 maneuvers on each side and for pain on each side is also reported.
Data analysis was performed using SPSS version 16 (SPSS Inc, Chicago, Illinois). Descriptive statistics are reported as frequencies, percentages, and mean ± SD as indicated. Chi-square comparisons were used to perform tests of significance between participants who did or did not report shoulder pain, and the Pearson correlations were used to explore relationships among specific measures. The sample size (n = 93) allowed detection of significant correlations (P < 0.05) with values ±0.28 or greater.
The demographics of the study population are shown in Table 1. Of the 93 participants, 90.3% were men and 9.7% women, 81.7% were white, and 18.3% African American. The mean age was 74.7 ± 10 years. In this sample, 48.4% had diabetes, and 58% were currently taking statin medications. Shoulder pain for 3 or more months in the last year was reported by 29 individuals (31%). These symptoms were often bilateral (41.4%) and interfered with sleep (48% of participants answered yes when asked whether the shoulder pain interfered with sleep). Furthermore, in those who reported chronic shoulder symptoms, 31% said that their condition affected grooming activities (measured with the MHAQ).
Impairments in performing physical maneuvers were common among the study participants, with 37 individuals (39.8%) having difficulty in performing 1 or more of the maneuvers. Participants were most likely to have trouble with touching their scapulae with their thumbs (internal rotation, 94.6% of those having difficulty with shoulder ROM); 19 of these individuals had trouble with the other maneuvers, and typically both the right and left sides were involved. Abnormal abduction, as evidenced by the “arm-to-ear” maneuver, was the second most affected shoulder maneuver in this study population, noted in around 18.3%.
Statistically significant correlates of impaired shoulder ROM were Health Assessment Questionnaire (HAQ) scores, pain on the side of impairment, and limited function and pain of the contralateral shoulder (Table 2). A “sum” function score of each shoulder was associated with a “sum” pain score on each side; that is, worse function/lower score of right shoulder correlated to greater pain (higher pain score) for the right shoulder (r = −0.391; P < .001), and same for the left shoulder (r = −0.423; P < .001). Overall impaired function on one side was correlated to overall poor function on the other (r = 0.849; P < .001), and pain on one side was correlated to pain on the other side (r = 0.554; P < .001). Decreased ability to perform daily activities as measured by the HAQ (higher HAQ score) was correlated to worse SAH (lower categorical score) (r = −0.410; P < .001), worse left shoulder function (r = −0.340; P = .001), more pain in both shoulders (r = 0.315; P = .002 right; r = 0.469, P < .001 left), and experience of pain for 3 or more months (r = 0.410; P < .001). In other words, those individuals with difficulty performing shoulder movements were more likely to experience pain, to have pain on both sides, and to have worse functional scores as measured by the HAQ scale. In this small sample, a statistically significant relationship was not found between reports of shoulder pain and a history of type 2 diabetes, or current use of statin medications.
Fewer than half of the 29 individuals (N = 14; 48%) reporting pain for 3 or more months in the last year also recalled speaking to their medical providers about their shoulder pain. When asked about possible causes of their shoulder pain, patients most commonly attributed it to “arthritis” (24%), injury (24%), or some other cause, such as “sleeping on it” or “age” (21%). The remainder was unsure as to the cause. A total of 38% reported taking medications for their condition, and 17% reported “exercise” as their treatment of choice; 28% reported taking no action for their shoulder symptoms.
Secondary chart review was performed on the 29 participants reporting shoulder pain for 3 or more months within the past year (Table 3). Only 10% (3 of the 29) had a shoulder issue noted on the problem list, and 45% (13 of the 29) had a shoulder problem documented in a progress note over the past year. In just more than half of these individuals (7 of 13), a shoulder examination was documented. Four notes described abnormal findings (decreased ROM, pain with ROM, gross weakness), and 3 “normal” shoulder examinations were noted. Imaging was obtained in 10 of the 29 participants during the previous year (Table 3). Pharmacologic treatment to address these individuals' shoulder pain was specifically recommended in 9 of 29 individuals. Treatments included nonsteroidal anti-inflammatory drugs, acetaminophen, narcotics, and topical agents among others. Specialty referrals were requested for 8 individuals, including physical therapy, occupational therapy, orthopedics, rheumatology, and physical medicine and rehabilitation.
We found a 31% prevalence of self-reported shoulder pain among this group of older, mostly male veteran individuals, even after excluding those with a prior history of shoulder injury or possibly confounding comorbid condition. In addition, 41% of these individuals reported bilateral shoulder pain for 3 or more months over the past year. This prevalence is at the highest end of the rates reported in younger adults.2 Participants with shoulder pain reported significantly more functional limitation. Worse SAH was significantly correlated to worse function measured with the HAQ.
Risk factors for shoulder pain and other musculoskeletal conditions have been studied by others. Bjelle3 mentions age, female gender, surrounding muscle strength, and diabetes as risk factors for shoulder problems. Hill and colleagues4 also noted female gender, age greater than 50 years, smoking history, and obesity as risk factors for shoulder pain and stiffness. Others have suggested waist circumference, waist-to-hip ratio, metabolic syndrome, diabetes, carotid intima-media thickness, as well as C-reactive protein level as factors associated with shoulder pain and rotator cuff tendinitis.5 Other studies suggest an association between diabetes and musculoskeletal disease.9 Statin use has been implicated as a possible risk factor for tendon disease, including tendon rupture and tendinitis, and shoulder stiffness.10,11 The extent of this risk and the influence of gender are not clear.12 Many of these risk factors for shoulder problems were present in a significant proportion of the study group, and we observed a high rate of shoulder pain despite the predominantly male gender of the subjects. The sample size was likely too small to detect statistically significant relationships between shoulder pain and some of these risk factors, despite the high prevalence of statin use (58%) and diabetes (50%). We are conducting a larger study to confirm these trends and corroborate the growing body of evidence supporting these putative shoulder pain risk factors.
We also observed a significant association between SAH and function measured by the HAQ and suspect that the presence of shoulder pain and dysfunction likely contributes to worse ratings of health and quality of life. In fact, the majority of the symptomatic individuals (69%) in our study group reported disruption in their activities of daily living as measured by the MHAQ. With an aging population, the overall impact of shoulder pain is likely to be considerable. Restricted ROM has been associated with the aging process13 and our results suggest that decreased internal rotation of the shoulder joint is the most common impairment, and one that we suspect negatively impacts perceived quality of life.
The chart review of the subset of patients reporting shoulder pain for 3 or more months in the past year gives an interesting glimpse into the variability of documentation and approach to management for this problem in the primary care setting. In the small proportion of patients whose pain was actually documented, treatment regimens varied widely. Only 31% had documented recommendation of pain medications, and only 28% were referred to other providers, including physical therapy. This referral rate is low considering the large amount of data suggesting physical therapy to be an important and effective treatment option.14–18 Further studies regarding management of shoulder pain are warranted and may help inform consistent treatment guidelines in this population. These studies are currently lacking. Although 34% of symptomatic patients underwent some type of imaging, including magnetic resonance imaging, it is unclear that this had any effect on management and treatment. The cost-effectiveness of imaging painful shoulders in older adults also warrants careful examination.
Taken together, these data suggest that shoulder problems in the older adult are underreported. Thus, prior studies showing the peak prevalence of shoulder problems in middle age may not be capturing the high prevalence of this condition in the geriatric population. To date, very little research addresses the prevalence and causes for underreporting shoulder pain in older adults. Prior literature suggests that many older individuals accept pain as a part of the normal aging process or are concerned that their health will be adversely affected by using pain medications.19 Other factors to consider are short appointment durations where other health issues are given higher priority, greater longevity among the older adult population while maintaining higher levels of function, and thus increasing the prevalence of shoulder pain in this demographic. Further studies are necessary to explore these hypotheses. Our results also suggest that reliance upon patient problem lists as a way to identify affected individuals greatly underestimates the prevalence of this significant health problem, and thus large studies using databases, such as the national VA database, may capture only a fraction of patients with shoulder symptoms.
This study was limited by a number of factors, first of which is its restriction to a VA population which included few women. The sample size only provided power to detect correlations between measures of r = 0.28 or greater. Because time to spend with each participant was limited, we did not assess current or past history of “repetitive use” vocational or recreational activity that might increase the risk of shoulder impairment.20 A much larger sample would be needed to determine whether activity supersedes other risk factors in the geriatric population. It was also not possible within the confines of this study to accurately describe history of statin use. Some of this difficulty is because many patients seen at the VA clinics follow with multiple “outside” or community-based providers. This might also contribute to the observed low rates of diagnostic and treatment documentation in the electronic medical record at the VA.
This study identified shoulder pain and dysfunction as a common problem within an older adult, predominantly male, veteran population, and suggests a significant disease burden with regard to functionality and quality of life. This problem appears to be frequently overlooked and therefore undertreated. Further studies regarding incidence, prevalence, risk factors, and appropriate evaluation and management of these shoulder conditions are warranted.
The authors thank the veterans who participated in this study and the Clement J. Zablocki VA Medical Center for the space, resources, and overall support in completing this project. We also thank REDCap,21 which was instrumental in our data collection and management.
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