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Pain catastrophizing behaviors and their relation to poor patient-reported outcomes after scapular muscle reattachment
ARTICLE IN PRESS J Shoulder Elbow Surg (2018) ■■, ■■–■■
www.elsevier.com/locate/ymse
ORIGINAL ARTICLE
Pain catastrophizing behaviors and their relation to poor patient-reported outcomes after scapular muscle reattachment W. Ben Kibler, MDa, Cale A. Jacobs, PhD, ATCb, Aaron D. Sciascia, PhD, ATC, PESc,* a
Shoulder Center of Kentucky, Lexington Clinic, Lexington, KY, USA Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA c Department of Exercise and Sport Science, Eastern Kentucky University, Richmond, KY, USA b
Hypothesis: We hypothesized that the patient-reported status following treatment of traumatic scapular muscle detachment would improve from the preoperative status and that higher pain catastrophizing scores would be more common in patients with poor postsurgical outcomes. Methods: We studied 50 patients who met the diagnostic criteria for scapular muscle detachment and in whom rehabilitation failed. American Shoulder and Elbow Surgeons (ASES) scores were collected preoperatively and postoperatively. Patients completed a 7-point global rating of change scale, the Pain Catastrophizing Scale (PCS), and a 10-point satisfaction scale (0-3, not satisfied [NS]; 4-6, moderately satisfied [MS]; or 7-10, highly satisfied [HS]) focused on current shoulder use. Statistical analyses compared preoperative and postoperative ASES scores, compared the 3 levels of satisfaction and ASES scores, and compared ASES scores in patients with low PCS scores (LPCS) (<20) versus high PCS scores (HPCS) (≥20). Significance was set at P < .05. Results: ASES scores significantly improved following surgery (42 ± 20 preoperatively and 73 ± 21 postoperatively) (P < .001), and the global rating of change score was 2 ± 2. There were 39 LPCS patients (mean PCS, 7 ± 6) and 11 HPCS patients (mean PCS, 34 ± 8). HPCS patients had significantly lower postoperative ASES scores (53 ± 18) than LPCS patients (79 ± 18) (P < .001). The MS patients (n = 11) had significantly higher ASES scores than the NS patients (n = 10) (P = .003), while the HS patients (n = 29) had significantly greater ASES scores than the other groups (P ≤ .001). Of the HPCS patients, 90% were in the NS and MS groups compared with 10% in the HS group. Conclusions: Surgical restoration for scapular muscle detachment can result in meaningful improvement in outcomes. Pain catastrophizing negatively affected the self-reported outcome scores. Level of evidence: Level II; Retrospective Design; Prognosis Study © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Scapular dysfunction; scapular muscle detachment; pain catastrophizing; shoulder; scapula surgery; outcomes
Institutional review board approval was received (LCO.2007.01). *Reprint requests: Aaron D. Sciascia, PhD, ATC, PES, Department of Exercise and Sport Science, Eastern Kentucky University, 521 Lancaster Ave, Richmond, KY 40475, USA. E-mail address: [email protected] (A.D. Sciascia).
Scapular muscle detachment has been demonstrated to be a clinical entity with distinct and reproducible clinical presentation, physical examination findings, and surgical findings.13 The incidence and prevalence of scapular muscle detachment have not been investigated or established, but the
1058-2746/$ - see front matter © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2018.02.071
ARTICLE IN PRESS 2 lead author (W.B.K.) has treated more than 300 patients from 28 states and 9 countries over the past 20 years for this problem. Admittedly, the incidence is likely under-reported because of the lack of widespread knowledge of the condition and lack of accurate imaging techniques. The major reason this condition is important is that these patients have high levels of dysfunction including pain, weakness, and an inability to perform many activities of daily living, as well as high levels of frustration because of lack of a diagnosis and consequent ineffective treatment.13 As described in our initial study, the etiology is related to an acute tensile injury, a direct blow, or contusion trauma to the medial scapular supporting musculature.13 The initial article reported the consistent grouping of clinical findings (scapular dyskinesis, pain along the medial scapular border, a palpable defect or loss of muscle bulk along the medial scapular border, pain and decreased ability to use the arm in overhead or forward flexion positions, muscle spasm headaches, and substantial relief of pain and increased arm function with manual scapular stabilization). The article emphasized that since diagnostic imaging has not been shown to be effective, the diagnosis is made by clinical history and physical findings. It was found that by strictly adhering to a set of well-defined clinical inclusion criteria, the diagnosis of medial scapular muscle detachment could be reliably made, and treatment based on this diagnosis could be instituted. The clinical inclusion criteria allow the clinician to differentiate patients with the medial scapular muscle detachment diagnosis from patients with other shoulder problems.13 The article also described the surgical procedure, which involved débridement, mobilization, and reattachment by sutures through paired drill holes of the involved lower trapezius and rhomboid muscles. The initial article describing this condition reported significant mediumterm improvement in pain and functional outcomes via the American Shoulder and Elbow Surgeons (ASES) score following treatment of the detachment. However, other factors relating to individual patients can have a sizable effect on the self-reported measures. For example, pain is the most common patient-reported symptom,35 but the perception of pain is individual and not always directly proportional to the extent of injury.10,37 Pain catastrophizing behavior, an alteration in how an individual perceives pain, is associated with an exaggerated negative mental state during actual or anticipated painful experiences and is often associated with poorer postoperative outcomes.7,27,30,31 This factor was selected because the clinical condition of many scapular muscle detachment patients, owing to the chronicity of the injury (average, 4.5 years), the lack of information regarding the injury, and the disability of the injury, could lead to difficulties in mentally coping with this problem.13 Knowledge of the patient-specific level of pain catastrophizing as it may relate to outcome could be beneficial in interpreting the patient-reported outcome measures and provide information to develop strategies for future treatment and for preoperative patient education. Therefore, the purpose of this study was to assess midterm clinical and func-
W.B. Kibler et al. tional outcomes, using established patient-reported outcome measures, and to include a patient-specific psychosocial factor of pain catastrophizing behavior to determine its effect on the outcome measures in a cohort of patients treated for scapular muscle detachment. The research hypotheses were that (1) patient-reported status would be improved from the preoperative status, (2) patient-reported outcomes would be equal to or better than the midterm results reported previously, and (3) higher pain catastrophizing scores would be more common in patients with poor postoperative patient-reported outcome measures.
Materials and methods All patients treated for post-traumatic scapular muscle detachment from 2010 to 2016 were eligible for this study. The clinical inclusion criteria for this cohort were the same as in the initial study.13 The inclusion criteria for the clinical diagnosis were tensile injury, localized high-level pain along the medial scapular border, inability to use the arm in forward flexion, and relief by manual scapular repositioning. Data are reported for the patients who completed all parts of the evaluation. Because of the wide geographic distribution of the patients and the length of time since treatment, complete data could be gathered on 50 patients (mean age, 38 ± 13 years; 23 female and 27 male patients) out of the 119 patients treated (42%). Of the 50 patients, 24 were part of the original study13 and 26 were new patients who entered the patient registry following reporting of the initial cohort’s results.
Surgical procedure The surgical procedure and postoperative care have previously been described in detail.13 Surgical indications were consistently applied for the entire group. They included the presence of all the clinical findings and inclusion criteria, no relief of the symptoms by a directed comprehensive scapula-based rehabilitation program, and consultation with the patient. As described in the initial study, current methods of advanced diagnostic imaging (computed tomography, magnetic resonance imaging, and so on) have not been helpful in demonstrating this chronic condition.13 Anecdotal reports about diagnostic ultrasound imaging in 2 patients in this cohort suggest that nonspecific thickening in the rhomboid tissue may be seen. It appears that, to display all the clinical findings of the inclusion criteria, the scapular muscle detachment must include injury to both the lower trapezius and rhomboid muscles, as injury to both muscles was found in every operative case. The same surgical technique was used for every patient in the study. The only difference in the surgical treatment was the number of drill holes and sutures, which was determined by the length of the medial scapular border, since the drill holes were placed at 1-cm intervals as described in the initial study.13 All patients were found to have injury to the lower trapezius and rhomboid muscles, and all underwent reattachment by multiple mattress sutures placed through paired drill holes in the scapula. The criteria for completeness of the operation to restore more normal anatomy were reattachment of the entire muscle, no gapping from the bone on probing, secure suture tying, reattachment of the infraspinatus and dorsal fascia, and static restoration of scapular retraction. There were no additional procedures performed on the glenohumeral or acromioclavicular joints. Patients were immobilized for 3-4 weeks in a
ARTICLE IN PRESS Scapular muscle detachment and pain catastrophizing sling, and all were given the same specific protocols and instructions for rehabilitation.
Subjective patient assessment Patient-reported outcome measures have been used as some of the standards for reporting patient outcomes following medical treatment. This study assessed 4 patient-reported outcomes: the ASES score, a 10-point numerical satisfaction rating (where 0 indicates not satisfied and 10 indicates highly satisfied with current arm function), a 7-point global rating of change (GROC) assessment to obtain the patient’s opinion regarding the effectiveness of treatment,11 and the Pain Catastrophizing Scale (PCS).27 Patient satisfaction (ie, satisfaction with the current state of the involved arm) was classified as not satisfied (NS) (scores between 0-3), moderately satisfied (MS) (scores between 4-6), or highly satisfied (HS) (scores between 7-10). The GROC scale ranged from 3 to –3 (much better, moderately better, slightly better, no change, slightly worse, moderately worse, or much worse). Patient-specific factors can include psychological factors (eg, depression, resilience, and catastrophizing), age, education level, race, socioeconomic status, job status, job expectations, and attitudes toward treatment.2,5,17,19,27,32,36,37 Because pain catastrophizing behavior was a factor of interest in this study, the PCS was used to determine whether patients exhibited different levels of pain catastrophizing behavior. The PCS is a 13-item self-reported scale that estimates patients’ attitudes toward the effect of pain on their function in their daily lives, with each item scored 0-4, resulting in a score of 0-52 (a lower score indicates fewer pain catastrophizing characteristics). A score of less than 20 on the PCS classified a patient as having low pain catastrophizing behavior (low PCS score [LPCS]), while a score of 20 or greater classified a patient as having high pain catastrophizing behavior (high PCS score [HPCS]). A score of 20 or greater on the PCS was used to classify a patient as having high pain catastrophizing behavior because 20 was the median score on the PCS established in individuals with upper extremity injuries7,15,22 and chronic conditions such as low-back pain.27 The ASES score was selected as a measure of patient-reported outcomes because both the pain and function subscales have been found to be clinically useful in determining the self-reported status of the shoulder.20,25 The ASES score and similar region-specific instruments appear to be at least as reliable and accurate at assessing patient physical functioning status as measurements of anatomic integrity.14,20,24,26,28 Accounting for both patient-perceived ability to physically function and possible alterations in pain processing and coping as part of the evaluation and treatment process is consistent with recent efforts to improve the diagnostic process by including information that relates to conditions specific to the individual patient as “value on the front end” to establish a comprehensive picture of the patient’s clinical presentation and create a better understanding of the outcomes, or “value on the back end.”1,12 Patients completed the ASES score at the initial evaluation and at the most recent follow-up, while the remaining outcome measures and PCS were completed at follow-up only. All forms were mailed to each patient annually for a minimum of 2 years following discharge from active care.
Statistical analysis Descriptive statistics were performed for demographic data with means, standard deviations, and ranges reported for continuous vari-
3 ables, while frequencies and percentages were reported for categorical variables. Distributions were assessed for normality using the ShapiroWilk test. For all patients, paired t tests were used to compare initial (preoperative) ASES scores with most recent follow-up ASES scores. An analysis of variance was performed to determine whether differences existed between the 3 levels of satisfaction and ASES scores. Independent t tests were used to compare ASES scores between catastrophizers and non-catastrophizers. The level of significance was set at P < .05. All statistical analyses were performed with STATA/SE 15.1 (StataCorp, College Station, TX, USA).
Results Prior to receiving the scapular muscle detachment diagnosis and subsequent surgical intervention, patients had active symptoms for an average of 4.5 years, were evaluated by an average of 6 physicians, and performed rehabilitation for 13 months (Table I). Although not statistically significant compared with patients who were not pain catastrophizers, patients classified as pain catastrophizers postoperatively had at least 1 additional surgical procedure performed prior to identification of the scapular muscle detachment, underwent an average of 6 additional months of physical therapy, and had experienced the injury for 34 additional months prior to identification of the scapular muscle detachment (Table I). Evaluation of the surgical outcomes revealed no failures of healing or reinjury during clinical follow-up. No patients reported any symptoms or demonstrated clinical findings including acute localized tenderness, palpable defect, or acute increase in pain suggesting a retear or lack of healing of the repair. All components of the ASES score for the entire group significantly improved (P < .001) from initial evaluation (ASES pain score, 21; ASES function score, 21; and ASES total score, 42) to most recent follow-up (ASES pain score, 39; ASES function score, 35, and ASES total score, 73), at a mean of 3.5 ± 1.5 years, and were comparable with the original case series values (Table II). However, unlike the values in the initial study, in which the pain score showed a larger improvement (17-point change) than the function score (8-point change),13 the current study group reported similar changes within both the pain (18-point change) and function (14point change) components of the ASES score. The pain score of 39 of 50 is roughly equal to a numeric pain rating of 2 of 10, demonstrating similar results between this group and the initial study group. The average GROC score was 2 ± 2, indicating the group considered themselves moderately better since initial evaluation. One in 5 patients (20%) reported not being satisfied with the current ability to use the arm. The follow-up ASES score for this group was 44 ± 17, which was a nonsignificant increase from the preoperative score (Table III). Similarly, 22% of patients reported moderate satisfaction, with a follow-up ASES score of 66 ± 11, while the majority of patients (58%) reported high satisfaction, with a follow-up ASES score of 85 ± 13. There was no difference in the initial ASES scores between the patient satisfaction groups. Both the MS and HS
ARTICLE IN PRESS 4
W.B. Kibler et al. Table I
Descriptive statistics for demographic variables
Age, yr Mean (SD) Range Previous surgical procedures Mean (SD) Range Previous physicians Mean (SD) Range Previous physical therapy, mo Mean (SD) Range Duration of injury, mo Mean (SD) Range Follow-up, mo Mean (SD) Range Sex Male Female
Overall (n = 50)
LPCS (n = 39)
HPCS (n = 11)
P value
38 (13) 17-65
38 (13) 17-65
38 (13) 21-62
.95
1 (2) 0-8
1 (2) 0-7
2 (3) 0-8
.32
6 (6) 1-35
6 (7) 1-35
5 (4) 1-15
.95
13 (15) 1-72
12 (14) 1-72
18 (15) 2-36
.28
53 (64) 1-360
46 (60) 1-360
80 (77) 6-204
.14
3.5 (1.5) 2-5
4 (1.5) 2-5
3 (1) 2-5
.03
8 (73%) 3 (27%)
.16
27 (54%) 23 (46%)
19 (49%) 20 (51%)
LPCS, low pain catastrophizing score; HPCS, high pain catastrophizing score; SD, standard deviation.
Table II
ASES score comparison of original case series and current follow-up study Original case series (n = 72)
ASES pain score ASES function score ASES total score
Current study (n = 50)
Before surgery
After surgery
Before surgery
After surgery
19 ± 12 20 ± 11 39 ± 16
36 ± 11* 28 ± 11* 63 ± 21*
21 ± 12 21 ± 10 42 ± 20
39 ± 12* 35 ± 11* 73 ± 21*
ASES, American Shoulder and Elbow Surgeons. * Significantly greater score from before surgery to after surgery (P < .001).
Table III
ASES and satisfaction scores following scapular muscle reattachment surgery ASES score
Not satisfied (n = 10) Moderately satisfied (n = 11) Highly satisfied (n = 29)
Satisfaction score
Before surgery
Most recent follow-up
P value
0-3 4-6 7-10
40 ± 16 41 ± 15 42 ± 23
44 ± 17 66 ± 11* 85 ± 13†
.52 .005 <.001
ASES, American Shoulder and Elbow Surgeons. * Significantly greater ASES score at most recent follow-up in moderately satisfied group compared with not satisfied group (P = .003). † Significantly greater ASES score at most recent follow-up in highly satisfied group compared with not satisfied group and moderately satisfied group (P ≤ .001).
groups’ most recent ASES scores significantly improved from the preoperative period (P ≤ .005). The MS group had significantly greater ASES scores at most recent follow-up than the NS group (P = .003), while the HS group’s ASES scores were significantly greater than both the NS and MS groups’ scores (P ≤ .001).
Of the patients, 39 were classified as having LPCS (mean PCS, 7 ± 6) whereas 11 were classified as having HPCS (mean PCS, 34 ± 8). More severe catastrophizing scores were associated with inferior ASES total scores. The average ASES pain, function, and total scores for the LPCS patients (42 points, 37 points, and 79 points, respectively) were
ARTICLE IN PRESS Scapular muscle detachment and pain catastrophizing
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Table IV Presurgical to most recent follow-up ASES scores between patients with LPCS and HPCS following scapular muscle reattachment surgery LPCS (n = 39) ASES pain score ASES function score ASES total score
HPCS (n = 11)
Before surgery
Most recent follow-up
P value
Before surgery
Most recent follow-up
P value
20 ± 12 21 ± 11 41 ± 21
42 ± 10* 37 ± 10* 79 ± 18*
<.001 <.001 <.001
24 ± 11 22 ± 9 46 ± 18
27 ± 12 27 ± 10 53 ± 18
.58 .05 .31
ASES, American Shoulder and Elbow Surgeons; LPCS, low pain catastrophizing score; HPCS, high pain catastrophizing score. * Significantly greater ASES pain, function, and total scores at most recent follow-up for LPCS compared with HPCS (P ≤ .005).
significantly greater (P ≤ .005) than the scores for the HPCS patients (27 points, 27 points, and 53 points, respectively) (Table IV). In addition, 90% of the HPCS patients were in either the NS or MS group (45% each) compared with 10% in the HS group.
Discussion There is evidence to accept each of the research hypotheses. The operative procedure resulted in no technical or postoperative deleterious outcomes, while the overall patientreported outcome scores were improved. There were statistically significant increases in all components of the ASES score, and 80% of all patients reported moderate to high satisfaction with the current status of arm function following surgery. The GROC scores indicated favorable perception of change in the patients’ perceived ability to physically function. As hypothesized, the patients who did not achieve a favorable outcome were found to have increased pain catastrophizing behavior. The data from the patient-reported outcome measures of this study and the initial study13 demonstrate and confirm that as a general approach, the described treatment intervention can be expected to result in favorable clinical outcomes, with significant improvements in pain and function, and therefore can be advocated for patients who meet the clinical inclusion criteria. This study also shows that the outcomes appear to be durable over several years. This method of repair addresses the damaged muscles and restores more normal anatomy and may create conditions for rehabilitation to restore scapular kinematics. Both this study and the initial study demonstrate that scapular muscle detachment appears to be a welldefined clinical diagnosis, with a consistent mechanism of injury, clinical presentation, patient dysfunction, and clinical examination, which can differentiate these patients from patients with other scapular problems. All the patients in this group met 100% of the inclusion criteria. They were all treated by 1 physician, according to the established protocol, resulting in all patients receiving the same surgical treatment. Likewise, discharge from treatment was based on completion of the rehabilitation progressions. The improvements in the ASES pain scores were similar to the initial study,13 resulting in a postoperative score ap-
proximately equivalent to a numeric pain rating score of 2 of 10, compared with a preoperative pain rating of 6 of 10 to 8 of 10 (P < .001). The majority of patients have attributed the significant improvement in pain to be the primary factor in lifestyle betterment and satisfaction. In the current study, the improvements in the ASES function and total scores were 7 and 10 points higher (albeit not statistically significant), respectively, than those in the initial study. The clinically improved scores may be attributed to further clinician experience and ability to more effectively guide patients through postoperative recovery. However, further clinical experience and subgroup analysis showed that a portion of the overall group did not achieve the expected favorable patient-reported outcome-based results. A major finding of this follow-up study is that patients demonstrating higher levels of pain catastrophizing behaviors as defined by HPCS (≥20) demonstrated inferior postoperative patient-reported outcome scores. This finding appears to parallel recent reports that have identified pain catastrophizing behavior as a negative influence on postsurgical rotator cuff outcomes7 and experimental pain protocols for individuals with shoulder pain.4,33,34 This negative influence has also been shown in a nonoperative cohort of patients complaining of shoulder pain.19 Furthermore, the current study identified that 90% of patients who were not satisfied or were moderately satisfied with the current function of the arm after surgery had high PCS scores that placed them in the HPCS group. By comparison, only 10% of HPCS patients were in the high satisfaction group. This finding would suggest that although scapular muscle detachment has not been frequently identified, the patients who were able to be diagnosed with the condition and received the recommended treatment appeared to psychologically mirror patients with more common shoulder problems. It is unclear whether pain catastrophizing is inherent to patients or whether it develops during the long course between the time of injury and definitive treatment. Persistent high levels of pain and dysfunction coupled with the frustration of not having a clear diagnosis may influence catastrophizing characteristics. Considering that the patients with high pain catastrophizing behavior in this study underwent at least 1 additional previous surgical procedure and were undergoing physical therapy prior to receiving the muscle detachment diagnosis for 6 additional months and that all had a longer
ARTICLE IN PRESS 6 chronicity of the initial injury (3 additional years) compared with those with low pain catastrophizing behavior, it is possible that these factors could have created or exacerbated alterations in pain processing for the patients. This is not uncommon because it has been shown that chronic pain can lead to a prolonged release of neuropeptides that alter central pain processing, resulting in an amplified pain response termed “central sensitization.”4,8,9,16 Conversely, pain catastrophizing relates to how a person copes with and responds to stimuli perceived as painful. On the basis of the results of the current study, the negative influence of pain catastrophizing on the outcome score suggests that pain catastrophizing may be viewed as another comorbidity where an underlying physical or psychological factor complicates the outcome. Because of the significant differences between the subgroups in this otherwise homogeneous cohort, it can be concluded that inferior patient-reported outcomes are more common for patients with high pain catastrophizing behaviors as defined by high PCS scores. While the current results cannot establish a true cause-and-effect relationship, we suggest that clinicians use assessment methods that target patientperceived pain. Because of the findings of this study, all patients presenting to our treatment center with scapular pain now complete the PCS form at the initial preoperative visit. The PCS score and the physical examination findings are both discussed with the patient as part of the formulation of the treatment. Finally, cognitive behavioral therapy interventions have recently been shown to decrease pain catastrophizing behaviors in patients with upper extremity musculoskeletal conditions,22 and future work is necessary to determine whether similar treatments may successfully augment postoperative rehabilitation to improve outcomes for this at-risk patient population. Our findings are consistent with other reports of the effect of individual patient factors on the outcomes of treatment.4,19,32,33,37 These results add support to the recommendation that pertinent patient-specific factors should be identified and included in the information gathered as part of determining the comprehensive diagnosis that guides the content and timing of the treatment1 and enhances the value on the front end that improves the treatment outcomes, that is, the value on the back end.12 Questionnaires designed to assess pain,3 pain-related characteristics,6,27 and different psychological constructs18,21,23,29 can be used to assess a patient’s perception of specific factors that may compound the actual anatomic injury and hinder his or her ability to recover as expected once treatment has been initiated. Reattachment has demonstrated both short-term and midterm pain reduction,13 and future studies are necessary to determine whether the reduction in pain is due to a decrease in tension on the muscle and/or the restoration of muscle activation. Similarly, future studies should be directed at determining whether improvement in self-reported function is due to the restoration of scapulohumeral rhythm and improvement in muscle strength that are theoretically provided by this procedure.
W.B. Kibler et al.
Limitations The following limitations have been identified. First, there was a wide geographic distribution of the patients. Patients in this population were located across the United States and the world. This could have negatively contributed to the low response rate for follow-up (42%). This limitation was also seen in the initial study.13 Second, objective clinical or performance data were not gathered for this follow-up study primarily because of the geographic distribution but also because of financial and feasibility difficulties, affecting physical contact with the patients. Therefore, the information that has been gathered has been primarily subjective. Efforts can be made to prospectively establish lines of communication and increase the ease of answering the questionnaires, but the response rate for these types of studies will typically be low. Third, we used a limited number of outcome measurements. The ASES score was used for comparison with the results of the initial study. While other patient-reported outcome measures may be considered and used, the ASES score is appropriate for this general patient population. Fourth, pain catastrophizing was only assessed at postoperative followup. This patient-specific factor may have existed prior to the injury; could have been affected by a multitude of other factors (stress or anxiety, previous experiences with treatment, and so on); or could be due to neuroplastic changes in the nociceptors, spinal cord, and brain known to contribute to chronic pain. However, with the rise in publications in the literature identifying the relationship between mental aspects of function and pain or injury and how that relationship can deleteriously affect outcome scores, assessing for the presence of pain catastrophizing at follow-up would help provide a possible explanation as to why the outcome is lower than expected. Furthermore, the combination of maladaptive pain behaviors and genetic factors has been demonstrated to be predictive of persistent postoperative pain 1 year after rotator cuff repair.7 Unfortunately, this information was not available at the initiation of our prospective outcome registry, and the inclusion of preoperative pain catastrophizing scales and even genetic factors could have strengthened both the current study and future studies from this registry. Finally, adherence to the rehabilitation protocol likely varied since most patients lived a long distance from the treatment facility. Patients were verbally asked about rehabilitation progress during clinical follow-up. Although this may have allowed recall bias to occur, patient progression through the rehabilitation phase was monitored by periodic contact with the treating clinician.
Conclusion Patient-reported outcomes measured using ASES scores, GROC scores, and patient satisfaction scores demonstrate that operative repair of post-traumatic scapular muscle detachment can be expected to provide value on the back
ARTICLE IN PRESS Scapular muscle detachment and pain catastrophizing end—significant and durable relief of pain and dysfunction—in a large percentage of patients who meet the inclusion criteria. However, a small group of patients did not report significant changes in the patient-reported outcome measures, despite meeting the same clinical inclusion criteria and following the same treatment protocol. Higher levels of pain catastrophizing behaviors as defined by high PCS scores were more common for patients with inferior postoperative outcome scores. Future studies are necessary to determine whether assessment of pain catastrophizing should be included in the comprehensive evaluation that produces value on the front end, viewing this patient-specific factor similarly to other comorbidities that may place the patient at increased risk of an inferior postoperative outcome.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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7 10. Jacobs CA, Burnham JM, Jochimsen KN, Molina D IV, Hamilton DA, Duncan ST. Preoperative symptoms in femoroacetabular impingement patients are more related to mental health scores than the severity of labral tear or magnitude of bony deformity. J Arthroplasty 2017;32:36036. http://dx.doi.org/10.1016/j.arth.2017.06.053 11. Kamper SJ, Maher CG, MacKay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther 2009;17:163-70. http://dx.doi.org/10.1179/jmt.2009.17.3.163 12. Kibler WB. Value on the front end: making the effective diagnosis for optimal treatment. Arthroscopy 2017;33:493-5. http://dx.doi.org/ 10.1016/j.arthro.2016.09.010 13. Kibler WB, Sciascia A, Uhl T. Medial scapular muscle detachment: clinical presentation and surgical treatment. J Shoulder Elbow Surg 2014;23:58-67. http://dx.doi.org/10.1016/j.jse.2013.05.008 14. Kocher MS, Horan MP, Briggs KK, Richardson TR, O’Holleran J, Hawkins RJ. Reliability, validity, and responsiveness of the American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis. J Bone Joint Surg Am 2005;87:2006-11. http://dx.doi.org/10.2106/ JBJS.C.01624 15. Kortlever JTP, Janssen SJ, van Berckel MMG, Ring D, Vranceanu AM. What is the most useful questionnaire for measurement of coping strategies in response to nociception? Clin Orthop Relat Res 2015;473:3511-8. http://dx.doi.org/10.1007/s11999-015-4419-2 16. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain 2009;10:895-926. http://dx.doi.org/10.1016/j.jpain.2009.06.012 17. Lollino N, Brunocilla PR, Poglio F, Vannini E, Lollino S, Lancia M. Non-orthopaedic causes of shoulder pain: what the shoulder expert must remember. Musculoskelet Surg 2012;96(Suppl 1):S63-8. http:// dx.doi.org/10.1007/s12306-012-0192-5 18. McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care 1994;32:40-66. 19. Menendez ME, Baker DK, Oladeji LO, Fryberger CT, McGwin G, Ponce BA. Psychological distress is associated with greater perceived disability and pain in patients presenting to a shoulder clinic. J Bone Joint Surg Am 2015;97:1999-2003. http://dx.doi.org/10.2106/ JBJS.O.00387 20. Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons standardized assessment form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg 2002;11:587-94. http://dx.doi.org/10.1067/mse.2002.127096 21. Michener LA, Snyder AR. Evaluation of health-related quality of life in patients with shoulder pain: are we doing the best we can? Clin Sports Med 2008;27:491-505. http://dx.doi.org/10.1016/j.csm.2008.03.001 22. Moradi A, Mellema JJ, Oflazoglu K, Isakov A, Ring D, Vranceanu AM. The relationship between catastrophic thinking and hand diagram areas. J Hand Surg Am 2015;40:2440-6. http://dx.doi.org/10.1016/ j.jhsa.2015.07.031 23. Parsons JT, Snyder AR. Health-related quality of life as a primary clinical outcome in sport rehabilitation. J Sport Rehabil 2011;20:17-36. http:// dx.doi.org/10.1123/jsr.20.1.17 24. Placzek JD, Lukens SC, Badalanmenti S, Roubal PJ, Freeman DC, Walleman KM, et al. Shoulder outcome measures: a comparison of 6 functional tests. Am J Sports Med 2004;32:1270-7. http://dx.doi.org/ 10.1177/0363546503262193 25. Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gristina AG, et al. A standardization method for the assessment of shoulder function. J Shoulder Elbow Surg 1994;3:347-52. 26. Sciascia AD, Morris BJ, Jacobs CA, Edwards TB. Responsiveness and internal validity of common patient-reported outcome measures following total shoulder arthroplasty. Orthopedics 2017;40:e513-9. http:// dx.doi.org/10.3928/01477447-20170327-02 27. Sullivan MJL, Bishop S, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995;7:524-32.
ARTICLE IN PRESS 8 28. Tashjian RZ, Deloach J, Green A, Porucznik CA, Powell AP. Minimal clinically important differences in ASES and simple shoulder test scores after nonoperative treatment of rotator cuff disease. J Bone Joint Surg Am 2010;92:296-303. http://dx.doi.org/10.2106/JBJS.H.01296 29. Terwee CB, Bot SDM, de Boer MR, van der Windt DAWM, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 2007;60:34-42. http://dx.doi.org/10.1016/j.jclinepi.2006.03.012 30. Tripp DA, Stanish W, Ebel-Lam A, Brewer BW, Birchard J. Fear of reinjury, negative affect, and catastrophizing predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year postsurgery. Rehabil Psychol 2007;52:74-81. http://dx.doi.org/10.1037/ 0090-5550.52.1.74 31. Tripp DA, Stanish WD, Reardon G, Coady C, Sullivan MJL. Comparing postoperative pain experiences of the adolescent and adult athlete after anterior cruciate ligament surgery. J Athl Train 2003;38:154-7. 32. Unruh KP, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, et al. The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg 2014;23:1052-8. http://dx.doi.org/10.1016/j.jse.2013.10.001
W.B. Kibler et al. 33. Valencia C, Fillingim RB, Bishop M, Wu SS, Wright TW, Moser M, et al. Investigation of central pain processing in postoperative shoulder pain and disability. Clin J Pain 2014;30:775-86. http://dx.doi.org/ 10.1097/AJP.0000000000000029 34. Valencia C, Kindler LL, Fillingim RB, George SZ. Investigation of central pain processing in shoulder pain: converging results from 2 musculoskeletal pain models. J Pain 2012;13:81-9. http://dx.doi.org/ 10.1016/j.jpain.2011.10.006 35. Van Wilgen CP, Kaptein AA, Brinker MS. Illness perceptions and mood states are associated with injury-related outcomes in athletes. Disabil Rehabil 2010;32:1576-85. http://dx.doi.org/10.3109/ 09638281003596857 36. Warth RJ, Briggs KK, Dornan GJ, Horan MP, Millett PJ. Patient expectations before arthroscopic shoulder surgery: correlation with patients’ reasons for seeking treatment. J Shoulder Elbow Surg 2013;22:1676-81. http://dx.doi.org/10.1016/j.jse.2013.05.003 37. Wylie JD, Suter T, Potter MQ, Granger EK, Tashjian RZ. Mental health has a stronger association with patient-reported shoulder pain and function than tear size in patients with full-thickness rotator cuff tears. J Bone Joint Surg Am 2016;98:251-6. http://dx.doi.org/10.2106/ JBJS.O.00444
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ORIGINAL ARTICLE
Pain catastrophizing behaviors and their relation to poor patient-reported outcomes after scapular muscle reattachment W. Ben Kibler, MDa, Cale A. Jacobs, PhD, ATCb, Aaron D. Sciascia, PhD, ATC, PESc,* a
Shoulder Center of Kentucky, Lexington Clinic, Lexington, KY, USA Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY, USA c Department of Exercise and Sport Science, Eastern Kentucky University, Richmond, KY, USA b
Hypothesis: We hypothesized that the patient-reported status following treatment of traumatic scapular muscle detachment would improve from the preoperative status and that higher pain catastrophizing scores would be more common in patients with poor postsurgical outcomes. Methods: We studied 50 patients who met the diagnostic criteria for scapular muscle detachment and in whom rehabilitation failed. American Shoulder and Elbow Surgeons (ASES) scores were collected preoperatively and postoperatively. Patients completed a 7-point global rating of change scale, the Pain Catastrophizing Scale (PCS), and a 10-point satisfaction scale (0-3, not satisfied [NS]; 4-6, moderately satisfied [MS]; or 7-10, highly satisfied [HS]) focused on current shoulder use. Statistical analyses compared preoperative and postoperative ASES scores, compared the 3 levels of satisfaction and ASES scores, and compared ASES scores in patients with low PCS scores (LPCS) (<20) versus high PCS scores (HPCS) (≥20). Significance was set at P < .05. Results: ASES scores significantly improved following surgery (42 ± 20 preoperatively and 73 ± 21 postoperatively) (P < .001), and the global rating of change score was 2 ± 2. There were 39 LPCS patients (mean PCS, 7 ± 6) and 11 HPCS patients (mean PCS, 34 ± 8). HPCS patients had significantly lower postoperative ASES scores (53 ± 18) than LPCS patients (79 ± 18) (P < .001). The MS patients (n = 11) had significantly higher ASES scores than the NS patients (n = 10) (P = .003), while the HS patients (n = 29) had significantly greater ASES scores than the other groups (P ≤ .001). Of the HPCS patients, 90% were in the NS and MS groups compared with 10% in the HS group. Conclusions: Surgical restoration for scapular muscle detachment can result in meaningful improvement in outcomes. Pain catastrophizing negatively affected the self-reported outcome scores. Level of evidence: Level II; Retrospective Design; Prognosis Study © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Scapular dysfunction; scapular muscle detachment; pain catastrophizing; shoulder; scapula surgery; outcomes
Institutional review board approval was received (LCO.2007.01). *Reprint requests: Aaron D. Sciascia, PhD, ATC, PES, Department of Exercise and Sport Science, Eastern Kentucky University, 521 Lancaster Ave, Richmond, KY 40475, USA. E-mail address: [email protected] (A.D. Sciascia).
Scapular muscle detachment has been demonstrated to be a clinical entity with distinct and reproducible clinical presentation, physical examination findings, and surgical findings.13 The incidence and prevalence of scapular muscle detachment have not been investigated or established, but the
1058-2746/$ - see front matter © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2018.02.071
ARTICLE IN PRESS 2 lead author (W.B.K.) has treated more than 300 patients from 28 states and 9 countries over the past 20 years for this problem. Admittedly, the incidence is likely under-reported because of the lack of widespread knowledge of the condition and lack of accurate imaging techniques. The major reason this condition is important is that these patients have high levels of dysfunction including pain, weakness, and an inability to perform many activities of daily living, as well as high levels of frustration because of lack of a diagnosis and consequent ineffective treatment.13 As described in our initial study, the etiology is related to an acute tensile injury, a direct blow, or contusion trauma to the medial scapular supporting musculature.13 The initial article reported the consistent grouping of clinical findings (scapular dyskinesis, pain along the medial scapular border, a palpable defect or loss of muscle bulk along the medial scapular border, pain and decreased ability to use the arm in overhead or forward flexion positions, muscle spasm headaches, and substantial relief of pain and increased arm function with manual scapular stabilization). The article emphasized that since diagnostic imaging has not been shown to be effective, the diagnosis is made by clinical history and physical findings. It was found that by strictly adhering to a set of well-defined clinical inclusion criteria, the diagnosis of medial scapular muscle detachment could be reliably made, and treatment based on this diagnosis could be instituted. The clinical inclusion criteria allow the clinician to differentiate patients with the medial scapular muscle detachment diagnosis from patients with other shoulder problems.13 The article also described the surgical procedure, which involved débridement, mobilization, and reattachment by sutures through paired drill holes of the involved lower trapezius and rhomboid muscles. The initial article describing this condition reported significant mediumterm improvement in pain and functional outcomes via the American Shoulder and Elbow Surgeons (ASES) score following treatment of the detachment. However, other factors relating to individual patients can have a sizable effect on the self-reported measures. For example, pain is the most common patient-reported symptom,35 but the perception of pain is individual and not always directly proportional to the extent of injury.10,37 Pain catastrophizing behavior, an alteration in how an individual perceives pain, is associated with an exaggerated negative mental state during actual or anticipated painful experiences and is often associated with poorer postoperative outcomes.7,27,30,31 This factor was selected because the clinical condition of many scapular muscle detachment patients, owing to the chronicity of the injury (average, 4.5 years), the lack of information regarding the injury, and the disability of the injury, could lead to difficulties in mentally coping with this problem.13 Knowledge of the patient-specific level of pain catastrophizing as it may relate to outcome could be beneficial in interpreting the patient-reported outcome measures and provide information to develop strategies for future treatment and for preoperative patient education. Therefore, the purpose of this study was to assess midterm clinical and func-
W.B. Kibler et al. tional outcomes, using established patient-reported outcome measures, and to include a patient-specific psychosocial factor of pain catastrophizing behavior to determine its effect on the outcome measures in a cohort of patients treated for scapular muscle detachment. The research hypotheses were that (1) patient-reported status would be improved from the preoperative status, (2) patient-reported outcomes would be equal to or better than the midterm results reported previously, and (3) higher pain catastrophizing scores would be more common in patients with poor postoperative patient-reported outcome measures.
Materials and methods All patients treated for post-traumatic scapular muscle detachment from 2010 to 2016 were eligible for this study. The clinical inclusion criteria for this cohort were the same as in the initial study.13 The inclusion criteria for the clinical diagnosis were tensile injury, localized high-level pain along the medial scapular border, inability to use the arm in forward flexion, and relief by manual scapular repositioning. Data are reported for the patients who completed all parts of the evaluation. Because of the wide geographic distribution of the patients and the length of time since treatment, complete data could be gathered on 50 patients (mean age, 38 ± 13 years; 23 female and 27 male patients) out of the 119 patients treated (42%). Of the 50 patients, 24 were part of the original study13 and 26 were new patients who entered the patient registry following reporting of the initial cohort’s results.
Surgical procedure The surgical procedure and postoperative care have previously been described in detail.13 Surgical indications were consistently applied for the entire group. They included the presence of all the clinical findings and inclusion criteria, no relief of the symptoms by a directed comprehensive scapula-based rehabilitation program, and consultation with the patient. As described in the initial study, current methods of advanced diagnostic imaging (computed tomography, magnetic resonance imaging, and so on) have not been helpful in demonstrating this chronic condition.13 Anecdotal reports about diagnostic ultrasound imaging in 2 patients in this cohort suggest that nonspecific thickening in the rhomboid tissue may be seen. It appears that, to display all the clinical findings of the inclusion criteria, the scapular muscle detachment must include injury to both the lower trapezius and rhomboid muscles, as injury to both muscles was found in every operative case. The same surgical technique was used for every patient in the study. The only difference in the surgical treatment was the number of drill holes and sutures, which was determined by the length of the medial scapular border, since the drill holes were placed at 1-cm intervals as described in the initial study.13 All patients were found to have injury to the lower trapezius and rhomboid muscles, and all underwent reattachment by multiple mattress sutures placed through paired drill holes in the scapula. The criteria for completeness of the operation to restore more normal anatomy were reattachment of the entire muscle, no gapping from the bone on probing, secure suture tying, reattachment of the infraspinatus and dorsal fascia, and static restoration of scapular retraction. There were no additional procedures performed on the glenohumeral or acromioclavicular joints. Patients were immobilized for 3-4 weeks in a
ARTICLE IN PRESS Scapular muscle detachment and pain catastrophizing sling, and all were given the same specific protocols and instructions for rehabilitation.
Subjective patient assessment Patient-reported outcome measures have been used as some of the standards for reporting patient outcomes following medical treatment. This study assessed 4 patient-reported outcomes: the ASES score, a 10-point numerical satisfaction rating (where 0 indicates not satisfied and 10 indicates highly satisfied with current arm function), a 7-point global rating of change (GROC) assessment to obtain the patient’s opinion regarding the effectiveness of treatment,11 and the Pain Catastrophizing Scale (PCS).27 Patient satisfaction (ie, satisfaction with the current state of the involved arm) was classified as not satisfied (NS) (scores between 0-3), moderately satisfied (MS) (scores between 4-6), or highly satisfied (HS) (scores between 7-10). The GROC scale ranged from 3 to –3 (much better, moderately better, slightly better, no change, slightly worse, moderately worse, or much worse). Patient-specific factors can include psychological factors (eg, depression, resilience, and catastrophizing), age, education level, race, socioeconomic status, job status, job expectations, and attitudes toward treatment.2,5,17,19,27,32,36,37 Because pain catastrophizing behavior was a factor of interest in this study, the PCS was used to determine whether patients exhibited different levels of pain catastrophizing behavior. The PCS is a 13-item self-reported scale that estimates patients’ attitudes toward the effect of pain on their function in their daily lives, with each item scored 0-4, resulting in a score of 0-52 (a lower score indicates fewer pain catastrophizing characteristics). A score of less than 20 on the PCS classified a patient as having low pain catastrophizing behavior (low PCS score [LPCS]), while a score of 20 or greater classified a patient as having high pain catastrophizing behavior (high PCS score [HPCS]). A score of 20 or greater on the PCS was used to classify a patient as having high pain catastrophizing behavior because 20 was the median score on the PCS established in individuals with upper extremity injuries7,15,22 and chronic conditions such as low-back pain.27 The ASES score was selected as a measure of patient-reported outcomes because both the pain and function subscales have been found to be clinically useful in determining the self-reported status of the shoulder.20,25 The ASES score and similar region-specific instruments appear to be at least as reliable and accurate at assessing patient physical functioning status as measurements of anatomic integrity.14,20,24,26,28 Accounting for both patient-perceived ability to physically function and possible alterations in pain processing and coping as part of the evaluation and treatment process is consistent with recent efforts to improve the diagnostic process by including information that relates to conditions specific to the individual patient as “value on the front end” to establish a comprehensive picture of the patient’s clinical presentation and create a better understanding of the outcomes, or “value on the back end.”1,12 Patients completed the ASES score at the initial evaluation and at the most recent follow-up, while the remaining outcome measures and PCS were completed at follow-up only. All forms were mailed to each patient annually for a minimum of 2 years following discharge from active care.
Statistical analysis Descriptive statistics were performed for demographic data with means, standard deviations, and ranges reported for continuous vari-
3 ables, while frequencies and percentages were reported for categorical variables. Distributions were assessed for normality using the ShapiroWilk test. For all patients, paired t tests were used to compare initial (preoperative) ASES scores with most recent follow-up ASES scores. An analysis of variance was performed to determine whether differences existed between the 3 levels of satisfaction and ASES scores. Independent t tests were used to compare ASES scores between catastrophizers and non-catastrophizers. The level of significance was set at P < .05. All statistical analyses were performed with STATA/SE 15.1 (StataCorp, College Station, TX, USA).
Results Prior to receiving the scapular muscle detachment diagnosis and subsequent surgical intervention, patients had active symptoms for an average of 4.5 years, were evaluated by an average of 6 physicians, and performed rehabilitation for 13 months (Table I). Although not statistically significant compared with patients who were not pain catastrophizers, patients classified as pain catastrophizers postoperatively had at least 1 additional surgical procedure performed prior to identification of the scapular muscle detachment, underwent an average of 6 additional months of physical therapy, and had experienced the injury for 34 additional months prior to identification of the scapular muscle detachment (Table I). Evaluation of the surgical outcomes revealed no failures of healing or reinjury during clinical follow-up. No patients reported any symptoms or demonstrated clinical findings including acute localized tenderness, palpable defect, or acute increase in pain suggesting a retear or lack of healing of the repair. All components of the ASES score for the entire group significantly improved (P < .001) from initial evaluation (ASES pain score, 21; ASES function score, 21; and ASES total score, 42) to most recent follow-up (ASES pain score, 39; ASES function score, 35, and ASES total score, 73), at a mean of 3.5 ± 1.5 years, and were comparable with the original case series values (Table II). However, unlike the values in the initial study, in which the pain score showed a larger improvement (17-point change) than the function score (8-point change),13 the current study group reported similar changes within both the pain (18-point change) and function (14point change) components of the ASES score. The pain score of 39 of 50 is roughly equal to a numeric pain rating of 2 of 10, demonstrating similar results between this group and the initial study group. The average GROC score was 2 ± 2, indicating the group considered themselves moderately better since initial evaluation. One in 5 patients (20%) reported not being satisfied with the current ability to use the arm. The follow-up ASES score for this group was 44 ± 17, which was a nonsignificant increase from the preoperative score (Table III). Similarly, 22% of patients reported moderate satisfaction, with a follow-up ASES score of 66 ± 11, while the majority of patients (58%) reported high satisfaction, with a follow-up ASES score of 85 ± 13. There was no difference in the initial ASES scores between the patient satisfaction groups. Both the MS and HS
ARTICLE IN PRESS 4
W.B. Kibler et al. Table I
Descriptive statistics for demographic variables
Age, yr Mean (SD) Range Previous surgical procedures Mean (SD) Range Previous physicians Mean (SD) Range Previous physical therapy, mo Mean (SD) Range Duration of injury, mo Mean (SD) Range Follow-up, mo Mean (SD) Range Sex Male Female
Overall (n = 50)
LPCS (n = 39)
HPCS (n = 11)
P value
38 (13) 17-65
38 (13) 17-65
38 (13) 21-62
.95
1 (2) 0-8
1 (2) 0-7
2 (3) 0-8
.32
6 (6) 1-35
6 (7) 1-35
5 (4) 1-15
.95
13 (15) 1-72
12 (14) 1-72
18 (15) 2-36
.28
53 (64) 1-360
46 (60) 1-360
80 (77) 6-204
.14
3.5 (1.5) 2-5
4 (1.5) 2-5
3 (1) 2-5
.03
8 (73%) 3 (27%)
.16
27 (54%) 23 (46%)
19 (49%) 20 (51%)
LPCS, low pain catastrophizing score; HPCS, high pain catastrophizing score; SD, standard deviation.
Table II
ASES score comparison of original case series and current follow-up study Original case series (n = 72)
ASES pain score ASES function score ASES total score
Current study (n = 50)
Before surgery
After surgery
Before surgery
After surgery
19 ± 12 20 ± 11 39 ± 16
36 ± 11* 28 ± 11* 63 ± 21*
21 ± 12 21 ± 10 42 ± 20
39 ± 12* 35 ± 11* 73 ± 21*
ASES, American Shoulder and Elbow Surgeons. * Significantly greater score from before surgery to after surgery (P < .001).
Table III
ASES and satisfaction scores following scapular muscle reattachment surgery ASES score
Not satisfied (n = 10) Moderately satisfied (n = 11) Highly satisfied (n = 29)
Satisfaction score
Before surgery
Most recent follow-up
P value
0-3 4-6 7-10
40 ± 16 41 ± 15 42 ± 23
44 ± 17 66 ± 11* 85 ± 13†
.52 .005 <.001
ASES, American Shoulder and Elbow Surgeons. * Significantly greater ASES score at most recent follow-up in moderately satisfied group compared with not satisfied group (P = .003). † Significantly greater ASES score at most recent follow-up in highly satisfied group compared with not satisfied group and moderately satisfied group (P ≤ .001).
groups’ most recent ASES scores significantly improved from the preoperative period (P ≤ .005). The MS group had significantly greater ASES scores at most recent follow-up than the NS group (P = .003), while the HS group’s ASES scores were significantly greater than both the NS and MS groups’ scores (P ≤ .001).
Of the patients, 39 were classified as having LPCS (mean PCS, 7 ± 6) whereas 11 were classified as having HPCS (mean PCS, 34 ± 8). More severe catastrophizing scores were associated with inferior ASES total scores. The average ASES pain, function, and total scores for the LPCS patients (42 points, 37 points, and 79 points, respectively) were
ARTICLE IN PRESS Scapular muscle detachment and pain catastrophizing
5
Table IV Presurgical to most recent follow-up ASES scores between patients with LPCS and HPCS following scapular muscle reattachment surgery LPCS (n = 39) ASES pain score ASES function score ASES total score
HPCS (n = 11)
Before surgery
Most recent follow-up
P value
Before surgery
Most recent follow-up
P value
20 ± 12 21 ± 11 41 ± 21
42 ± 10* 37 ± 10* 79 ± 18*
<.001 <.001 <.001
24 ± 11 22 ± 9 46 ± 18
27 ± 12 27 ± 10 53 ± 18
.58 .05 .31
ASES, American Shoulder and Elbow Surgeons; LPCS, low pain catastrophizing score; HPCS, high pain catastrophizing score. * Significantly greater ASES pain, function, and total scores at most recent follow-up for LPCS compared with HPCS (P ≤ .005).
significantly greater (P ≤ .005) than the scores for the HPCS patients (27 points, 27 points, and 53 points, respectively) (Table IV). In addition, 90% of the HPCS patients were in either the NS or MS group (45% each) compared with 10% in the HS group.
Discussion There is evidence to accept each of the research hypotheses. The operative procedure resulted in no technical or postoperative deleterious outcomes, while the overall patientreported outcome scores were improved. There were statistically significant increases in all components of the ASES score, and 80% of all patients reported moderate to high satisfaction with the current status of arm function following surgery. The GROC scores indicated favorable perception of change in the patients’ perceived ability to physically function. As hypothesized, the patients who did not achieve a favorable outcome were found to have increased pain catastrophizing behavior. The data from the patient-reported outcome measures of this study and the initial study13 demonstrate and confirm that as a general approach, the described treatment intervention can be expected to result in favorable clinical outcomes, with significant improvements in pain and function, and therefore can be advocated for patients who meet the clinical inclusion criteria. This study also shows that the outcomes appear to be durable over several years. This method of repair addresses the damaged muscles and restores more normal anatomy and may create conditions for rehabilitation to restore scapular kinematics. Both this study and the initial study demonstrate that scapular muscle detachment appears to be a welldefined clinical diagnosis, with a consistent mechanism of injury, clinical presentation, patient dysfunction, and clinical examination, which can differentiate these patients from patients with other scapular problems. All the patients in this group met 100% of the inclusion criteria. They were all treated by 1 physician, according to the established protocol, resulting in all patients receiving the same surgical treatment. Likewise, discharge from treatment was based on completion of the rehabilitation progressions. The improvements in the ASES pain scores were similar to the initial study,13 resulting in a postoperative score ap-
proximately equivalent to a numeric pain rating score of 2 of 10, compared with a preoperative pain rating of 6 of 10 to 8 of 10 (P < .001). The majority of patients have attributed the significant improvement in pain to be the primary factor in lifestyle betterment and satisfaction. In the current study, the improvements in the ASES function and total scores were 7 and 10 points higher (albeit not statistically significant), respectively, than those in the initial study. The clinically improved scores may be attributed to further clinician experience and ability to more effectively guide patients through postoperative recovery. However, further clinical experience and subgroup analysis showed that a portion of the overall group did not achieve the expected favorable patient-reported outcome-based results. A major finding of this follow-up study is that patients demonstrating higher levels of pain catastrophizing behaviors as defined by HPCS (≥20) demonstrated inferior postoperative patient-reported outcome scores. This finding appears to parallel recent reports that have identified pain catastrophizing behavior as a negative influence on postsurgical rotator cuff outcomes7 and experimental pain protocols for individuals with shoulder pain.4,33,34 This negative influence has also been shown in a nonoperative cohort of patients complaining of shoulder pain.19 Furthermore, the current study identified that 90% of patients who were not satisfied or were moderately satisfied with the current function of the arm after surgery had high PCS scores that placed them in the HPCS group. By comparison, only 10% of HPCS patients were in the high satisfaction group. This finding would suggest that although scapular muscle detachment has not been frequently identified, the patients who were able to be diagnosed with the condition and received the recommended treatment appeared to psychologically mirror patients with more common shoulder problems. It is unclear whether pain catastrophizing is inherent to patients or whether it develops during the long course between the time of injury and definitive treatment. Persistent high levels of pain and dysfunction coupled with the frustration of not having a clear diagnosis may influence catastrophizing characteristics. Considering that the patients with high pain catastrophizing behavior in this study underwent at least 1 additional previous surgical procedure and were undergoing physical therapy prior to receiving the muscle detachment diagnosis for 6 additional months and that all had a longer
ARTICLE IN PRESS 6 chronicity of the initial injury (3 additional years) compared with those with low pain catastrophizing behavior, it is possible that these factors could have created or exacerbated alterations in pain processing for the patients. This is not uncommon because it has been shown that chronic pain can lead to a prolonged release of neuropeptides that alter central pain processing, resulting in an amplified pain response termed “central sensitization.”4,8,9,16 Conversely, pain catastrophizing relates to how a person copes with and responds to stimuli perceived as painful. On the basis of the results of the current study, the negative influence of pain catastrophizing on the outcome score suggests that pain catastrophizing may be viewed as another comorbidity where an underlying physical or psychological factor complicates the outcome. Because of the significant differences between the subgroups in this otherwise homogeneous cohort, it can be concluded that inferior patient-reported outcomes are more common for patients with high pain catastrophizing behaviors as defined by high PCS scores. While the current results cannot establish a true cause-and-effect relationship, we suggest that clinicians use assessment methods that target patientperceived pain. Because of the findings of this study, all patients presenting to our treatment center with scapular pain now complete the PCS form at the initial preoperative visit. The PCS score and the physical examination findings are both discussed with the patient as part of the formulation of the treatment. Finally, cognitive behavioral therapy interventions have recently been shown to decrease pain catastrophizing behaviors in patients with upper extremity musculoskeletal conditions,22 and future work is necessary to determine whether similar treatments may successfully augment postoperative rehabilitation to improve outcomes for this at-risk patient population. Our findings are consistent with other reports of the effect of individual patient factors on the outcomes of treatment.4,19,32,33,37 These results add support to the recommendation that pertinent patient-specific factors should be identified and included in the information gathered as part of determining the comprehensive diagnosis that guides the content and timing of the treatment1 and enhances the value on the front end that improves the treatment outcomes, that is, the value on the back end.12 Questionnaires designed to assess pain,3 pain-related characteristics,6,27 and different psychological constructs18,21,23,29 can be used to assess a patient’s perception of specific factors that may compound the actual anatomic injury and hinder his or her ability to recover as expected once treatment has been initiated. Reattachment has demonstrated both short-term and midterm pain reduction,13 and future studies are necessary to determine whether the reduction in pain is due to a decrease in tension on the muscle and/or the restoration of muscle activation. Similarly, future studies should be directed at determining whether improvement in self-reported function is due to the restoration of scapulohumeral rhythm and improvement in muscle strength that are theoretically provided by this procedure.
W.B. Kibler et al.
Limitations The following limitations have been identified. First, there was a wide geographic distribution of the patients. Patients in this population were located across the United States and the world. This could have negatively contributed to the low response rate for follow-up (42%). This limitation was also seen in the initial study.13 Second, objective clinical or performance data were not gathered for this follow-up study primarily because of the geographic distribution but also because of financial and feasibility difficulties, affecting physical contact with the patients. Therefore, the information that has been gathered has been primarily subjective. Efforts can be made to prospectively establish lines of communication and increase the ease of answering the questionnaires, but the response rate for these types of studies will typically be low. Third, we used a limited number of outcome measurements. The ASES score was used for comparison with the results of the initial study. While other patient-reported outcome measures may be considered and used, the ASES score is appropriate for this general patient population. Fourth, pain catastrophizing was only assessed at postoperative followup. This patient-specific factor may have existed prior to the injury; could have been affected by a multitude of other factors (stress or anxiety, previous experiences with treatment, and so on); or could be due to neuroplastic changes in the nociceptors, spinal cord, and brain known to contribute to chronic pain. However, with the rise in publications in the literature identifying the relationship between mental aspects of function and pain or injury and how that relationship can deleteriously affect outcome scores, assessing for the presence of pain catastrophizing at follow-up would help provide a possible explanation as to why the outcome is lower than expected. Furthermore, the combination of maladaptive pain behaviors and genetic factors has been demonstrated to be predictive of persistent postoperative pain 1 year after rotator cuff repair.7 Unfortunately, this information was not available at the initiation of our prospective outcome registry, and the inclusion of preoperative pain catastrophizing scales and even genetic factors could have strengthened both the current study and future studies from this registry. Finally, adherence to the rehabilitation protocol likely varied since most patients lived a long distance from the treatment facility. Patients were verbally asked about rehabilitation progress during clinical follow-up. Although this may have allowed recall bias to occur, patient progression through the rehabilitation phase was monitored by periodic contact with the treating clinician.
Conclusion Patient-reported outcomes measured using ASES scores, GROC scores, and patient satisfaction scores demonstrate that operative repair of post-traumatic scapular muscle detachment can be expected to provide value on the back
ARTICLE IN PRESS Scapular muscle detachment and pain catastrophizing end—significant and durable relief of pain and dysfunction—in a large percentage of patients who meet the inclusion criteria. However, a small group of patients did not report significant changes in the patient-reported outcome measures, despite meeting the same clinical inclusion criteria and following the same treatment protocol. Higher levels of pain catastrophizing behaviors as defined by high PCS scores were more common for patients with inferior postoperative outcome scores. Future studies are necessary to determine whether assessment of pain catastrophizing should be included in the comprehensive evaluation that produces value on the front end, viewing this patient-specific factor similarly to other comorbidities that may place the patient at increased risk of an inferior postoperative outcome.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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