Clinician and Patient-reported Outcomes Are Associated With Psychological Factors in Patients With Chronic Shoulder Pain.

Background: Validated clinician outcome scores are considered less associated with psychosocial factors than patient-reported outcome measurements (PROMs). This belief may lead to misconceptions if both instruments are related to similar factors.

Questions: We asked: In patients with chronic shoulder pain, what biopsychosocial factors are associated (1) with PROMs, and (2) with clinician-rated outcome measurements?

Methods: All new patients between the ages of 18 and 65 with chronic shoulder pain from a unilateral shoulder injury admitted to a Swiss rehabilitation teaching hospital between May 2012 and January 2015 were screened for potential contributing biopsychosocial factors. During the study period, 314 patients were screened, and after applying prespecified criteria, 158 patients were evaluated. The median symptom duration was 9 months (interquartile range, 5.5-15 months), and 72% of the patients (114 patients) had rotator cuff tears, most of which were work injuries (59%, 93 patients) and were followed for a mean of 31.6 days (SD, 7.5 days). Exclusion criteria were concomitant injuries in another location, major or minor upper limb neuropathy, and inability to understand the validated available versions of PROMs. The PROMs were the DASH, the Brief Pain Inventory, and the Patient Global Impression of Change, before and after treatment (physiotherapy, cognitive therapy and vocational training). The Constant-Murley score was used as a clinician-rated outcome measurement. Statistical models were used to estimate associations between biopsychosocial factors and outcomes.

Results: Greater disability on the DASH was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.64; 95% CI, 0.25-1.03; p = 0.002) and social factors (language, professional qualification combined coefficient, -6.15; 95% CI, -11.09 to -1.22; p = 0.015). Greater pain on the Brief Pain Inventory was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale combined coefficient, 0.076; 95% CI, 0.021-0.13; p = 0.006). Poorer impression of change was associated with psychological factors (Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia coefficient, 0.93; 95% CI, 0.87-0.99; p = 0.026) and social factors (education, language, and professional qualification coefficient, 6.67; 95% CI, 2.77-16.10; p < 0.001). Worse clinician-rated outcome was associated only with psychological factors (Hospital Anxiety and Depression Scale (depression only), Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia combined coefficient, -0.35; 95% CI, -0.58 to -0.12; p = 0.003).

Conclusions: Depressive symptoms and catastrophizing appear to be key factors influencing PROMs and clinician-rated outcomes. This study suggests revisiting the Constant-Murley score.

Level Of Evidence: Level III, prognostic study.