Saturday, January 9, 2016

Shoulder pain, psychological stress, perceived disability

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

In order to determine how psychological factors (namely depression, catastrophic thinking, and self-efficacy) affect pain and perceived disability in the shoulder, these authors studied 139 patients who completed a sociodemographic survey and elements from the The Shoulder Pain and Disability Index (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.

Greater catastrophic thinking, higher body mass index, and being disabled or retired 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.

The authors concluded that (1) catastrophic thinking and decreased self-efficacy are associated with greater shoulder pain and disability and (2) patient-to-patient variation in symptom intensity and magnitude of disability is more strongly related to psychological distress than to the specific shoulder diagnosis.

Comment: The items in the different psychological scales are:
Pain Catastrophizing Scale 
I feel I can’t go on.
It’s terrible and I think it’s never going to get any better. 
It’s awful and I feel that it overwhelms me. 
I feel I can’t stand it anymore. 
I become afraid that the pain may get worse. 
I think of other painful experiences. 
I anxiously want the pain to go away. 
I can’t seem to keep it out of my mind. 
I keep thinking about how much it hurts. 
I keep thinking about how badly I want the pain to stop. 
There is nothing I can do to reduce the intensity of the pain. 
I wonder whether something serious may happen.

I can enjoy things, despite the pain. 
I can do most of the household chores despite the pain. 
I can socialise with my friends or family members as often as I used to do, despite the pain.
I can cope with my pain in most situations.

Patient Health Questionnaire Depression Scale (PHQ-2)
I have little interest or pleasure in doing things
I am feeling down depressed or hopeless

The common theme is whether or not the patient is successfully coping with the pain they are experiencing.

It is interesting to note how the multivariate analysis reduced the number of influencing factors and that BMI and working status are important associates with shoulder functional status.

This paper is illuminating. It emphasizes that if the patient emphasizes that pain is the problem, surgery may not be the solution. By contrast, if the patient is focused on their functional deficits, surgeons may have a better opportunity to improve the working of the shoulder.

We have learned to be cautious when patients give very graphic descriptions of the pain ("it feels like someone is twisting a knife in my shoulder") or suggest radical treatment for the pain ("can't you just cut the arm off?"). 

We often explain that surgery can often improve the workings of the shoulder, but is not necessarily a procedure to relieve pain. This is especially the case if the patient has had long standing pain treated with narcotic medication.