Department of Rehabilitation Science, University of Kentucky, Lexington, KY, USA.
Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Clin Orthop Relat Res. 2021 Sep 1;479(9):1982-1992. doi: 10.1097/CORR.0000000000001750.
Patient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores.
QUESTION/PURPOSE: After controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?
Fifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05.
This model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r2 = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r2 = 0.65; p < 0.001).
Our results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan.
Level II, prognostic study.
患者报告的测量结果指导医生做出临床决策，因此确定哪些临床因素与这些评分相关至关重要。在患有肩袖撕裂的患者中，通常分别研究心理和生理因素，以确定它们对结果的影响。众所周知，在患有症状性肩袖撕裂的患者中，存在心理困扰和肩胛运动改变。然而，这些因素尚未在临床环境中同时进行研究，以确定它们与肩部结局评分的关联。
问题/目的：在控制相关混杂变量后，哪些生理和心理因素与（1）美国肩肘外科医师协会（ASES）功能评分、（2）ASES 疼痛评分和（3）总 ASES 评分更好相关？
招募了 59 名可能患有症状性肩袖撕裂的患者，并同意参与这项横断面研究。其中，59 名患者中有 85%（50 名/59 名）符合主要诊断标准，即 MRI 证实的症状性部分厚度或全厚度肩袖撕裂，且无肩部手术史。经验丰富的检查人员使用标准化程序评估患者的人口统计学数据、肩袖撕裂大小、手臂弯曲度以及主动手臂弯曲时的临床肩胛运动。患者完成了 ASES 问卷和最佳筛选预测转诊和结果-黄旗评估表，该表测量了 11 种不同的与疼痛相关的心理困扰症状。对 ASES 疼痛、功能和总分进行了 3 项单独的逐步多元线性回归分析，显著性水平设置为 p < 0.05。
该模型发现，ASES 功能评分与四个因素相关：年龄较大、手臂弯曲度增加、手臂弯曲时肩胛外旋的百分比增加、对慢性疼痛的接受程度增加（调整 r2=0.67；p=0.01）。这四个因素似乎可以解释肩袖撕裂患者 ASES 功能评分中 67%的可观察变异。此外，手臂弯曲时肩胛外旋的百分比增加和与身体活动相关的恐惧回避信念得分降低（调整 r2=0.36；p<0.01）与 ASES 疼痛评分的改善相关。最后，更好的 ASES 总分与四个因素相关：手臂弯曲度增加、肩胛上旋百分比增加、手臂弯曲时肩胛外旋增加以及与身体活动相关的恐惧回避信念得分降低（调整 r2=0.65；p<0.001）。
我们的结果倾向于对肩袖撕裂患者采用全面的生物心理临床评估，该评估特别包括肱骨和肩胛运动、恐惧回避行为以及疼痛应对行为以及人口统计学数据。这些特定的生理和心理变量与 ASES 相关，因此应同时进行临床检查，并作为量身定制治疗计划的一部分进行针对性治疗。
二级，预后研究。
