90 day reverse total shoulder complications: over 14% in patients without depression and over 45% in patients with depression

Depression is not included in the Charlson Comorbidity Index calculation, yet it may be one of the most important factors in determining surgical outcomes.

Picasso 1904

The authors of How Does Depressive Disorder Impact Outcomes in Patients with Glenohumeral Osteoarthritis Undergoing Primary Reverse Shoulder Arthroplasty? sought to compare in-hospital length of stay (LOS); medical complications; emergency department (ED) utilizations; and cost of care for patients with and without depression disorder undergoing primary reverse total shoulder (RSA).

Their retrospective query of a nationwide administrative claims database found 28,410 patients who underwent primary RSA for the treatment of glenohumeral osteoarthritis. Interestingly, of these 14% (4,084) had ICD 9 or ICD 10 codes for depression disorder (DD).

Patients with DD undergoing primary RSA had significantly longer length of stay, higher frequency of complications such as pneumonia, cerebrovascular accidents, myocardial infarctions, and other adverse events. 

Patients with DD also had a 2-3 fold increase in postoperative ED use within 90 days after surgery.

Comment: These data are interesting, both with respect to the rate of 90 day medical complications in patients without a depression diagnosis (15%) and the increased rate of these complications in patients with depression (47%). 

It is important to note that many of the complications of RSA occur well beyond the 90 postoperative period covered in this study. It would be of interest to know how the 2 and 5 year complication rates for DD and non-DD patients compare.

The study did not compare self-assessed comfort and function after RSA for patients without and with a depression diagnosis.

Some questions not answered in this study are:

(1) in a surgeon's arthroplasty practice, what is the most practical method for diagnosing depression?

(2) is depression a modifiable risk factor? (note that patients with diagnosed depressive disorder taking selective serotonin re-uptake inhibitors (SSRIs) and receiving other types of treatments for depression were excluded in this study).

(3) what is the best approach to a patient who has both depression and shoulder arthritis: 

    (a) avoid surgery because of the increased complication rate?

    (b) delay surgery until the depression has been satisfactorily treated?

    (c) proceed with surgery after informing the patient that they are at significantly increased risk for complications (would that make the patient even more depressed)?

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

One in three patients having shoulder arthroplasty had depression or anxiety - what effect did this have on outcome and what should we do about it?

Anxiety and depression are the most commonly diagnosed psychiatric disorders in the United States, with a lifetime prevalence of about 29% and 17%, respectively. Thus, it is not surprising that a substantial percentage of patients considering shoulder arthroplasty (TSA) carry these diagnosis. Several questions arise:
(1) what are the effects of these mental health conditions on the outcomes of shoulder arthroplasty?
(2) can the adverse effects of depression and/or anxiety be modified (i.e are these risk factors modifiable)?
(3) how should the presence of depression and/or anxiety affect the decision to proceed with shoulder arthroplasty, recognizing the increased risk for suboptimal results and adverse outcomes?

The authors of the Impact of Mental Health on Outcomes After Total Shoulder Arthroplasty sought to examine the correlation between the preoperative diagnoses of anxiety and depression and their association with postoperative outcomes for TSA. A secondary goal was to determine whether patients on medication for their mental health diagnosis fared better than those not receiving medication.

In the authors' practice over one-third (37%: 218 patients (114 rTSA and 95 aTSA)) had anxiety and/or depression while 378 (153 rTSA and 217 aTSA) had no such history.

For patients having reverse total shoulder arthroplasty, the preoperative patient and shoulder characteristics of those without and with depression and/or anxiety were essentially the same. However, the postoperative comfort, function, satisfaction and adverse event rate were significantly worse for those with depression and/or anxiety.

For patients having anatomic total shoulder arthroplasty, the results were similar, but somewhat less striking.

Patients on medications for treatment of depression and/or anxiety did not have better postoperative outcomes or satisfaction rates compared to those who had depression and/or anxiety but who not on medication. However, it is not known (1) whether the patients on medication had more severe depression and/or anxiety than those not on medication and (2) whether the patients on medication would have had even worse outcomes had they not been medicated.

Poorer mental health correlated with worse postoperative functional outcomes, worse patient satisfaction, and higher rates of adverse events.

Comment: The high prevalence of anxiety/depression is striking. As emphasized in this study as well as in Shoulder arthritis: the relationship of function, depression and anxiety and Total shoulder - one in seven patients have depression; what difference does that make? poor mental health is associated with poorer outcomes following shoulder arthroplasty.

The authors suggest that preoperative identification of these mental health disorders may allow for treatment and "an opportunity to intervene and mitigate any deleterious effect". However it is not clear whether medical management of anxiety/depression mitigates their adverse effects on arthroplasty outcomes. To figure this out, it would be necessary to randomize patients with anxiety/depression to treatment and non-treatment groups prior to arthroplasty.

It is also not clear how surgeons should consider the patient with suboptimal mental health. Should they counsel these patients that they are more likely to get a poor result? Or should they consider not offering surgery to these patients to avoid the ramifications of bad outcomes for the patient and for the surgeons themselves?

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Rotator cuff tears - what determines the patient's comfort and function?

The symptoms experienced by patients with rotator cuff pathology vary widely, ranging from asymptomatic to disabling (see Asymptomatic Rotator Cuff Tears). In A prospective multipractice investigation of patients with full-thickness rotator cuff tears: the importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status the authors found that shoulder function of patients with cuff tears was correlated with medical and social comorbidities. 

In a study of 191 patients with full thickness cuff tears, the authors of A prospective, multipractice study of shoulder function and health status in patients with documented rotator cuff tears  found that shoulder function was significantly correlated with  patient sex, involvement of the infraspinatus tendon and workers’ compensation claims. 

The authors of Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity found that the extent of the cuff tear was poorly associated with the shoulder's comfort or function. 

A systematic review, Are Psychosocial Factors Associated With Patient-reported Outcome Measures in Patients With Rotator Cuff Tears? found that lower emotional and mental health function was associated with greater pain, disability and lower physical function in patients with cuff tears.

The authors of Psychological distress negatively affects self-assessment of shoulder function in patients with rotator cuff tears found that higher levels of psychological distress are associated with inferior patient self-assessment of shoulder pain and function using the VAS, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score.

Depression may drive patients to have evaluation and treatment for cuff disorders as suggested by the authors of Depression increases the risk of rotator cuff tear and rotator cuff repair surgery: a nationwide population-based study. who found that a diagnosis of cuff tear and the incidence of rotator cuff repair surgery was greater in patients with depression. Depressed patients also had a significantly increased risk of subsequent rotator cuff repair surgery.

Recently, the authors of Rotator cuff tendinopathy: magnitude of incapability is associated with greater symptoms of depression rather than pathology severity again pointed out that while rotator cuff tendinopathy develops in most persons during their lifetimes, it is often accommodated, and that there is limited correspondence between symptom intensity and pathology severity. 

They studied the relative association of functional capability with symptoms of anxiety or depression and with quantifications of rotator cuff pathology such as defect size, degree of retraction, and muscle atrophy among 71 adults seeking specialty care for symptoms of rotator cuff tendinopathy who had a recent shoulder MRI and completed the following questionnaires: 

1.Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health questionnaire (a measure of symptom intensity and magnitude of

capability, consisting of mental and physical health subscores), 

2. Generalized Anxiety Disorder (GAD) questionnaire (measuring symptoms of anxiety), and 

3. Patient Health Questionnaire (PHQ) (measuring symptoms of depression). 

Muscle atrophy was assessed based on oblique-sagittal plane MRI images medial to

the coracoid process according to the system of Warner et al with conversion to a 4-point numeric scale. Grade 0 (no atrophy) was assigned when the muscle completely filled its fossa and there was a convex extension out of the fossa; grade 1 (mild atrophy), when the muscle filled the fossa and the outer contour was flat with respect to the fossa; grade 2 (moderate atrophy), when the muscle was concave with respect to the fossa; and grade 3 (severe atrophy), when the muscle was barely apparent in the fossa.

They found the magnitude of incapability among patients seeking care for rotator cuff pathology was associated with symptoms of depression but not with the severity of the rotator cuff pathology.

Comment: Taken together these studies suggest that the symptoms and degree of disability experienced by patients with rotator cuff tears is strongly influenced by factors other than the magnitude of the cuff pathology. Such factors may include coverage by workers' compensation insurance, patient sex, social well being and mental health. These same factors may influence the tipping point for rotator cuff repair surgery and may have negative effects on the outcome of this procedure as well.

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Follow on facebook: https://www.facebook.com/frederick.matsen

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Depression affects the manifestations of rotator cuff pathology.

Rotator Cuff Tendinopathy: Magnitude of Incapability is Associated with Greater Symptoms of Depression Rather than Pathology Severity

These authors point out that most people develop rotator cuff tendinopathy during their lifetime, that it is often well accommodated by the patient without major functional loss, and that there is limited correspondence between symptom intensity and pathology severity. Furthermore they note mounting evidence that the ability to adapt to painful pathology, measured as symptom severity and magnitude of capability using patient reported outcome measures (PROMs), has notable inverse associations with unhelpful thoughts and distress (worry and despair) regarding symptoms.

They analyzed a retrospective cohort of 71 adults seeking specialty care for symptoms of rotator cuff tendinopathy, that had a recent Magnetic Resonance Imaging (MRI) of the shoulder, and completed the following questionnaires: PROMIS Global Health (a measure of symptom intensity and magnitude of capability, consisting of the mental and physical Health subscores), the Generalized Anxiety Disorder (symptoms of anxiety), and the Patient Health Questionnaire (symptoms of depression). 

They measured the sagittal length of the rotator cuff defect and tendon retraction in millimeters on MRI (excellent reliability) and rated the rotator cuff muscle atrophy and fat infiltration (more limited reliability) and we used the average of measurement or rating for each patient. 

They found that  lower scores on the PROMIS Global Health total score and physical health subscale were independently associated with greater symptoms of depression but not with measures of tendon pathology. 

Comment: The observation that the global health and physical health scores among people seeking care for symptoms from rotator cuff pathology is inversely associated with symptoms of depression but not with measures of the severity of the rotator cuff pathology is important because impaired global heath and physical health are often used both (1) as a major component of the indications for rotator cuff surgery and (2) as tools for evaluating the efficacy of treatment. If depression is a major driver of these metrics, the presence and severity of depression will confound analyses of treatment indications and outcomes.

An important implication of this study is that individuals with good mental health may be better able to maintain the functional capability of their shoulders in spite of the natural age-related deterioration in their rotator cuff tissue.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Symptomatic re-tears after arthroscopic cuff repair - association with subacromial steroid injections and depression.

 Risk factors for symptomatic retears after arthroscopic repair of full-thickness rotator cuff tears

These authors analyzed consecutive patients having full-thickness tears of the supraspinatus repaired arthroscopically.

They identified symptomatic re-tears, defined as "Sugaya type IV and V on magnetic resonance imaging that were associated with intensive pain and/or functional impairment."

These patients were compared to those without symptomatic re-tears with respect to potential risk factors for symptomatic re-tears.

Corticosteroid injection (CSI) was defined when the patient received 1 or more preoperative injections.

Depression was defined when the patient had a medical diagnosis of depression at the time of the surgical assessment and/or was receiving antidepressant treatment because of depression. 

The symptomatic retear rate was 9.5% in 158 patients. Patients in the symptomatic retear group were more likely to be smoking, to have massive tears, a short acromiohumeral distance, and moderate to severe fatty infiltration.

On multivariate analysis, corticosteroid injections were associated with a 7 fold increase and depression was associated with an 8 fold increase in symptomatic re-tear risk.

Comment:  It is well recognized that a high percentage of rotator cuff repair attempts fail to durably re-establish a secure connection between the torn tendon and bone, even for repairs of tears confined to the supraspinatus. It is also recognized that a high percentage of anatomically failed repair attempts yield improved postoperative shoulder comfort and function in spite of having a Sugaya 4 or 5 re-tear. 

Patients with re-tears but without substantial symptoms would have been assigned to the "control" group in this study: asymptomatic patients were not routinely examined by MRI. Thus the "symptomatic retear rate" of 9.5% (15 of 158 patients) in this study is likely to be substantially lower than the actual anatomic failure rate. Only 25 postoperative MRIs were obtained in 158 patients.

Most of the findings of this study are consistent with prior publications regarding the risks factors for rotator cuff repair failure. The observation that depression was associated with post operative intensive pain and/or functional impairment and Sugaya types IV and V on magnetic resonance imaging may be due to the fact that patients with depression are more likely to have "intensive pain and/or functional impairment" after surgery and thus to meet the criteria for a "symptomatic re-tear".

Follow on twitter: https://twitter.com/shoulderarth

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Total shoulder - one in seven patients have depression; what difference does that make?

 Preoperative depression is a risk factor for complication and increased health care utilization following total shoulder arthroplasty

These authors sought define the relationship between a preoperative diagnosis of depression and postoperative outcomes in 22,623 patients having total shoulder arthroplasty (TSA).  Of these, 3209 (14%) had a preoperative diagnosis of depression.

Patients with depression have a number of characteristics that are different from those without depression. Specifically, they are more likely to be women, younger patients, obese patients, those who are smoking, as well as those with coronary artery disease, anxiety and rheumatoid arthritis.

Multivariate analysis demonstrated that the following were more common in patients with depression: 

sepsis (odds ratio [OR], 2.04), 

prosthetic joint infection within 1 year (OR, 1.41), 

return to the operating room for irrigation and debridement (OR, 2.72),

prosthetic complication (OR, 1.54), and

wound complication (OR, 1.84). 

Patients with depression also had greater health care utilization including higher odds of 

non-home discharge (OR, 1.43), 

90-day readmission (OR, 1.55), 

90-day emergency department visit (OR, 1.39), and 

extended length of stay (3 days; OR, 1.23).

Comment: This is an important study that points out (1) the commonality of depression among patients having shoulder arthroplasty and (1)  the importance of screening for depression and modifying the preoperative informed consent and the postoperative surveillance for complications. As the authors point out, additional investigation is needed to determine whether this risk factor is modifiable.

The nature of the relationship between adverse our come remains unclear: is it the fact that depression itself increases the risk or is it that adverse outcomes are more likely in women, younger patients, obese patients, those who are smoking, as well as those with coronary artery disease, anxiety and rheumatoid arthritis?

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Total shoulder arthroplasty - the effect of mental health

The Influence of Mental Health on Outcomes Following Total Shoulder Arthroplasty

Anxiety and depression symptoms have been associated with higher pain and lower functional scores in patients with glenohumeral osteoarthritis (GHOA). These authors conducted an observational cohort study including 143 shoulders in 135 subjects undergoing total shoulder arthroplasty for glenohumeral osteoarthritis. The types of implants used and the methods used for addressing non-concentric glenoids are not specified.

Radiographs were reviewed for all 143 shoulders included. Advanced imaging was available for 60 shoulders. On initial review, there was 68.5% (99/143 shoulders) agreement on modified Walch glenoid morphology according to each subtype. Preoperative glenoid pathology was classed as either concentric wear (glenoid types A1 or A2) or eccentric wear (glenoid types B1, B2, B3, C, or D). When grouped as concentric vs. eccentric glenoids, initial review agreement improved to 86% (123/143 shoulders). 65 shoulders (45.5%) were graded as concentric and 78 shoulders (54.5%) were graded as eccentric following consensus analysis. Final Walch subtype classification included 26 shoulders graded as A1, 39 as A2, 8 as B1, 45 as B2, 23 as B3, and 2 as C. There were no glenoids graded as D.

Patients with anxiety and depression reported similar improvements in pain and function following TSA similar to those without depression or anxiety.

Patients with moderate-to-severe depression were less likely to want to undergo the same procedure again (p=.035) and were more likely to regret undergoing surgery.

The ASES scores were somewhat higher for the patients with non-concentric glenoid.

Comment: This article demonstrates an association between the degree of anxiety and depression with the preoperative and postoperative ASES scores. It does not suggest how this information might be used to improve the care of patients having shoulder arthroplasty. For example, how should patients undergoing TSA be screened for anxiety/depression? Should the presence of anxiety/depression influence the indications for surgery? Might the management of anxiety/depression preoperatively improve the outcomes of total shoulder arthroplasty?

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Shoulder arthritis: the relationship of function, depression and anxiety

The influence of mental health on Patient-Reported Outcomes Measurement Information System (PROMIS) and traditional outcome instruments in patients with symptomatic glenohumeral arthritis

These authors explored the influence of patients' mental health on their self-reported pain and function using the Patient-Reported Outcomes Measurement Information System (PROMIS) assessment. They performed a cross-sectional study of 284 shoulders in 276 patients presenting with isolated glenohumeral osteoarthritis. All patients completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), Visual Analog Pain Scale (VAS), and PROMIS CATs at the time of presentation. 

Patients with scores corresponding to a diagnosis of anxiety or depression reported lower functional and higher pain scores compared to those with scores in the normal range (P < .001). The severity of anxiety and depression correlated with a lowering of function and with an increase in pain scores.

The relation of the degree of anxiety and depression to the Simple Shoulder Test score is shown below.

Comment:  As the authors point out, this analysis does not  determine whether worse mental health is related to more severe glenohumeral arthritis or whether the patients’ anxiety and depressive symptoms create a more intense perception of their limitations. In this regard, it would be of great interest to correlate the radiographic severity of arthritis with the severity of anxiety, the severity of depression and the patient self-assessed comfort and function using a metric such as the Simple Shoulder Test.

We are reminded of an important article from seven years ago, the abstract of which is reproduced below. We have been especially informed by the last part of the last sentence in this abstract.

Association Between Comorbid Depression and Osteoarthritis Symptom Severity in Patients with Knee Osteoarthritis

Background: We sought to investigate the reported association between depression and severity of knee osteoarthritis symptoms stratified by radiographic severity of osteoarthritis and to quantify the contribution made by depression to symptom severity.

Methods: Six hundred and sixty elderly Koreans (sixty-five years or older) were evaluated for radiographic severity of knee osteoarthritis on the basis of the Kellgren-Lawrence grading system and also for symptom severity on the basis of the Western Ontario and McMaster Universities Osteoarthritis Index scales. Patient interviews and a questionnaire that made use of a geriatric depression scale were conducted for the purpose of assessing depressive disorders. Regression analyses were performed to assess the relative contributions by radiographic severity and depression severity to Western Ontario and McMaster Universities Osteoarthritis Index scores and to explore any associations between radiographic severity and the presence of a depressive disorder with regard to the risk of symptomatic knee osteoarthritis. Symptomatic knee osteoarthritis was defined as a Western Ontario and McMaster Universities Osteoarthritis Index score of ≥39.

Results: The presence of a depressive disorder was found to be associated with an increased risk of symptomatic knee osteoarthritis (odds ratio = 5.87 [95% confidence interval, 3.01 to 11.44]). However, the influence of the presence of a depressive disorder was limited to subjects with a radiographic severity of minimal to moderate (Kellgren-Lawrence grade 0 to 3). The presence of a depressive disorder was not associated with the risk of symptomatic knee osteoarthritis in subjects with severe osteoarthritis (Kellgren-Lawrence grade 4).

Conclusions: This study indicates that the assessment and management of coexisting depression should be integrated with the assessment and management of knee osteoarthritis, particularly when radiographic changes of osteoarthritis in the knee joint are not severe.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

The effect of anxiety and depression

Anxiety and depression predict poor outcomes in arthroscopic subacromial decompression


These authors conducted a review of 86 patients undergoing arthroscopic acromioplasty. Their inclusion criteria were patients with isolated 'subacromial impingement (SI)' aged between 25 and 75 years with shoulder pain on overhead activity or in the mid arc of abduction, a positive Hawkins test result on repeated examination, pain relief of a minimum of 2 weeks after subacromial steroid injection, and radiologic evidence of impingement (sclerosis, cysts, or osteophyte at the grater tuberosity and acromion). They state that "rotator cuff tears were excluded", but cuff imaging findings of the included patients are not provided.  Patients with other concurrent shoulder diseases were excluded, including "SI" accompanied by rotator cuff tear (partial or full thickness) on preoperative ultrasound scan, acromioclavicular arthritis, calcific tendinitis, calcific bursitis, adhesive capsulitis, labral tear, biceps tendinitis, superior labral anteriorposterior  tear, and instability. It is unclear how they excluded diagnosis of frozen shoulder or glenohumeral arthritis.

Patients were analyzed in 2 groups defined by Hospital Anxiety and Depression Scale (HADS) scores, group A being depressed and group B nondepressed. Both groups had less pain and improved Oxford Shoulder Score (OSS) at 6 months; however, group B improved faster with improved scores at 6 weeks, which were maintained to 6 months. Group B had less pain and higher OSS at 6 months than group A. There was strong negative correlation between preoperative HADS score and 6-week and 6-month OSS and HADS scores. There was strong positive correlation between HADS score and 6-week and 6-month pain scores. High preoperative HADS score was negatively correlated to 6-month satisfaction.

Comment: As the authors point out, "subacromial impingement" is frequently used as an indication for acromioplasty. In this paper it is difficult to know exactly what pathology was being treated in these patients with an age span of 50 years. It has been suggested that we can stop using the term "impingement syndrome" now that a clear understanding of cuff pathology is available through a good history, physical exam and MRI as is explained in this post.

With respect to the HADS, anxiety and depression are each rated by assigning a value from 0-3 to each of seven items:

The items on the questionnaire that relate to anxiety are:
I feel tense or wound up
I get a sort of frightened feeling as if something bad is about to happen
Worrying thoughts go through my mind
I can sit at ease and feel relaxed
I get a sort of frightened feeling like butterflies in the stomach
I feel restless and have to be on the move
I get sudden feelings of panic

The items that relate to depression are:
I still enjoy the things I used to enjoy
I can laugh and see the funny side of things
I feel cheerful
I feel as if I am slowed down
I have lost interest in my appearance
I look forward with enjoyment to things
I can enjoy a good book or radio or TV program

So that the anxiety score can range from 0-21 and the depression score can range from 0-21. Apparently these to scales were added so that the maximal value for anxiety+depression was 42.

The relationships between the HADS and three different outcome metrics are shown below

While these effects are significant, it is apparent that a relatively small percentage of the variation on the outcome is associated with the preop HADS score: the respective coefficients of determination (see this link) for the three outcomes were 39%, 7% and 25%.

This study is important because it highlights the fact that many factors, including the patient's emotional heath, can affect the result of a treatment.

There are many different instruments for assessing emotional health. Our practice is to use the SF 36 which includes these three questions about depression:

When we suspect that a patient is depressed or over-anxious we try to explain that these conditions may interfere with the success of treatment and seek whether specialist help may be in order before proceeding with surgery.


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Consultation for those who live a distance away from Seattle.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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