A. M. Thorpe, P. B. O'Sullivan, T. Mitchell, A. Smith, School of Physiotherapy and Exercise Science, Curtin University, Bentley, Western Australia M. Hurworth, Murdoch Orthopaedic Clinic, Perth, Western Australia J. Spencer, A. Tay, Hollywood Orthopaedic Group, Nedlands, Western Australia G. Booth, S. Goebel, Perth Shoulder Clinic, Claremont, Western Australia P. Khoo, Coastal Orthopaedic Group, Claremont, Western Australia.
Clin Orthop Relat Res. 2018 Oct;476(10):2062-2073. doi: 10.1097/CORR.0000000000000389.
Psychologic factors are associated with pain and disability in patients with chronic shoulder pain. Recent research regarding the association of affective psychologic factors (emotions) with patients' pain and disability outcome after surgery disagrees; and the relationship between cognitive psychologic factors (thoughts and beliefs) and outcome after surgery is unknown.
QUESTIONS/PURPOSES: (1) Are there identifiable clusters (based on psychologic functioning measures) in patients undergoing shoulder surgery? (2) Is poorer psychologic functioning associated with worse outcome (American Shoulder and Elbow Surgeons [ASES] score) after shoulder surgery?
This prospective cohort study investigated patients undergoing shoulder surgery for rotator cuff-related shoulder pain or rotator cuff tear by one of six surgeons between January 2014 and July 2015. Inclusion criteria were patients undergoing surgery for rotator cuff repair with or without subacromial decompression and arthroscopic subacromial decompression only. Of 153 patients who were recruited and consented to participate in the study, 16 withdrew before data collection, leaving 137 who underwent surgery and were included in analyses. Of these, 124 (46 of 124 [37%] female; median age, 54 years [range, 21-79 years]) had a complete set of four psychologic measures before surgery: Depression, Anxiety and Stress Scale; Pain Catastrophizing Scale; Pain Self-Efficacy Questionnaire; and Tampa Scale for Kinesiophobia. The existence of clusters of people with different profiles of affective and cognitive factors was investigated using latent class analysis, which grouped people according to their pattern of scores on the four psychologic measures. Resultant clusters were profiled on potential confounding variables. The ASES score was measured before surgery and 3 and 12 months after surgery. Linear mixed models assessed the association between psychologic cluster membership before surgery and trajectories of ASES score over time adjusting for potential confounding variables.
Two clusters were identified: one cluster (84 of 124 [68%]) had lower scores indicating better psychologic functioning and a second cluster (40 of 124 [32%]) had higher scores indicating poorer psychologic functioning. Accounting for all variables, the cluster with poorer psychologic functioning was found to be independently associated with worse ASES score at all time points (regression coefficient for ASES: before surgery -9 [95% confidence interval {CI}, -16 to -2], p = 0.011); 3 months after surgery -15 [95% CI, -23 to -8], p < 0.001); and 12 months after surgery -9 [95% CI, -17 to -1], p = 0.023). However, both clusters showed improvement in ASES score from before to 12 months after surgery, and there was no difference in the amount of improvement between clusters (regression coefficient for ASES: cluster with poorer psychologic function 31 [95% CI, 26-36], p < 0.001); cluster with better psychologic function 31 [95% CI, 23-39], p < 0.001).
Patients who scored poorly on a range of psychologic measures before shoulder surgery displayed worse ASES scores at 3 and 12 months after surgery. Screening of psychologic factors before surgery is recommended to identify patients with poor psychologic function. Such patients may warrant additional behavioral or psychologic management before proceeding to surgery. However, further research is needed to determine the optimal management for patients with poorer psychologic function to improve pain and disability levels before and after surgery.
Level II, therapeutic study.
心理因素与慢性肩痛患者的疼痛和残疾有关。最近关于情感心理因素（情绪）与手术后患者疼痛和残疾结果之间的关联的研究存在分歧；并且认知心理因素（思想和信念）与手术后结果之间的关系尚不清楚。
问题/目的：（1）在接受肩部手术的患者中是否存在可识别的聚类（基于心理功能测量）？（2）较差的心理功能是否与肩部手术后（美国肩肘外科医生协会 [ASES] 评分）的结果较差相关？
本前瞻性队列研究调查了 2014 年 1 月至 2015 年 7 月期间由六位外科医生为肩袖相关肩痛或肩袖撕裂而接受肩部手术的患者。纳入标准为接受肩袖修复术的患者，包括伴或不伴肩峰下减压术和关节镜下肩峰下减压术。在招募并同意参加研究的 153 名患者中，有 16 名在数据收集前退出，137 名接受手术并纳入分析。其中，124 名（46/124 [37%]女性；中位年龄为 54 岁[范围，21-79 岁]）在手术前完成了四项完整的心理测量：抑郁、焦虑和压力量表；疼痛灾难化量表；疼痛自我效能问卷；和坦帕运动恐惧症量表。使用潜在类别分析调查了具有不同情感和认知因素特征的人群聚类的存在，该分析根据四项心理测量的得分模式对人群进行分组。根据潜在的混杂变量对结果聚类进行分析。术前和术后 3 个月和 12 个月测量 ASES 评分。线性混合模型评估了术前心理聚类成员与 ASES 评分随时间变化的轨迹之间的关联，调整了潜在混杂变量的影响。
确定了两个聚类：一个聚类（124 人中的 84 人[68%]）得分较低，表明心理功能更好，另一个聚类（124 人中的 40 人[32%]）得分较高，表明心理功能更差。考虑到所有变量，发现心理功能较差的聚类与所有时间点的 ASES 评分较差独立相关（ASES 回归系数：术前 -9 [95%置信区间 {CI}，-16 至-2]，p = 0.011）；术后 3 个月 -15 [95% CI，-23 至-8]，p < 0.001）；术后 12 个月 -9 [95% CI，-17 至-1]，p = 0.023）。然而，两个聚类的 ASES 评分均从术前改善到术后 12 个月，并且聚类之间的改善程度没有差异（ASES 回归系数：心理功能较差的聚类为 31 [95% CI，26-36]，p < 0.001）；心理功能较好的聚类为 31 [95% CI，23-39]，p < 0.001）。
在肩部手术前对一系列心理测量进行评分较差的患者，在术后 3 个月和 12 个月时的 ASES 评分较差。建议在手术前筛查心理因素，以识别心理功能较差的患者。对于心理功能较差的患者，可能需要在手术前进行额外的行为或心理管理。但是，需要进一步研究以确定改善手术前后疼痛和残疾水平的较差心理功能患者的最佳管理方法。
二级，治疗性研究。
