Pain-related beliefs are associated with arm function in persons with frozen shoulder

Prognostic factors of nonsurgical intervention outcomes for patients with frozen shoulder: a retrospective study

PURPOSE

This study aimed to investigate the correlation between mental and physical health-related quality of life and the outcomes of conservative treatment in patients with frozen shoulder (FS).

METHODS

This was a two-center retrospective study. It included 84 consecutive patients who underwent a 3-month treatment comprising education, physical therapy, and corticosteroid-anesthetic injections. Changes in range of motion (ROM) and Shoulder Pain and Disability Index (SPADI) scores, measured at baseline and after 3 months, were selected as dependent variables. Data on age, sex, Body Mass Index, duration of symptoms, dominant affected limb, and Short Form-36 (SF-36) subscales were gathered at baseline and investigated as prognostic factors. Backward stepwise regression models were used to identify significant associations.

RESULTS

At 3-month follow-up, all the patients showed significant improvement. Higher SF-36 General Health, Mental Health and Social Functioning scores at baseline were associated with a greater beneficial change in ROM and SPADI. In contrast, lower SF-36 Bodily Pain and Role Emotional scores were found to be associated with greater improvement.

CONCLUSION

The study findings indicate that the self-perceived mental and physical health of patients have a significant impact on both subjective and objective clinical outcomes and healthcare professionals should take these aspects into account.

LEVEL OF EVIDENCE

Prognostic Level II.

The health economic analysis of surgery versus rehabilitation in non-traumatic musculoskeletal shoulder disorders: A systematic review of trial-based studies

OBJECTIVE

Non-traumatic musculoskeletal shoulder disorders are common. Their treatment, surgical or non-surgical, is associated with a considerable financial burden to health systems. The aim of this study was therefore to investigate the cost-effectiveness of surgical or rehabilitative treatments in this population.

DATA SOURCES

PubMed, Embase, NHS Economic Evaluation Database, Cost-Effectiveness Analysis registry, PEDro Database, Cochrane Library, and Google Scholar.

REVIEW METHODS

Trial-based economic evaluations assessing nonoperative and/or operative interventions for the management of non-traumatic shoulder disorders, published from January 2000 to October 2024, were searched. The selection process, data extraction and quality assessment (carried out with the Quality of Health Economic Studies instrument) were independently conducted by two reviewers.

RESULTS

Four studies (883 patients) were included in the review. Subacromial decompression for rotator cuff-related shoulder pain was found not to be cost-effective when compared with physiotherapy. Although it was not as cost-effective, Physiotherapy could be a socially beneficial alternative to mobilisation under anaesthesia in the early management of a frozen shoulder, due to lower costs and the delays in accessing surgical management in the pain-predominant phase. Productivity loss was the main driver of costs. It was not possible to determine the cost-effectiveness of other shoulder-related disorders due to sparsity of evidence.

CONCLUSION

Priority should be given to interventions that reduce productivity loss and facilitate patients' return to work as soon as possible. There is a definite need for multiplication and standardization of high-quality economic studies (and the trials they are based on) regarding the management of non-traumatic musculoskeletal shoulder disorders.

Effects of Disturbed Body Perception on Arm Function in Patients With Frozen Shoulder

Purpose Considering pain-related beliefs, this study aimed to investigate the influence of disturbed body perception on arm function in patients with frozen shoulder (FS). Methods This study included 90 patients with FS who visited the orthopedic outpatient clinic. We recorded measurements including the Visual Analog Scale (VAS) for pain at rest and during movement, the quick disability of the arm, shoulder, and hand (QDASH) questionnaire for perceived arm function, the short version of the Pain Self-Efficacy Questionnaire-2 (PSEQ-2) for self-efficacy in pain, the short version of the Pain Catastrophizing Scale (PCS-6) for catastrophic thoughts about pain, the short version of the Tampa Scale for Kinesiophobia (TSK-11) for fear of movement, and the Fremantle Shoulder Awareness Questionnaire (FreSHAQ) for disturbed perception around the shoulder. For statistical analysis, we constructed three models. Model 1 used the QDASH score as the dependent variable, with gender, age, duration of disease onset, VAS score at rest, and VAS score during movement as control variables. Model 2 included pain-related beliefs (PSEQ-2, PCS-6, and TSK-11) added to the variables in Model 1. Model 3 further included the FreSHAQ to the variables in Model 2. We calculated the difference in the adjusted coefficients of determination (R² adj) from Model 1 to Model 2 and Model 3 to determine the amount of change (ΔR² adj). Additionally, we calculated the standardized regression coefficient (β-value) of the input factors to examine their effects. Result Hierarchical multiple regression analysis showed a ΔR² adj of 0.13 and 0.17 for Models 2 and 3, respectively, indicating an increase in ΔR²adj after adding the FreSHAQ. Furthermore, the FreSHAQ had the largest effect of all factors, with β = 0.27 (p<0.05). Conclusions The influence of disturbed body perception on perceived arm function in patients with FS was demonstrated, suggesting the importance of considering somatosensory factors in clinical practice.

Landau model for illustrating the learning and unlearning process of nociplastic pain

Recent advancements in understanding the consolidation of nociplastic pain point to a complex, non-conscious learned process of threat perception. Neurobiological pain education is emerging as a promising approach to unlearn nociplastic pain, supported by biopsychosocial tools such as exposure to movement, mindfulness, and group sharing formats. However, this approach is still not well-known among clinicians and the society at large, creating a communication problem that unfortunately perpetuates the suffering of patients. Herein, we propose a Landau model to describe the learning and unlearning process of nociplastic pain, aiming to clarify this complex situation and facilitate communication across different sectors of the society. Nociplastic pain corresponds to a first-order transition, with attention more likely in the alert-protection state than in the trust-explore state. Two appealing results of the model are that the perception of the critical context depends on personal history regarding the symptom and that biopsychosocial loops are formed when there is alarming learned historical information about the symptom, along with confused and contradictory expert information, as seen in nocebo messages. Learning and unlearning in the model correspond to a chang in control parametrs that can weigh more on the alert-protection state, trust-explore state, uncertain state or neutral state. This description clarifies why neurobiological education is the foundational therapy from which others must be built to embody the accessible, clear, and trustworthy information.

Perspectives, perceptions, and expectations of subjects with frozen shoulder: a web-based Italian survey

Introduction

Frozen shoulder (FS) is a musculoskeletal disorder affecting the glenohumeral joint. This condition leads to disability and a worsening in quality of life. Despite its considerable impact on patients and its economic burden, research on the psychological and social implications of FS-as well as patients' perspectives and needs-is limited. This study aims to explore the perspectives, perceptions, and expectations of individuals suffering from FS, providing a comprehensive understanding of their experiences and needs.

Methods

A cross-sectional observational study was conducted following STROBE guidelines. A 59-question survey was administered to Italian individuals diagnosed with FS from April 1 to July 1, 2023.

Results

All 110 participants completed the survey. Most preferred an experienced and empathetic physiotherapist (73.64%) and relied primarily on physiotherapy (49.09%) for FS management. Additionally, 45.45% were open to a multidisciplinary approach. Subjects reported reducing night pain (71.82%) and achieving full range of motion (ROM) recovery (70.91%) as their top priorities. Participants reported a notable shift in their mood from "pre" to "post" FS, with many experiencing fear and catastrophizing thoughts and perceiving a lack of social support. Furthermore, 27.27% were open to cortisone use, while 25.45% considered electrophysical agents beneficial for managing the painful phase of FS.

Conclusion

These results underscore a strong preference for empathetic physiotherapists and the value of a multidisciplinary approach. Addressing night pain and restoring ROM are crucial priorities-emphasizing the need for tailored and shared decision-making. Additionally, these findings highlight the importance of addressing psychological well-being alongside physical symptoms.

Sensitivity to movement-evoked pain, central sensitivity symptoms, and pro-nociceptive profiles in people with chronic shoulder pain: A parallel-group cross-sectional investigation

OBJECTIVE

To investigate whether sensitivity to movement-evoked pain (SMEP), central sensitivity symptom burden, and quantitative sensory testing (QST) outcomes differ between healthy controls and people with chronic shoulder pain.

METHODS

People with chronic shoulder pain (n = 39) and healthy controls (n = 26) completed validated questionnaires measuring demographic, pain characteristics, psychological factors, social support, sleep quality, central sensitivity inventory (CSI), and physical activity levels. A blinded assessor administered QST measuring pressure pain threshold, temporal summation, conditioned pain modulation, and cold hyperalgesia. All participants performed repeated lifting of weighted canisters and reported severity of pain over successive lifts of the weighted canisters. Between-group differences in the QST, SMEP and CSI scores were investigated. Demographic and psychosocial variables were adjusted in the analyses.

RESULTS

Dynamic mechanical allodynia, mechanical temporal summation, movement-evoked pain scores, SMEP index, and CSI scores were significantly (p ≤ 0.05) higher in the chronic shoulder pain group than in healthy controls. A significant proportion of people with chronic shoulder pain presented with pro-nociceptive profiles and experienced higher pain severity, interference, and disability.

CONCLUSIONS

People with chronic shoulder pain displayed symptoms and signs of central sensitization. Future research should investigate the predictive role of central sensitization on clinical outcomes in shoulder pain.

Autonomic Nervous System Function and Central Pain Processing in People With Frozen Shoulder: A Case-control Study

OBJECTIVES

The pathophysiology of a frozen shoulder (FS) is thought to be related to chronic inflammation. Chronic inflammation may disturb the immune system and consequently the nervous system as part of an overarching system. The aim of this study was to determine the presence of disturbed autonomic nervous system function and altered central pain processing (CPP) in patients with FS. Secondarily, the presence of psychological variables (catastrophizing and hypervigilance) and self-reported associated symptoms of altered CPP in patients with FS were investigated.

METHODS

Patients with FS and healthy controls completed the Composite Autonomic Symptom Score (autonomic function) and underwent quantitative sensory testing to assess tactile sensitivity (ie, allodynia), pressure pain thresholds (PPTs, ie, hyperalgesia), temporal summation of pain, and Conditioned Pain Modulation (CPM). Psychological issues were explored with the Pain Catastrophizing Scale and the Pain Vigilance and Awareness Questionnaire, and self-reported symptoms associated with altered CPP were determined with the Central Sensitization Inventory.

RESULTS

Thirty-two patients with FS and 35 healthy controls were analyzed in the study. Patients with FS showed more self-reported autonomic symptoms and symptoms of altered CPP, higher levels of pain catastrophizing and hypervigilance, and are more sensitive to tactile touches and mechanical pressure compared with controls.

DISCUSSION

On the basis of the effect sizes, between-group differences in allodynia, hyperalgesia, catastrophizing, and hypervigilance were clinically relevant, but only local allodynia, hyperalgesia, catastrophizing, and hypervigilance were statistically different. Therefore, obvious altered CPP was not present at the group level in patients with FS compared with controls.

Frozen shoulder

Frozen shoulder is a common debilitating disorder characterized by shoulder pain and progressive loss of shoulder movement. Frozen shoulder is frequently associated with other systemic conditions or occurs following periods of immobilization, and has a protracted clinical course, which can be frustrating for patients as well as health-care professionals. Frozen shoulder is characterized by fibroproliferative tissue fibrosis, whereby fibroblasts, producing predominantly type I and type III collagen, transform into myofibroblasts (a smooth muscle phenotype), which is accompanied by inflammation, neoangiogenesis and neoinnervation, resulting in shoulder capsular fibrotic contractures and the associated clinical stiffness. Diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present. Management consists of physiotherapy, therapeutic modalities such as steroid injections, anti-inflammatory medications, hydrodilation and surgical interventions; however, their effectiveness remains unclear. Facilitating translational science should aid in development of novel therapies to improve outcomes among individuals with this debilitating condition.

Depression and Anxiety Are Associated With Worse Subjective and Functional Baseline Scores in Patients With Frozen Shoulder Contracture Syndrome: A Systematic Review

Purpose

To investigate whether psychological factors, such as avoidance behavior, fear, pain catastrophization, kinesiophobia, anxiety, depression, optimism, and expectation are associated with different subjective and functional baseline scores in patients with frozen shoulder contracture syndrome (FSCS).

Methods

Searches were conducted in MEDLINE, Cochrane Library (CENTRAL Database), PEDro, Pubpsych, and PsychNET.APA without restrictions applied to language, date, or status of publication. Two authors reviewed study titles, abstract, and full text based on the following inclusion criteria: adult population (≥ 30 < 70 years old) with FSCS.

Results

Seven hundred and seventy-six records were included by the search strategies. After title final screening, 6 studies were included for the qualitative synthesis. Psychological features investigated were anxiety, depression, pain-related fear, pain catastrophizing, and pain self-efficacy; reported outcomes included pain, function, disability, quality of life, and range of motion. Data suggest that anxiety and depression impact self-assessed function, pain, and quality of life. There is no consensus on the correlation between psychological variables and range of motion. Associations were suggested between pain-related fear, pain-related beliefs, and pain-related behavior and perceived arm function; pain-related conditions showed no significant correlation with range of motion and with perceived stiffness at baseline.

Conclusion

Scores traditionally thought to assess physical dimensions like shoulder pain, disability, and function seem to be influenced by psychological variables. In FSCS patients, depression and anxiety were associated with increased pain perception and decreased function and quality of life at baseline. Moreover, pain-related fear and catastrophizing seem to be associated with perceived arm function.

Living with a frozen shoulder - a phenomenological inquiry

BACKGROUND

Frozen shoulder (adhesive capsulitis) is an inflammatory condition affecting the capsule of the glenohumeral joint. It is characterised by a painful restricted range of passive and active movement in all planes of motion. The impact of frozen shoulder on affected individuals remains poorly characterised. In this study we sought to better understand the lived experience of people suffering from frozen shoulder to characterise the physical, psychological and socioeconomic impact of the condition.

METHODS

A qualitative study using a phenomenological approach was undertaken. Purposeful sampling was used to identify individuals for interview. Semi-structured interviews were performed and continued until saturation was achieved. A biopsychosocial framework was used during the analysis in order to generate themes which best described the phenomenon and reflected the lived experience of individuals' suffering from this condition.

RESULTS

Ten interviews were conducted, and five main themes emerged including; the severity of the pain experience, a loss of independence, an altered sense of self, the significant psychological impact, and the variable experience with healthcare providers.

CONCLUSIONS

These findings offer an insight into the lived experience of individuals with frozen shoulder, both on a personal and sociocultural level. The pain endured has profound impacts on physical and mental health, with loss of function resulting in a narrative reconstruction and altered sense of self. Our findings illustrate that frozen shoulder is much more than a benign self-limiting musculoskeletal condition and should be managed accordingly.

TRIAL REGISTRATION

ANZCTR 12620000677909 Registered 28/04/2020 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379719&isReview=true.