What factors are predictors of emotional health in patients with full-thickness rotator cuff tears?

doi:10.1016/j.jse.2016.04.007

Journal of Shoulder and Elbow Surgery

Volume 25, Issue 11, November 2016, Pages 1769-1773

https://doi.org/10.1016/j.jse.2016.04.007 Get rights and content

Background

The importance of emotional and psychological factors in treatment of patients with rotator cuff disease has been recently emphasized. Our goal was to establish factors most predictive of poor emotional health in patients with full-thickness rotator cuff tears (FTRCTs).

Methods

In 2007, we began to prospectively collect data on patients with symptomatic, atraumatic FTRCTs. All patients completed a questionnaire collecting data on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcomes (12-Item Short Form Health Survey, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff Index [WORC], Single Assessment Numeric Evaluation score, Shoulder Activity Scale). Physicians recorded physical examination and imaging data. To evaluate the predictors of lower WORC emotion scores, a linear multiple regression model was fit.

Results

Baseline data for 452 patients were used for analysis. In patients with symptomatic FTRCTs, the factors most predictive of worse WORC emotion scores were higher levels of pain (interquartile range odds ratio, −18.9; 95% confidence interval, −20.2 to −11.6; P < .0001) and lower Single Assessment Numeric Evaluation scores (rating of percentage normal that patients perceive their shoulder to be; interquartile range odds ratio, 6.2; 95% confidence interval, 2.5-9.95; P = .0012). Higher education (P = .006) and unemployment status (P = .0025) were associated with higher WORC emotion scores.

Conclusions

Education level, employment status, pain levels, and patient perception of percentage of shoulder normalcy were most predictive of emotional health in patients with FTRCTs. Structural data, such as tendon tear size, were not. Those with poor emotional health may perceive their shoulder to be worse than others and experience more pain. This may allow us to better optimize patient outcomes with nonoperative and operative treatment of rotator cuff tears.

Section snippets

Materials and methods

In 2007, our team of fellowship-trained orthopedic surgeons and research personnel from across the country began to prospectively collect data on patients with magnetic resonance imaging–documented, symptomatic, atraumatic FTRCTs. All patients completed a questionnaire collecting data on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcomes (12-Item Short Form Health Survey, American Shoulder and Elbow Surgeons score, WORC score,

Results

In patients with symptomatic, atraumatic FTRCTs, worse WORC emotion scores were associated with higher pain levels (IQROR, −18.9; 95% confidence interval [CI], −20.2 to −11.6; P < .0001) and lower SANE scores (IQROR, 6.2; 95% CI, 2.5-9.95; P = .0012; Table I). Better WORC emotion scores were associated with higher levels of education and employment status (Table II). More specifically, compared with those with a high-school education or less, a college degree (OR, 9.9; 95% CI, 2.6-17.3; P

Discussion

In recent years, more emphasis has been placed on the role of biopsychosocial factors in pain, function, and outcomes of orthopedic illnesses. Rotator cuff disease provides an excellent disease process for investigation of these factors, given the prevalence of rotator cuff disease, the ongoing controversies in treatment and surgical indications, and the diversity in demographics of patients with rotator cuff disease. Previous authors have catalogued that a number of psychosocial variables have

Conclusions

In a multicenter cohort of patients with atraumatic rotator cuff tears being treated nonoperatively, higher pain scores and lower SANE scores correlated with worse WORC emotion scores. Alternatively, higher employment status and education correlated with better WORC emotion scores. These factors may provide the treating physician insight into the emotional well-being of the patient.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Cited by (21)

One-year patient-reported outcomes following primary arthroscopic rotator cuff repair vary little by surgeon
2023, JSES International
This study’s purpose was to investigate the extent to which differences among operating surgeons may influence 1-year patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair (RCR) surgery, after controlling for general and disease-specific patient factors. We hypothesized that surgeon would be additionally associated with 1-year PROMs, specifically the baseline to 1-year improvement in Penn Shoulder Score (PSS).
We used mixed multivariable statistical modeling to assess the influence of surgeon (and alternatively surgical case volume) on 1-year PSS improvement in patients undergoing RCR at a single health system in 2018, controlling for eight patient- and six disease-specific preoperative factors as possible confounders. Contributions of predictors to explaining variation in 1-year PSS improvement were measured and compared using Akaike’s Information Criterion.
518 cases performed by 28 surgeons met inclusion criteria, with median (quartiles) baseline PSS of 41.9 (31.9, 53.9) and 1-year PSS improvement of 42 (29.1, 55.3) points. Contrary to expectation, surgeon and surgical case volume were neither statistically significantly nor clinically meaningfully associated with 1-year PSS improvement. Baseline PSS and mental health status (VR-12 MCS) were the dominant and only statistically significant predictors of 1-year PSS improvement, with lower baseline PSS and higher VR-12 MCS predicting larger 1-year PSS improvement.
Patients generally reported excellent 1-year outcomes following primary RCR. This study did not find evidence that the individual surgeon or surgeon case volume influences 1-year PROMs, independently of case-mix factors, following primary RCR in a large employed hospital system.
Social Determinants of Health Disparities Are Associated With Increased Costs, Revisions, and Infection in Patients Undergoing Arthroscopic Rotator Cuff Repair
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
The purpose of this study was to use a national claims database to assess the impact of pre-existing social determinants of health disparities (SDHD) on postoperative outcomes following rotator cuff repair (RCR).
A retrospective review of the Mariner Claims Database was used to capture patients undergoing primary RCR with at least 1 year of follow-up. These patients were divided into two cohorts based on the presence of a current or previous history of SDHD, encompassing educational, environmental, social, or economic disparities. Records were queried for 90-day postoperative complications, consisting of minor and major medical complications, emergency department (ED) visits, readmission, stiffness, and 1-year ipsilateral revision surgery. Multivariate logistic regression was employed to assess the impact of SDHD on the assessed postoperative outcomes following RCR.
58,748 patients undergoing primary RCR with a SDHD diagnosis and 58,748 patients in the matched control group were included. A previous diagnosis of SDHD was associated with an increased risk of ED visits (OR 1.22, 95% CI 1.18-1.27; P < .001), postoperative stiffness (OR 2.53, 95% CI 2.42-2.64; P < .001), and revision surgery (OR 2.35, 95% CI 2.13-2.59; P < .001) compared to the matched control group. Subgroup analysis revealed educational disparities had the greatest risk for 1-year revision (OR 3.13, 95% CI 2.53-4.05; P < .001).
The presence of a SDHD was associated with an increased risk of revision surgery, postoperative stiffness, emergency room visits, medical complications, and surgical costs following arthroscopic RCR. Overall, economic and educational SDHD were associated with the greatest risk of 1-year revision surgery.
III, retrospective cohort study.
Associations of preoperative patient mental health status and sociodemographic and clinical characteristics with baseline pain, function, and satisfaction in patients undergoing primary shoulder arthroplasty
2021, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
We plan to investigate the associations of these general patient factors with postoperative PROMs in the OME cohort in future work. The association between lower mental health status and worse preoperative shoulder PROMs has previously been demonstrated in patients undergoing RC repair,1,5-7,36,40,56,57 but such an association has not been shown prior to shoulder arthroplasty.54 Lower preoperative pain and function subscores in patients with lower preoperative VR-12 MCS values could be due to pre-existing mental health issues in such patients that may alter how they perceive their shoulder pain and function.
Shoulder pain and dysfunction are common indications for shoulder arthroplasty, yet the factors that are associated with these symptoms are not fully understood. This study aimed to investigate the associations of patient and disease-specific factors with preoperative patient-reported outcome measures (PROMs) in patients undergoing primary shoulder arthroplasty. We hypothesized that worse mental health status assessed by the Veterans RAND 12-Item Health Survey (VR-12) mental component score (MCS), glenoid bone loss, and increasing rotator cuff tear severity would be associated with lower values for the preoperative total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscores.
We prospectively identified 12 patient factors and 4 disease-specific factors as possible statistical predictors of preoperative PROMs in patients undergoing primary shoulder arthroplasty at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in the preoperative PSS and its subscores.
A total of 788 cases performed by 12 surgeons met the inclusion criteria, with a preoperative median total PSS of 31 points (pain, 10 points; function, 18 points; and satisfaction, 1 point). As hypothesized, a lower VR-12 MCS was associated with lower preoperative PSS pain, function, and total scores, but patients with intact status or small to medium rotator cuff tears had modestly lower PSS pain subscores (ie, more pain) than patients with large to massive superior-posterior rotator cuff tears. Glenoid bone loss was not associated with the preoperative PSS. Female sex and fewer years of education (for all 4 outcomes), lower VR-12 MCS and preoperative opioid use (for all outcomes but satisfaction), and rotator cuff tear severity (for pain only) were the factors most prominently associated with preoperative PROMs.
In addition to mental health status and rotator cuff tear status, patient sex, years of education, and preoperative opioid use were most prominently associated with preoperative PROMs in patients undergoing shoulder arthroplasty. Further studies are needed to investigate whether these factors will also predict postoperative PROMs.
The effect of psychological factors on pain, function and quality of life in patients with rotator cuff tendinopathy: A systematic review
2020, Musculoskeletal Science and Practice
Citation Excerpt :
Clinical diagnostic tests were performed in three studies to determine the diagnosis of rotator cuff tendinopathy, three studies used intraoperative diagnosis, four studies used imaging (Magnetic Resonance Imaging (MRI), Ultrasound), one study combined the use of MRI and intraoperative diagnosis, and three studies combined the use of clinical diagnostic test and imaging to confirm the diagnosis of rotator cuff tendinopathy. Of the included studies, four studies investigated depression assessed by Hospital Anxiety and Depression Scale – Depression (HADS-D) (Cho et al., 2013, 2015; Thorpe et al., 2018; Alizadehkhaiyat et al., 2017), four studies investigated anxiety assessed by Hospital Anxiety and Depression Scale – Anxiety (HADS-A) (Cho et al., 2013, 2015; Thorpe et al., 2018; Alizadehkhaiyat et al., 2017), two studies investigated fear of pain or fear-avoidance belief assessed by Fear of Pain Questionnaire (FPQS-III) or Fear-Avoidance Beliefs Questionnaire (FABQ) (Kromer et al., 2014; George and Hirsh, 2009), one study investigated pain self-efficacy assessed by Pain Self-Efficacy Questionnaire (FSEQ) (Thorpe et al., 2018), three studies investigated pain catastrophizing assessed by Pain Catastrophizing Scale (PCS) (Kromer et al., 2014; Thorpe et al., 2018; George and Hirsh, 2009), one study investigated distress assessed by Modified Zung Depression Scale & the Modified Somatic Perception Questionnaire (Potter et al., 2014), one study investigated emotion well-being assessed by Western Ontario Rotator Cuff Index (WORC) (Barlow et al., 2016), three studies investigated sleep disturbance assessed by Pittsburgh Sleep Quality Index (PSQI) (Austin et al., 2015; Cho et al., 2015; Khazzam et al., 2018), two studies investigated expectation assessed by Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) (Oh et al., 2012; Tashjian et al., 2004), and two studies investigated mental health assessed by Short Form-36 questionnaire (SF-36 – mental component summary). ( Piitulainen et al., 2012; Wylie et al., 2016).
Psychological factors may affect the pain level, shoulder function and quality of life in patients with rotator cuff tendinopathy.
To systematically review the prevalence of psychological factors reported in patients with rotator cuff tendinopathy; and to determine the association between psychological factors and pain, function and quality of life in patients with rotator cuff tendinopathy.
Systematic review
Pubmed, Embase, CINAHL and Web of Science were systematically searched from inception to June 2019. Studies that investigated patients with signs and symptoms suggestive of rotator cuff tendinopathy, and reported psychological variables and patient-reported outcome measures including pain, shoulder function or disability and quality of life.
A total of 14 studies were included. Our results showed that 22.8%–26.2% of patients with rotator cuff tendinopathy reported depression; 23% reported anxiety; and 70.2%–89% of patients reported sleep disturbance or insomnia. Overall, nine psychological factors were identified to be associated with pain, function and quality of life in patients with rotator cuff tendinopathy. Low-to-moderate quality of evidence suggests that various psychological factors are associated with pain, function and quality of life in patients with rotator cuff tendinopathy
This review identified various psychological factors may affect the pain level, shoulder function and quality of life in patients with rotator cuff tendinopathy, and the causal relationship warrants future high-quality prospective studies.
The Effect of Psychosocial Factors on Outcomes in Patients With Rotator Cuff Tears: A Systematic Review
2019, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Ultimately, on linear regression analysis, the HADS-D was shown to independently predict the ASES score, KSS score, and WHOQOL-BREF score. Five preoperative studies evaluated the effect of tear size on psychosocial factors.12-14,20,24 None found a significant difference in the mental status component compared with the size of the rotator cuff tear.
To determine whether psychosocial factors affect patient-reported outcomes in individuals with rotator cuff tears or after rotator cuff repair.
A systematic review was conducted using a computerized search of the PubMed and Web of Science electronic databases in adherence with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Articles were then evaluated based on inclusion and exclusion criteria. The Newcastle-Ottawa Scale was used to assess study quality and risk of bias. Because of study heterogeneity and varied levels of evidence, meta-analysis was not possible.
Of 980 identified articles, 15 met the inclusion and exclusion criteria. In those reported, the visual analog scale correlation with distress scales ranged from –0.476 to 0.334, depending on outcome, with a trend toward increased pain in patients with distress. The depression subscale of the Hospital Anxiety and Depression Scale was negatively correlated with the American Shoulder and Elbow Surgeons score in 2 of 3 studies (–0.309 to 0.235). Six studies evaluated the presence of psychosocial factors and their correlation with patient-reported outcomes prior to surgery. These showed a significant correlation between rotator cuff pathology and psychological distress (i.e., depression or anxiety) as identified on standardized patient-reported outcome measures. Nine studies evaluated psychosocial factors either before and after surgery or only postoperatively. Of these 9 studies, 3 found no statistically significant differences in outcomes as related to psychosocial factors. In contrast, 6 of 9 reported an association between outcomes and psychosocial factors. Moreover, 2 of these 6 studies reported a direct relationship between patient expectations and outcomes, with 1 of these 2 studies finding that higher expectations improved baseline scores on the mental component summary of the Short Form 36 (r = 0.307). One study found significant differences in mental status in patients with rotator cuff tears based on age and sex.
This review found that most studies support that psychosocial factors do significantly influence the level of disability and pain experienced by patients preoperatively; however, 3 of 9 studies showed significant improvements in postoperative pain and function even with significant psychosocial confounders. These studies, however, do support that there is a direct relation between patient expectations and outcomes in rotator cuff surgery.
Level IV, systematic review of Level I through IV studies.
A prospective evaluation of predictors of pain after arthroscopic rotator cuff repair: psychosocial factors have a stronger association than structural factors
2018, Journal of Shoulder and Elbow Surgery
We evaluated the correlation of preoperative factors with pain after arthroscopic rotator cuff repair (ARCR). We hypothesized that nonstructural factors, including metrics of psychological well-being and preoperative narcotic use, would correlate with higher pain levels postoperatively and that structural factors, such as tear size, would not be predictive.
Ninety-three patients were prospectively enrolled and evenly distributed by tear size. Patient sex, age, occupation, smoking status, tear mechanism, tear characteristics on magnetic resonance imaging, visual analog scale (VAS) pain scores, narcotic usage, range of motion (ROM) by goniometry, and functional and psychological assessments through the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Simple Shoulder Test, Western Ontario Rotator Cuff Index (WORC), and RAND 36-item Short Form Survey questionnaires were obtained preoperatively. VAS scores and ROM were collected postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. The ASES, SST, WORC, and RAND 36-item Short Form Survey questionnaires were repeated 1 year postoperatively.
The patients (54% men) were a mean age of 56.4 years. There were 68% traumatic tears, 11% smokers, and 13% used narcotics preoperatively. ROM, VAS, ASES, and WORC scores improved significantly from the preoperative to 1-year postoperative assessment. Correlating with increased pain scores at 1 year were preoperative narcotic use, higher preoperative VAS, and lower scores on the WORC index and emotion sections.
Our data show that the factors most predictive of persistent pain after ARCR are psychosocial characteristics, including poor performance on validated measures of emotional well-being. Demographic and tear-specific structural factors did not correlate with postoperative pain scores.

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: This study was approved by Institutional Review Boards at the University of Colorado (CRV009-1), Hospital for Special Surgery (2013-123-CR2), University of Iowa (200605752), Brany (07-08-88-122), Avera (2006.049), The Ohio State University (2006H0154), University of California–San Francisco (10-00940), Vanderbilt University (060109), and Washington University in St. Louis (201103049).

¹: MOON Shoulder Group collaborators: Keith M. Baumgarten, MD, Orthopedic Institute, Sioux Falls, SD, USA; Robert H. Brophy, MD, Washington University, St. Louis, MO, USA; James L. Carey, MD, MPH, University of Pennsylvania, Philadelphia, PA, USA; Brian G. Holloway, MD, Knoxville Orthopaedic Clinic, Knoxville, TN, USA; Grant L. Jones, Department of Orthopaedics, The Ohio State University, Columbus, OH, USA; C. Benjamin Ma, MD, University of California–San Francisco, San Francisco, CA, USA; Robert G. Marx, MD, Hospital for Special Surgery, New York, NY, USA; Eric C. McCarty, MD, University of Colorado, Boulder, CO, USA; Sourav K. Poddar, MD, CU Sports Medicine Center, Denver, CO, USA; Matthew V. Smith, MD, Washington University, St. Louis, MO, USA; Edwin E. Spencer Jr, MD, Knoxville Orthopaedic Clinic, Knoxville, TN, USA; Armando F. Vidal, MD, CU Sports Medicine, Denver, CO, USA; Brian R. Wolf, MD, MS, University of Iowa, Iowa City, IA, USA; and Rick W. Wright, MD, Washington University, St. Louis, MO, USA.

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What factors are predictors of emotional health in patients with full-thickness rotator cuff tears?

Background

Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Conclusions

Disclaimer

Physiotherapy

Psychosomatics

J Shoulder Elbow Surg

J Pain

J Pain

J Shoulder Elbow Surg

J Hand Surg Am

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Hand Surg Am

The role of emotional health in functional outcomes after orthopaedic surgery: extending the biopsychosocial model to orthopaedics: AOA critical issues

J Bone Joint Surg Am

Chronic shoulder pain in the community: a syndrome of disability or distress?

Ann Rheum Dis

Shoulder activity level is not associated with the severity of symptomatic, atraumatic rotator cuff tears in patients electing nonoperative treatment

Am J Sports Med

Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability

J Bone Joint Surg Am