Mental toughness - how does it relate to longer term ream and run and total shoulder arthroplasty outcomes?

Shoulder arthroplasty provides a great opportunity for patients with arthritis to recover lost shoulder comfort and function. However, recovery from the operation may challenge the patients' mental as well as their physical toughness. There is evidence that resilience may be an important attribute in the recovery from shoulder surgery.

Several scales have been validated for assessing a person's resilience, including the Brief Resilence Scale

and the The Connor-Davidson Resilience Scale, which assesses the ability to adapt to change, to deal with whatever comes, to see the humorous side of things, to cope with stress, to bounce back after illness or hardship, to achieve goals despite obstacles, to stay focused under pressure, to avoid being discouraged by failure, to think of oneself as being a strong person, and to handle unpleasant feelings.

The authors of Anatomic Shoulder Arthroplasty: The Correlation between Patient Resilience, Mental Health, and Outcome studied 399 patients (195 ream and run (RnR) and 204 anatomic total shoulder (aTSA)) at a mean follow-up of 6.3 ± 3.3 years. 

In this study of anatomic arthroplasties, increased resilience and better mental health were correlated with better outcomes.

In univariable analysis, the Connor Davidson Resilience Scale-10 (CD RISC-10) at latest follow-up was positively correlated with postoperative Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Score (ASES) and satisfaction after both RnR and aTSA. Mean CD RISC-10 scores were higher in the RnR cohort (34.3 ± 4.8 vs. 32.5 ± 6.2 for aTSA, p<0.001). 

In the multivariable linear regression analysis, greater resilience was associated with better outcomes after anatomic total shoulder arthroplasty: CD RISC-10 was independently associated with postoperative SST, ASES and satisfaction scores in aTSA patients. 

Better mental health was associated with superior outcomes after the ream and run procedure: CD RISC-10 was correlated with satisfaction.Veteran’s RAND-12 Mental Component Score (VR-12 MCS) was correlated with ASES and satisfaction after RnR.

Comment: It may be useful for surgeons to get a sense of the patient's mental toughness before proceeding with surgery and to be sure that appropriate support is in place for those whose resilience may be challenged during post-arthroplasty recovery. 

see also

Is resilience a predictor of the outcomes of total shoulder arthroplasty?

Resiliency Influences Post-Operative Outcomes Following Rotator Cuff Repair

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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).

What determines the outcome of arthroscopic cuff repair? Version 2.0

Rotator cuff pathology is the commonest reason for patients to present for medical evaluation. It is now recognized that the severity of the patient's symptoms may range from none at all to devastating and that factors other than the severity of the tendon pathology are the major determinants of the patient's comfort and function (see Rotator cuff tears - what determines the patient's comfort and function?).

As surgeons it is tempting for us to believe that the outcome of cuff repair is determined by our technical skill (see Rotator cuff repair - does the repair method matter?).

However, it is becoming increasing evident that the result realized by the patient is strongly influenced by factors that are not directly related to the shoulder or the procedure performed. For example a recent post (What determines the outcome of rotator cuff repair?) pointed to the strong relationship between social determinants of health and cuff repair outcomes. A prior post ("Resiliency" - how does it correlate with clinical outcomes of shoulder surgery?) demonstrated that a patient's resiliency after surgery is correlated with the postoperative Simple Shoulder Test and ASES scores. They used the "LOT-R" questions:
In uncertain times, I usually expect the best.
If something can go wrong for me, it will.
I'm always optimistic about my future.
I hardly ever expect things to go my way.
I rarely count on good things happening to me.
Overall, I expect more good things to happen to me than bad.

Postoperative LOT-R scores exhibited a significant correlation with ASES and SST scores.

Recently the authors of Low resilience is associated with decreased patient reported outcomes following arthroscopic rotator cuff repair sought to evaluate the relationship between preoperative resiliency and outcomes following arthroscopic rotator cuff repair in 81 patients. Preoperative evaluation included range of motion, and the following patient-reported outcomes: visual analog scale pain, the American Shoulder and Elbow Surgeons, Veterans RAND 12- Item Health Survey, and the Single Assessment Numeric Evaluation tests and a Brief Resilience Scale.




Low resiliency was defined as a score of less than 20.8, high resiliency was a score greater than 28.8.
There were potentially important differences in patient and shoulder characteristics that did not achieve statistical significance due to the small numbers in the low and high resiliency groups.


Despite similar baseline characteristics and postoperative range of motion and VAS scores, patients with low resiliency had poorer two year postoperative ASES scores and satisfaction compared to patients with high resiliency. Preoperative low resilience was associated with 20-point lower postoperative ASES scores following ARCR. On regression analysis, the final ASES score increased 1.6 points for every 1-point increase in the BRS.

Comment: The relationship of surgical outcomes to resiliency applies not only to cuff repair as shown in Is resilience a predictor of the outcomes of total shoulder arthroplasty?.

These studies bring up some important questions:
(1) what causes lower resiliency?
(2) can these causes be effectively addressed in clinical practice?
(3) how should surgeons use resiliency questionnaires (and other instruments to detect mental health status)?
(4) if low resiliency is detected, how does the surgeon use this information in conversations with the patient and in decision making ("I'm not going to operate on you because you're not resilient." or "I'll operate, but your surgery is less likely to be effective")?

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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Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

"Resiliency" - how does it correlate with clinical outcomes of shoulder surgery?

 Resiliency Influences Post-Operative Outcomes Following Rotator Cuff Repair

These authors attempted to assess the effects of resiliency on postoperative outcome scores and complications in 49 patients four years after rotator cuff repair (RCR).

These patients were monitored for American Shoulder and Elbow Surgeons score (ASES), Simple Shoulder Test (SST), and Life Orientation Test-Revised (LOT-R). 

LOT-R

Please be as honest and accurate as you can throughout. Try not to let your response to one statement influence your responses to other statements. There are no "correct" or "incorrect" answers. Answer according to your own feelings, rather than how you think "most people" would answer. A = I agree a lot B = I agree a little C = I neither agree nor disagree  D = I disagree a little

E = I disagree a lot 1. In uncertain times, I usually expect the best.  [2. It's easy for me to relax.] 3. If something can go wrong for me, it will.  4. I'm always optimistic about my future. [5. I enjoy my friends a lot.] [6. It's important for me to keep busy.] 7. I hardly ever expect things to go my way. [8. I don't get upset too easily.] 9. I rarely count on good things happening to me. 10. Overall, I expect more good things to happen to me than bad. Note: Items 2, 5, 6, and 8 are fillers and not scored. Responses to "scored" items are to be coded so that high values imply optimism.

There was a statistically significant difference between cohorts and their scores of resiliency and optimism, measured by LOT-R (ASESf, p=0.048; ASESp, p=0.003; SST, p=0.009).

LOT-R scores exhibited a significant impact on outcome scores (ASESf, p=0.043; ASESp, p=0.002; SST, p=0.007). 

Correlational analysis indicated that LOT-R directly correlated with higher ASESp,ASESf, and SST scores (ASESf p=0.029, ASESp p=0.003, SST p=0.018). 

Comment: This study reminds us that the degree of optimism and resilience that the patient brings to surgery correlates with the outcome. 

It is interesting to contemplate whether optimism and resilience can be improved by preoperative coaching and education.

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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   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery 

Is resilience a predictor of the outcomes of total shoulder arthroplasty?

Resilience correlates with outcomes after total shoulder arthroplasty

The Brief Resilience Scale (BRS) is a six item questionnaire that essentially ask in six different phraseologies "do you bounce back easily from disappointment?" 

For 70 patients having primary total shoulders, these authors examined the correlation between resilience, as measured by the BRS, and the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn scores in patients undergoing total shoulder arthroplasty (TSA) at minimum of 2 years (mean, 30 ± 3 months) after surgery. 

Patients were stratified into low-resilience (LR), normal-resilience (NR), and high-resilience (HR) patients.

Postoperative BRS scores significantly correlated with ASES, Penn, and SANE scores (r = 0.41-0.44, P < .004 for all scores). When we evaluated patients based on resilience group, the LR group had a Penn score that was 34 points lower than that in the HR group. Likewise, the LR group had a SANE score that averaged 40 points lower than that in the HR group (SANE score of 53 points in LR group and 92 points in HR group, P = .05). When we evaluated ASES subscores, it appeared that the pain subscale was responsible for most of the difference between the LR and HR groups (29 points and 48 points [out of 50 points], respectively; P = .03).

Comment: These authors concluded that "Resilience is a major predictor of postoperative outcomes after TSA." 

They correlated a number of variables (sex (19 male and 51 female), surgeon (one of three), brand of TSA, resilience) with outcome scores  ≥2 years after surgery. As they point out in the Discussion, the preoperative scores for each patient (recognized by others as a strong predictor of the improvement after TSA) were not available. It is also of note that the BRS was obtained at followup rather than before surgery, so it cannot be known how it was affected by or predicted the outcome.

It would be of interest to see a multivariate analysis that analyzed the relationship of preoperative BRS, preoperative patient-reported shoulder comfort and function, sex, surgeon, diagnosis, and brand of anatomic TSA to the final patient-reported shoulder comfort and function. Such an analysis would reveal the predictive value of the BRS.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

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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