- Research article
- Open Access
Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review
BMC Musculoskeletal Disorders volume 22, Article number: 560 (2021)
Psychological factors may impact recovery in patients undergoing treatment for shoulder complaints. The aim of this review is to systematically analyse the evidence for the effect of modifiable psychological factors (MPF) on outcome, for patients with musculoskeletal shoulder disorders undergoing conservative or surgical treatment. MPF refers to factors that may change with intervention.
This is a systematic literature review. Five databases searched (MEDLINE, CINAHL, Cochrane Library, Embase and PsycInfo), for longitudinal studies investigating the influence of MPF on prognosis of patients with shoulder disorders, all diagnoses, undergoing clinical interventions (conservative or surgical). Level of evidence was determined using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Moderate and high quality evidence was included. We extracted all MPF, categorized constructs into the following domains: beliefs (self-efficacy, expectation of recovery), coping (catastrophizing, avoidant coping), and affect (depression, anxiety). We evaluated constructs for its predictive value of at least one outcome. Outcomes were informed by this review. Evidence was classified into three categories: evidence for, inconclusive evidence, and evidence against.
Of 1170 references, 40 distinct publications based on 35 datasets were included (intervention type: 20 surgical; 20 conservative). Overall, 22 studies (20 cohort studies and 2 RCTs) were classified as high quality and 18 studies (16 cohort studies, 2 RCTs) were classified as moderate quality. Outcomes reported included pain, disability/function, perceived recovery, physical and mental health, and work status. Based on the review, of the psychological constructs explored, these data would suggest that expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety may predict outcome for patients managed surgically. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome.
Five constructs were predictive of outcome for surgically managed patients. This suggests that implementing the biopsychosocial approach (i.e., preoperative screening, intervention by a trained clinician) may be advantageous for patients recommended for shoulder surgery,,. The same is not indicated for conservatively managed patients as no conclusive association of MPF with outcomes was noted. The importance of other MPF on outcome requires further investigation.
Shoulder conditions are the third most common musculoskeletal complaint [1, 2]. Only 50 % of patients with a new episode of shoulder pain experience complete recovery within 6 months and pain persists in 40% for more than 1 year . In those who seek care, there is limited understanding of how to identify patients who may or may not respond to interventions . Therefore, we need to understand barriers to and facilitators of recovery in patients with shoulder pain.
To improve treatment outcomes for shoulder complaints, modifiable factors that influence the prognosis should be identified. The focus of this review is on psychological factors. Modifiable psychological factors (MPF) are patient cognitions and emotions associated with health conditions that may impact recovery, and may respond to treatment [4, 5]. Exploring the relationship between MPF and outcome is valuable, as effective management may improve outcomes [6, 7]. MPF are different than psychological traits and refractory psychiatric diagnoses that are more difficult to manage, such as bipolar disorder and pervasive depressive disorder, and not considered in this review. Some MPF have been recognized as impacting recovery in other musculoskeletal conditions [1, 2, 8,9,10,11]. Maladaptive pain beliefs, negative affective reactions and poor coping are indicators of psychological distress that may influence both the short and long-term outcomes of treatments in patients with spine, hip and knee conditions [5, 12,13,14].
. Conversely, self-efficacy and positive expectation of recovery are coping resources that have been associated with better functional outcomes in patients with musculoskeletal disorders [10, 11]. Kendall and Burton propose that in the absence of red flags suggestive of an emergent medical situation, all musculoskeletal conditions that limit activity may be treated like low back pain . This treatment would include advice for self-care, education on expectation of a good recovery and instruction to continue with usual activity as tolerated. Despite compelling evidence to monitor and address MPF in patients with spine pain as part of routine care evidence to monitor and address MPF in patients with spine pain as part of routine clinical care [16, 17], to date there is equivocal evidence to support the importance of MPF in MSD [11, 18,19,20,21,22]. As such, these factors typically are not part of routine clinical evaluation and treatment for patients with MSD [23, 24].
Recent reviews explored psychological factors in various patient groups, including those receiving conservative and surgical care [18, 25], conservatively managed patients only [19, 20], patients with selective diagnoses, [21, 25,26,27,28], patients undergoing arthroplasty  or with conditions associated with chronic shoulder pain [11, 25]. The heterogeneity of these diagnoses makes it difficult to compare the conclusions. In addition, methodologic limitations and variability of previous reviews was also noted [11, 18, 22, 29]. Therefore, [11, 25] the current reviews provide a limited perspective on the relationship between MPF and outcomes in patients with musculoskeletal shoulder disorders (MSD).
The aim of this literature review was to systematically summarize the current evidence on the importance of MPF on outcome in patients receiving care (conservative or surgical) for MSD. The MPF that may be found to be associated with outcome in MSD includes patient beliefs, coping and affect. Unlike previous systematic reviews that focused on some MPF and did not subcategorize studies based on intervention, our aim was to capture studies on all MPF in surgical and conservative studies to better identify those that predict outcomes. This review included all phases of shoulder disorders (acute, subacute, chronic) and all MPF referenced in the reviewed studies, to gain insights regarding the relationship between MPF and MSD.
This systematic review followed the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement .
The framework to determine the research questions, search strategy and criteria for inclusion was defined by the authors by consulting the relevant literature on MPF. We searched five databases, without any language and date range limits, in September 2019: MEDLINE (EBSCOhost), CINAHL (EBSCOhost), Cochrane Library, Embase (Elsevier), and PsycInfo (EBSCOhost), seeking literature for all psychological factors found to be associated with shoulder pain and disability/function, and focused on those considered to be modifiable . An updated search was conducted in December 2020.
The search was conducted with the help of a research librarian (MG). Two detailed search strategies are depicted in Appendix 1.
To ensure the completeness of the literature search, one reviewer (MW) conducted an electronic hand search of the four most often-retrieved journals and added all potentially eligible references not retrieved by the systematic search. In addition, two reviewers (MW, EB) examined bibliographies of included studies and review articles related to the research question, and relevant references were considered for full-text review (inclusion and exclusion criteria applied). We further searched clinical trials.gov for additional trials relevant to the topic and searched the grey literature after consulting with experts in the field. In potentially relevant studies with insufficient details for data extraction, we contacted the study authors for additional information.
Inclusion and exclusion criteria
Included were all longitudinal studies (cohort studies, randomized controlled trials (RCT), and studies on registry data) investigating patients with shoulder complaints undergoing conservative or surgical treatment for the shoulder disorder. Studies were eligible when they included the influence of MPF on the prognosis or treatment outcome. Excluded were experimental studies (i.e., identification of genetic markers) in which clinical interventions were not used to modify outcome (i.e., pain, function), cross-sectional studies, case series, epidemiological studies, and studies on patients younger than 18 years of age. Studies of personality traits and psychiatric conditions were excluded. Although we did not specifically exclude studies on joint arthroplasty, the search was not set up to identify all studies on total shoulder joint replacement. Therefore, excluded studies on joint arthroplasty for the current review.
Data collection and abstraction
Two reviewers (MW and ERB), a physician and a physical therapist with extensive clinical and research experience, screened all references independently by title and abstract. Disagreements were discussed and resolved by consensus or by third-party arbitration (SSW), a physical therapist. For any study where questions arose regarding psychological constructs or outcome measures, a psychologist (SW, co-author) was consulted. References with insufficient information in the title or abstract to assess eligibility, were included in the full text review. All full texts were then appraised by both reviewers independently (MW and ERB) for inclusion or exclusion. Alternative researchers with specific language proficiencies were used for non-English language references, with no language restrictions. In the case of several publications for the same cohort without change in outcome or follow-up duration, the most recent publication was chosen and missing information from the previous publication was added. Systematized criteria were defined to extract specific variables from each reference and were followed by each reviewer. All information needed to describe the study population and methodology was collected: study setting, study design, number of patients, age, proportion of women, intervention, and follow-up duration. In addition, the methods of assessment and information on the type of analysis of the prognostic, predictive or mediating factors were extracted. The inclusion/exclusion criteria guided this process.
Assessment of study quality
A quality rating was assigned based on the risk of bias, using the Scottish Intercollegiate Guidelines Network (SIGN) methodology checklist for cohort studies and randomized clinical trials and the overall quality was rated as high, moderate, or low . The ratings were as follows: high quality (++), most (≥60%) of the criteria fulfilled; moderate quality (+), some criteria fulfilled (< 60%); and low quality (−), few or no criteria fulfilled. Two reviewers (MW and EBR) assessed each reference. Any discrepancies were resolved by another member of the research team (SSW). High and moderate quality studies were included in this review.
Definition of terms
For this study, MPF are defined as those factors that may be expected to change with appropriate therapeutic intervention and are therefore states rather than traits. We utilized a framework of psychological domains  and modifiable constructs extracted from the included studies (Table 1) in order to synthesize the findings. It is important to note that there is no gold standard for the definition and classification of MPF. Therefore, for those constructs that may fall into more than one domain, we sought the guidance of a clinical mental health expert to inform the distinct classification based on the context in which the constructs were considered in the studies. This allowed for the classification of all constructs within one domain.
The term prognostic factor is used to describe a MPF that influences or predicts the course or outcome of a shoulder disorder. The prognostic value of a psychological factor is based on the reported results and conclusions of the primary studies. No predefined outcomes were identified for this review. Study outcome was extracted from each included reference based on the reported measure of assessment.
We classified studies based on patients’ duration of pain as subacute (< 12 weeks), chronic (> 12 weeks) or a mixed duration of shoulder complaints.
Classification of evidence
All included studies were grouped based on the MPF addressed, time from onset and clinical intervention (conservative, surgical). We evaluated each construct based on the number of studies that reported it as a predictor of at least one outcome or not a predictor of any outcome. Outcomes were purposefully not predefined, as our objective was to identify all outcomes that have been included in studies on MPF in patients with MSD. If the number of studies with results showing that a construct was predictive of outcome was greater than the number of studies showing it was not predictive, we considered the construct predictive. If the opposite was true, then we considered the construct to not be a predictor of outcome. In those cases where an equal number of studies found evidence for and against the predictive value of the construct, the evidence was found inconclusive. Based on these criteria, the evidence was classified into three categories: Category 1) Evidence for – a majority of the studies found the construct to be a predictor of outcome; Category 2) Inconclusive evidence – An equal number of studies found evidence for and against the predictive value of the construct, Category 3) Evidence against-a majority of studies did not find the construct to be a predictor of outcome.
In the initial search 1140 references were screened, and 121 full-text articles assessed for eligibility. After excluding 86 publications, 35 publications based on 33 patient data sets were included for data extraction and analysis, hereafter referred to as 35 studies. The main reasons for exclusion were mixed patient populations without reporting specific results for subjects with shoulder complains (n = 31) and studies that did not assess MPF (n = 26, Fig. 1). In the updated search conducted on December 20, 2020 we identified 138 additional references. After title and abstract screen, an additional 19 references were read in full text. Finally, we included 5 additional publications (2 additional publications of previously included studies and 3 publications from 2 additional studies). In total, the narrative analysis reflects our review of 40 distinct publications based on 35 patient data sets, hereafter referred to as 40 studies.
Of the 40 included studies, four were randomized clinical trials. There were 20 studies on conservative intervention and 20 on surgical intervention. Follow-up duration ranged from end-of-treatment to 12 months. The studies represented a broad spectrum of shoulder diagnoses, representative of a typical clinical population (Table 2).
Risk of bias in 40 studies was assessed using the SIGN method (Appendix 2A). In all tables, high-quality studies included in this manuscript (Appendix 2A) are indicated by bold typeface. Twenty cohort studies were rated as high quality and 16 studies rated as moderate quality. Two randomized clinical trials were rated as high quality and two were rated as moderate. Overall, 20 (50%) of included studies were rated as high quality, 14 studies related to conservative care, and 6 studies related to surgical intervention. Most studies did not provide a formal sample size calculation. Six (30%) of the conservative studies reported a required sample size and met the requirement. Five (25%) surgical studies reported a required sample size; three studies met the required sample size, and two studies did not (150 instead of 360 patients, same data set for both studies).
Study outcomes and measures
Various outcomes were noted in the reviewed literature and included those related to pain, disability/function, perceived recovery, physical and mental health, and work status. The most common outcomes noted in the reviewed literature were pain (16 (40%) publications), disability/function (21 (58%) publications), combined pain and disability/function (19 (48%) publications). Outcome measures most commonly utilized in the reviewed studies included the Visual Analog Scale (VAS) for pain (8 (23%) publications), the Disabilities of the Arm, Shoulder and Hand (DASH and QuickDASH) measuring function (8 (20%) publications), and the Shoulder Pain and Disability Index (SPADI) (12 (30%) publications). All outcome measures are listed in Tables 3 and 4.
Clinical intervention and time from onset
Among the 20 studies on conservative intervention, four addressed patients with subacute MSD, five addressed patients with chronic MSD and 11 did not specify time from onset or presented a mixed population. All six MPF were investigated (Table 5).
Among the 20 studies on surgical intervention, one addressed patients with subacute MSD, five addressed patients with chronic MSD, and fourteen studies did not specify time from onset or presented a mixed population. Five of six MPF were addressed. There were no studies investigating the construct of self-efficacy for surgical cases, Table 5.
Modifiable psychological domains and constructs
In this sample, the domains of “coping” and “affect” were most investigated, 14 (40%) publications and 29 (73%) publications respectively, and the domain of “beliefs” was least investigated, 9 (23%) publications (Tables 3, 4 and 5). Of the six predefined constructs, depression (Domain: Affect) was the most studied construct, 27 (68%) publications, and self-efficacy (Domain: Beliefs), the least studied, two publication (5%). For surgical care, we found evidence for catastrophizing, avoidant coping, depression, anxiety, and expectation of recovery as predictors of outcome. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome. The following provides details of the prognostic value of each MPF in patients with shoulder problems managed conservatively or surgically.
Catastrophizing as a predictor of outcome was explored in ten publications (five surgical, five conservative). In seven publications (five (100%) surgical [two high quality], two (40%) conservative [two high quality]) catastrophizing predicted at least one outcome. Therefore, based on this review, catastrophizing in surgical cases fell into Category 1, evidence for, while for conservative cases it was Category 3, evidence against.
Avoidant coping/fear avoidance
Avoidant coping as a predictor of outcome was explored in eleven publications (five surgical, six conservative). In seven publications (four (80%) surgical [three high quality], three (50%) conservative [two high quality]) avoidant coping/fear avoidance predicted at least one outcome. Therefore, based on this review, avoidant coping/fear avoidance in surgical cases fell into Category 1, evidence for, while for conservative cases it was Category 2, inconclusive.
Depression as a predictor of outcome was explored in 27 publications (15 surgical, 12 conservative). In 14 publications (nine (60%) surgical [four high quality], four (33%) conservative [three high quality]) depression predicted at least one outcome. Therefore, based on this review, evidence for depression in surgical cases fell into Category 1, evidence for, while for conservative cases it was Category 3, evidence against.
Anxiety as a predictor of outcome was explored in 16 publications (nine surgical, seven conservative). In eight publications (six (67%) surgical [three high quality], two (29%) conservative [two high quality]) anxiety predicted at least one outcome. Therefore, based on this review, evidence for anxiety as a predictor in surgical cases fell into Category 1, evidence for, while for conservative cases it was Category 3, evidence against.
Self-efficacy as a predictor of outcome was explored in two publications (two conservative [two high quality]). In one publication (50%) self-efficacy predicted at least one outcome. Therefore, based on this review, evidence for self-efficacy as a predictor in conservative cases fell into Category 2, inconclusive evidence.
Expectation of recovery
Expectation of recovery as a predictor of outcome was explored in eight publications (two surgical, six conservative). In five publications (two (100%) surgical [one high quality], three (50%) conservatives [three high quality]) expectation of recovery predicted at least one outcome. Therefore, based on this review, evidence for expectation of recovery as a predictor in surgical cases fell into Category 1, evidence for, while for conservative cases it was Category 2, inconclusive evidence.
In this study we explored the relationship between MPF and outcomes in patients with shoulder disorders, within the context of management (conservative, surgical) and temporal framework (time from onset). The main finding of this review is that psychological factors affect recovery in patients with shoulder pain managed surgically. However, MPF was not associated with outcome in patients receiving conservative care for shoulder disorders, regardless of duration of pain. This suggests that type of clinical management and time from onset are critically important variables to consider when defining the prognostic value of MPF on outcome in patients with MSD.
Previous systematic reviews
Previous systematic reviews [11, 18, 22] have explored the association between MPF and outcome in patients with shoulder conditions including those receiving conservative and surgical care [18, 25], conservatively managed patients only [19, 20], patients with selective diagnoses, [21, 25,26,27,28], patients undergoing arthroplasty  or with conditions associated with chronic shoulder pain [11, 25]. However, they did not account for confounding factors that may impact this relationship, such as the approach to management (conservative, surgical) and time from onset. In addition, these reviews explored this topic through a narrow lens considering only several psychological factors or specific diagnoses. Therefore, previous reviews provide a limited perspective on the relationship between MPF and patients with shoulder conditions. The question that was addressed in this review was broad and included all reported diagnoses, time from onset, approaches to management, and did not predefine MPF or outcome.
We classified studies based on conservative and surgical intervention and all diagnostic phases from acute through chronic. Furthermore, we did not predefine psychological factors or outcomes but rather extracted from the reviewed studies. In addition, we applied no language or publication timeframe restrictions in our search allowing for a broad body of literature from which this topic could be explored. Defining and focusing specifically on psychological factors that are modifiable is relevant as these factors are responsive to short-term intervention, as opposed to more refractory psychiatric diagnoses that are more difficult to manage . For these reasons, the findings of this review may be clinically relevant in that they may guide the approach to preoperative care.
Evidence supporting MPF
In this review six distinct MPF were identified. However, for most of these factors, few studies have explored their relationship with outcome and not all were graded as high quality. For the purpose of this review, our conclusion regarding the effect of each factor on outcome was based on the preponderance of the included references. However, it should be noted that very small numbers of studies or nearly equivocal numbers of studies supporting or refuting the findings were used to determine our conclusions. This was particularly true in the review of those studies on conservatively managed cases.
This can be highlighted by examining the findings for individual MPF. Depression was the most widely studied construct with 27 studies (12 conservative and 15 surgical) management. In the case of conservative management, four predicted outcome and eight did not, a clear conclusion. In the case of surgical management, nine predicted and six did not, also a clear finding. In contrast, self-efficacy was far less studied with only two studies for conservatively managed cases and none for surgical. In one study self-efficacy predicted outcome and in one it did not, and therefore the conclusion must be weighed carefully. Therefore, it is important to consider the total number of studies reviewed when interpreting the relationships between each individual MPF and outcome (Table 5).
Approach to management PPROACH TO MANAGEMENT
The implications of this review suggest that MPF are important considerations for those patients with MSD who are managed surgically. Our findings show that there is evidence for the predictive value of expectation of recovery, catastrophizing, avoidant coping, depression, and anxiety in patients receiving surgically intervention. In this group, there was no evidence that self-efficacy affected outcome. The results suggest the importance of assessment of these MPF as a part of routine surgical care for patient with shoulder disorders. In contrast, for those patients managed conservatively, the evidence for self-efficacy, expectation of recovery, and avoidant coping was equivocal and requires further study. However, there was no evidence for catastrophizing, depression and anxiety affecting outcome in this group. When evaluating the findings for each construct as it relates to management it is important to consider not only the number of studies but also the quality of studies informing the conclusion, as more high-quality studies were noted for conservative management (Table 5).
Time from onset
In this review we explored the temporal influence, represented as time from onset, on the relationship between MPF and outcome. Time from onset of shoulder pain was not defined in 60% of the included references (14 of the surgical studies [82%] and ten of the conservative studies [50%]). When interpreting the findings, it is important to recognize that typically surgical intervention occurs during the chronic phase, after failed conservative management often recommended during earlier phases . Therefore, it may be reasonable to conclude that in the absence of trauma, the majority of patients undergoing surgical intervention were likely in the chronic phase . Although less than 20% of the surgical studies reported time from onset, in those that did, a relationship between MPF and outcome was found.
In the case of conservative intervention, it is difficult to draw conclusions regarding the temporal impact of MPF on outcome. This is because among those studies that did report time from onset, the findings were either inconclusive or against the predictive value of MPF on outcome. Therefore, we believe time from onset deserves further study in this group.
Many included studies were small and may therefore not have sufficient power to capture a clinically relevant influence of the subgroups we have defined for this review. None of the included studies investigated all predefined constructs and therefore the full impact of these variables cannot be completely described. In addition, not all MPF were equally explored. Furthermore, some psychological constructs are complex, such as catastrophizing, which may be considered a belief or a coping strategy. For example, two studies that used the Pain Coping Scale designated catastrophizing as a coping strategy [42, 50]. Yet most studies used the Pain Coping Scale to assess the impact of beliefs on expectation of outcome [46, 55,56,57, 69]. There is no gold standard for the definition and classification psychological constructs. In this review, catastrophizing was assigned to the coping domain based on the opinion of a clinical mental health expert. However, future studies need to clarify the difference between beliefs and coping strategies and their impact on treatment outcome. In one study, the Orebro, a composite measure for MPF and other variables associated with outcome, was used to assess MPF . Due to its composite nature, it was not possible to include the findings for specific MPF in this review. However, composite instruments may allow for the assessment of several domains simultaneously and may have clinical utility, compared to the methods in this review that explored each MPF individually. The impact of treatment for the MPF (i.e., medication, psychological interventions) on shoulder outcomes was not addressed in this review. The limitations of our review reflect the lack of a strong literature base, including the heterogeneity of study populations, which precluded the possibility of a meta-analysis [22, 25]. Future studies need to address these methodological shortcomings.
There is mention of the importance of assessing psychological factors in clinical practice guidelines for managing shoulder pain . However, this does not seem to be a routine part of clinical practice as is apparent from the limited number of studies found for this review. To gain deeper insight into how to explore the role of psychological factors as predictors of outcome, it is informative to look to the spine literature. Compared to the management of shoulder disorders, an extensive literature base drives clinical management of psychological factors associated with low back pain. Consistent evidence supports the role of these psychological factors on prognosis  and the relationship with outcome for patients with low back pain [75, 76]. However, there are limitations in generalizing the findings to other musculoskeletal disorders such as shoulder pain. While the overall relationship of low back pain with physical functioning and MPF has been described, it is unclear if the same relationship may exist for other musculoskeletal conditions.
One consideration is the relationship between psychological factors and the natural history/tissue healing associated with various musculoskeletal conditions. For instance, in patients with low back pain, fear of pain is a strong predictor of outcome [75, 76]. The concept that pain does not equal damage, an important message to patients with spinal pain, may not be relevant for patients with shoulder conditions. Furthermore, while studies on back pain may inform the methodologies and research questions for shoulder pain populations, researchers must be prudent in recognizing the limitations of transposing these ideas. For example, many of the tools used to measure psychological constructs have not been validated for shoulder complaints . Finally, other psychological responses to pain, such as anger, have been studied in other musculoskeletal conditions, yet are not addressed in the shoulder literature . Future studies should focus on developing shoulder-specific instruments, clinical management, time from onset and all relevant psychological factors that are potentially modifiable as they relate to outcome.
Based on this review, expectation of recovery, catastrophizing, avoidant coping style, depression, and anxiety were the MPF most predictive of outcome in surgically managed patients with shoulder complaints. This provides sufficient evidence to suggest that implementing a biopsychosocial care paradigm to this population may be advantageous. In patients undergoing conservative intervention the evidence was either against (catastrophizing, depression, anxiety) or inconclusive (self-efficacy, expectation of recovery, avoidant coping) for the predictive value of psychological factors on outcome. However, future high-quality comparative investigations and those assessing understudied constructs may shed more light on the prognostic value of MPF on outcome in this population. There is clearly a place for the study of psychological factors associated with shoulder disorders. Further investigation of all psychological factors may provide deeper insight into understanding patients with shoulder MSD, and best approaches to clinical management.
Availability of data and materials
Not applicable. All data are available in public domains.
- DASH :
Disabilities of the Arm, Shoulder and Hand
Numeric Pain Rating Scale
Numeric Rating Scale
Modifiable psychological factors
Musculoskeletal shoulder disorders
Preferred Reporting Items for Systematic Reviews and Meta-analyses
Randomized controlled trials
Scottish Intercollegiate Guidelines Network
Shoulder Pain and Disability Index
Visual Analog Scale
Greving K, Dorrestijn O, Winters JC, Groenhof F, van der Meer K, Stevens M, et al. Incidence, prevalence, and consultation rates of shoulder complaints in general practice. Scand J Rheumatol. 2012;41(2):150–5. https://doi.org/10.3109/03009742.2011.605390.
Macfarlane GJ, Beasley M, Smith BH, Jones GT, Macfarlane TV. Can large surveys conducted on highly selected populations provide valid information on the epidemiology of common health conditions? An analysis of UK biobank data on musculoskeletal pain. Br J Pain. 2015;9(4):203–12. https://doi.org/10.1177/2049463715569806.
Kuijpers T, van der Windt DA, van der Heijden GJ, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain. 2004;109(3):420–31. https://doi.org/10.1016/j.pain.2004.02.017.
Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. 2016.
Khatib Y, Madan A, Naylor JM, Harris IA. Do psychological factors predict poor outcome in patients undergoing TKA? A systematic review. Clin Orthop Relat Res. 2015;473(8):2630–8. https://doi.org/10.1007/s11999-015-4234-9.
Doiron-Cadrin P, Lafrance S, Saulnier M, Cournoyer E, Roy JS, Dyer JO, et al. Shoulder rotator cuff disorders: a systematic review of clinical practice guidelines and semantic analyses of recommendations. Arch Phys Med Rehabil. 2020;101(7):1233–42. https://doi.org/10.1016/j.apmr.2019.12.017.
Ring D, Ayers DC. Editorial comment: symposium: psychosocial aspects of musculoskeletal illness. Clin Orthop Relat Res. 2015;473(11):3468–9. https://doi.org/10.1007/s11999-015-4544-y.
GBD 2015 DALYs and HALE Collaborators. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1603–58.
Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33(2):73–81. https://doi.org/10.1080/03009740310004667.
Wertli MM, Held U, Lis A, Campello M, Weiser S. Both positive and negative beliefs are important in patients with spine pain: findings from the occupational and industrial Orthopaedic center registry. Spine J. 2018;18(8):1463–74. https://doi.org/10.1016/j.spinee.2017.07.166.
Martinez-Calderon J, Meeus M, Struyf F, Miguel Morales-Asencio J, Gijon-Nogueron G, Luque-Suarez A. The role of psychological factors in the perpetuation of pain intensity and disability in people with chronic shoulder pain: a systematic review. BMJ Open. 2018;8(4):e020703. https://doi.org/10.1136/bmjopen-2017-020703.
Bletterman AN, de Geest-Vrolijk ME, Vriezekolk JE. Nijhuis-van der Sanden MW, van Meeteren NL, Hoogeboom TJ. Preoperative psychosocial factors predicting patient's functional recovery after total knee or total hip arthroplasty: a systematic review. Clin Rehabil. 2018;32(4):512–25. https://doi.org/10.1177/0269215517730669.
Vissers MM, Bussmann JB, Verhaar JAN, Busschbach JJV, Bierma-Zeinstra SMA, Reijman M. Psychological factors affecting the outcome of Total hip and knee arthroplasty: a systematic review. Semin Arthritis Rheum. 2012;41(4):576–88. https://doi.org/10.1016/j.semarthrit.2011.07.003.
Wertli MM, Held U, Lis A, Campello M, Weiser S. Both positive and negative beliefs are important in patients with spine pain: findings from the oioc registry. Spine J. 2017;17(10):S213. https://doi.org/10.1016/j.spinee.2017.08.084.
Burton AK, Kendall NA, Pearce BG, Birrell LN, Bainbridge LC. Management of work-relevant upper limb disorders: a review. Occup Med (Lond). 2009;59(1):44–52. https://doi.org/10.1093/occmed/kqn151.
National Health Committee. New Zealand Acute Low back pain Guide. 2004.
Nicholas MK, Linton SJ, Watson PJ, Main CJ. Early identification and management of psychological risk factors ("yellow flags") in patients with low back pain: a reappraisal. Phys Ther. 2011;91(5):737–53. https://doi.org/10.2522/ptj.20100224.
De Baets L, Matheve T, Meeus M, Struyf F, Timmermans A. The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain: a systematic review. Clin Rehabil. 2019;33(6):980–91. https://doi.org/10.1177/0269215519831056.
Kooijman MK, Barten DJ, Swinkels IC, Kuijpers T, de Bakker D, Koes BW, et al. Pain intensity, neck pain and longer duration of complaints predict poorer outcome in patients with shoulder pain--a systematic review. BMC Musculoskelet Disord. 2015;16(1):288. https://doi.org/10.1186/s12891-015-0738-4.
Struyf F, Geraets J, Noten S, Meeus M, Nijs J. A multivariable prediction model for the Chronification of non-traumatic shoulder pain: a systematic review. Pain Physician. 2016;19(2):1–10. https://doi.org/10.36076/ppj/2016.19.1.
Mallows A, Debenham J, Walker T, Littlewood C. Association of psychological variables and outcome in tendinopathy: a systematic review. Br J Sports Med. 2017;51(9):743–8. https://doi.org/10.1136/bjsports-2016-096154.
Martinez-Calderon J, Struyf F, Meeus M, Luque-Suarez A. The association between pain beliefs and pain intensity and/or disability in people with shoulder pain: a systematic review. Musculoskel Sci Prac. 2018;37:29–57. https://doi.org/10.1016/j.msksp.2018.06.010.
Rodeghero JR, Cleland JA, Mintken PE, Cook CE. Risk stratification of patients with shoulder pain seen in physical therapy practice. J Eval Clin Pract. 2017;23(2):257–63. https://doi.org/10.1111/jep.12591.
Ristori D, Miele S, Rossettini G, Monaldi E, Arceri D, Testa M. Towards an integrated clinical framework for patient with shoulder pain. Arch Physiother. 2018;8(1):7. https://doi.org/10.1186/s40945-018-0050-3.
Kennedy P, Joshi R, Dhawan A. The effect of psychosocial factors on outcomes in patients with rotator cuff tears: a systematic review. Arthroscopy. 2019;35(9):2698–706. https://doi.org/10.1016/j.arthro.2019.03.043.
Coronado RA, Seitz AL, Pelote E, Archer KR, Jain NB. Are psychosocial factors associated with patient-reported outcome measures in patients with rotator cuff tears? A systematic review. Clin Orthop Relat Res. 2018;476(4):810–29. https://doi.org/10.1007/s11999.0000000000000087.
Ring D. CORR insights(R): are psychosocial factors associated with patient-reported outcome measures in patients with rotator cuff tears? A systematic review. Clin Orthop Relat Res. 2018;476(4):830–1. https://doi.org/10.1007/s11999.0000000000000173.
Wong WK, Li MY, Yung PS, Leong HT. The effect of psychological factors on pain, function and quality of life in patients with rotator cuff tendinopathy: a systematic review. Musculoskelet Sci Pract. 2020;47:102173. https://doi.org/10.1016/j.msksp.2020.102173.
Vajapey SP, Cvetanovich GL, Bishop JY, Neviaser AS. Psychosocial factors affecting outcomes after shoulder arthroplasty: a systematic review. J Shoulder Elb Surg. 2020;29(5):e175–e84. https://doi.org/10.1016/j.jse.2019.09.043.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Bmj. 2009;339(jul21 1):b2535. https://doi.org/10.1136/bmj.b2535.
Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis. 1998;57(11):649–55. https://doi.org/10.1136/ard.57.11.649.
Scotish Intercollegiate Guidelines Network (SIGN). Methodology Checklist for Cohort Studies and Randomized Controlled Trials Edinburgh Scotish Intercollegiate Guidelines Network (SIGN); 2012 [updated 2012. Available from: http://www.sign.ac.uk/methodology/checklists.html.
Berk SN, Moore ME, Resnick JH. Psychosocial factors as mediators of acupuncture therapy. J Consult Clin Psychol. 1977;45(4):612–9. https://doi.org/10.1037/0022-006X.45.4.612.
Chester R, Khondoker M, Shepstone L, Lewis JS, Jerosch-Herold C. Self-efficacy and risk of persistent shoulder pain: results of a classification and regression tree (CART) analysis. Br J Sports Med. 2019;53(13):825–34. https://doi.org/10.1136/bjsports-2018-099450.
Ekeberg OM, Bautz-Holter E, Juel NG, Engebretsen K, Kvalheim S, Brox JI. Clinical, socio-demographic and radiological predictors of short-term outcome in rotator cuff disease. BMC Musculoskelet Disord. 2010;11(1):239. https://doi.org/10.1186/1471-2474-11-239.
Engebretsen K, Grotle M, Bautz-Holter E, Ekeberg OM, Brox JI. Predictors of shoulder pain and disability index (SPADI) and work status after 1 year in patients with subacromial shoulder pain. BMC Musculoskelet Disord. 2010;11(1):218. https://doi.org/10.1186/1471-2474-11-218.
Engebretsen KB, Brox JI, Juel NG. Patients with shoulder pain referred to specialist care; treatment, predictors of pain and disability, emotional distress, main symptoms and sick-leave: a cohort study with a six-months follow-up. Scand J Pain. 2020;20(4):775–83. https://doi.org/10.1515/sjpain-2020-0044.
Geraets JJX, Goossens MEJ, de Groot IJM, de Bruijn CPC, de Bie RA, Dinant G, et al. Effectiveness of a graded exercise therapy program for patients with chronic shoulder complaints. Aust J Physiother. 2005;51(2):87–94. https://doi.org/10.1016/S0004-9514(05)70037-4.
Karel Y, Verhagen AP, Thoomes-de Graaf M, Duijn E, van den Borne MPJ, Beumer A, et al. Development of a prognostic model for patients with shoulder complaints in physical therapist practice. Phys Ther. 2017;97(1):72–80. https://doi.org/10.2522/ptj.20150649.
Kennedy CA, Haines T, Beaton DE. Eight predictive factors associated with response patterns during physiotherapy for soft tissue shoulder disorders were identified. J Clin Epidemiol. 2006;59(5):485–96. https://doi.org/10.1016/j.jclinepi.2005.09.003.
Kromer TO. Influence of fear-avoidance beliefs on disability in patients with subacromial shoulder pain in primary care: a secondary analysis. Phys Ther. 2014;94(12):1775–84. https://doi.org/10.2522/ptj.20130587.
Kuijpers T, Van Der Windt DAWM, Boeke AJP, Twisk JWR, Vergouwe Y, Bouter LM, et al. Clinical prediction rules for the prognosis of shoulder pain in general practice. Pain. 2006;120(3):276–85. https://doi.org/10.1016/j.pain.2005.11.004.
Kvalvaag E, Roe C, Engebretsen KB, Soberg HL, Juel NG, Bautz-Holter E, et al. One year results of a randomized controlled trial on radial extracorporeal shock wave treatment, with predictors of pain, disability and return to work in patients with subacromial pain syndrome. Eur J Phys Rehabil Med. 2018;54(3):341–50. https://doi.org/10.23736/S1973-9087.17.04748-7.
Laslett M, Steele M, Hing W, McNair P, Cadogan A. Shoulder pain in primary care--part 2: predictors of clinical outcome to 12 months. J Rehabil Med. 2015;47(1):66–71. https://doi.org/10.2340/16501977-1885.
O'Malley KJ, Roddey TS, Gartsman GM, Cook KF. Outcome expectancies, functional outcomes, and expectancy fulfillment for patients with shoulder problems. Med Care. 2004;42(2):139–46. https://doi.org/10.1097/01.mlr.0000108766.00294.92.
Reilingh ML, Kuijpers T, Tanja-Harfterkamp AM, van der Windt DA. Course and prognosis of shoulder symptoms in general practice. Rheumatology. 2008;47(5):724–30. https://doi.org/10.1093/rheumatology/ken044.
Ryall C, Coggon D, Peveler R, Poole J, Palmer KT. A prospective cohort study of arm pain in primary care and physiotherapy - prognostic determinants. Rheumatology. 2007;46(3):508–15. https://doi.org/10.1093/rheumatology/kel320.
Sindhu BS, Lehman LA, Tarima S, Bishop MD, Hart DL, Klein MR, et al. Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder. Phys Ther. 2012;92(8):992–1005. https://doi.org/10.2522/ptj.20110309.
Smedbraten K, Oiestad BE, Roe Y. Emotional distress was associated with persistent shoulder pain after physiotherapy: a prospective cohort study. BMC Musculoskelet Disord. 2018;19(1):304. https://doi.org/10.1186/s12891-018-2142-3.
Van Der Windt DAWM, Kuijpers T, Jellema P, Van Der Heijden GJMG, Bouter LM. Do psychological factors predict outcome in both low-back pain and shoulder pain? Ann Rheum Dis. 2007;66(3):313–9. https://doi.org/10.1136/ard.2006.053553.
Wolfensberger A, Vuistiner P, Konzelmann M, Plomb-Holmes C, Léger B, Luthi F. Clinician and patient-reported outcomes are associated with psychological factors in patients with chronic shoulder pain. Clin Orthop Relat Res. 2016;474(9):2030–9. https://doi.org/10.1007/s11999-016-4894-0.
Cho C-H, Song K-S, Hwang I, Warner J, Warner JJP. Does rotator cuff repair improve psychologic status and quality of life in patients with rotator cuff tear? Clin Orthop Relat Res. 2015;473(11):3494–500. https://doi.org/10.1007/s11999-015-4258-1.
Dambreville A, Blay M, Carles M, Hovorka I, Boileau P. Can the postoperative pain level be predicted preoperatively? Rev Chir Orthop Reparatrice Appar Mot. 2007;93(6):541–5. https://doi.org/10.1016/S0035-1040(07)92675-6.
Dekker AP, Salar O, Karuppiah SV, Bayley E, Kurian J. Anxiety and depression predict poor outcomes in arthroscopic subacromial decompression. J Shoulder Elb Surg. 2016;25(6):873–80. https://doi.org/10.1016/j.jse.2016.01.031.
George SZ, Wallace MR, Wright TW, Moser MW, Greenfield WH 3rd, Sack BK, et al. Evidence for a biopsychosocial influence on shoulder pain: pain catastrophizing and catechol-O-methyltransferase (COMT) diplotype predict clinical pain ratings. Pain. 2008;136(1–2):53–61. https://doi.org/10.1016/j.pain.2007.06.019.
George SZ, Wu SS, Wallace MR, Moser MW, Wright TW, Farmer KW, et al. Biopsychosocial influence on shoulder pain: influence of genetic and psychological combinations on twelve-month postoperative pain and disability outcomes. Arthritis Care Res. 2016;68(11):1671–80. https://doi.org/10.1002/acr.22876.
George SZ, Wallace MR, Wu SS, Moser MW, Wright TW, Farmer KW, et al. Biopsychosocial influence on shoulder pain: risk subgroups translated across preclinical and clinical prospective cohorts. Pain. 2015;156(1):148–56. https://doi.org/10.1016/j.pain.0000000000000012.
Simon CB, Valencia C, Coronado RA, Wu SS, Li Z, Dai Y, et al. Biopsychosocial influences on shoulder pain: analyzing the temporal ordering of postoperative recovery. J Pain. 2020;21(7–8):808–19. https://doi.org/10.1016/j.jpain.2019.11.008.
Henn RF 3rd, Kang L, Tashjian RZ, Green A. Patients' preoperative expectations predict the outcome of rotator cuff repair. J Bone Joint Surg Am. 2007;89(9):1913–9. https://doi.org/10.2106/00004623-200709000-00004.
Jain NB, Ayers GD, Fan R, Kuhn JE, Baumgarten KM, Matzkin E, et al. Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. J Shoulder Elb Surg. 2018;27(8):1393–400. https://doi.org/10.1016/j.jse.2018.04.016.
Koorevaar RCT, Kleinlugtenbelt YV, Landman EBM, Van 't Riet E, Bulstra SK. Psychological symptoms and the MCID of the DASH score in shoulder surgery. J Orthop Surg Res. 2018;13.
Koorevaar RC, van 't Riet E, Gerritsen MJ, Madden K, Bulstra SK. The Influence of Preoperative and Postoperative Psychological Symptoms on Clinical Outcome after Shoulder Surgery: A Prospective Longitudinal Cohort Study. PLoS One. 2016;11(11):e0166555.
Lau BC, Scribani M, Wittstein J. The effect of preexisting and shoulder-specific depression and anxiety on patient-reported outcomes after arthroscopic rotator cuff repair. Am J Sports Med. 2019;47(13):3073–9. https://doi.org/10.1177/0363546519876914.
Lau BC, Scribani M, Wittstein J. Patients with depression and anxiety symptoms from adjustment disorder related to their shoulder may be ideal patients for arthroscopic rotator cuff repair. J Shoulder Elb Surg. 2020;29(7S):S80–S6. https://doi.org/10.1016/j.jse.2020.03.046.
Oh JH, Yoon JP, Kim JY, Kim SH. Effect of expectations and concerns in rotator cuff disorders and correlations with preoperative patient characteristics. J Shoulder Elb Surg. 2012;21(6):715–21. https://doi.org/10.1016/j.jse.2011.10.017.
Potter MQ, Wylie JD, Granger EK, Greis PE, Burks RT, Tashjian RZ. One-year patient-reported outcomes after arthroscopic rotator cuff repair do not correlate with mild to moderate psychological distress. Clin Orthop Relat Res. 2015;473(11):3501–10. https://doi.org/10.1007/s11999-015-4513-5.
Ravindra A, Barlow JD, Jones GL, Bishop JY. A prospective evaluation of predictors of pain after arthroscopic rotator cuff repair: psychosocial factors have a stronger association than structural factors. J Shoulder Elb Surg. 2018;27(10):1824–9. https://doi.org/10.1016/j.jse.2018.06.019.
Thorpe AM, O'Sullivan PB, Mitchell T, Hurworth M, Spencer J, Booth G, et al. Are psychologic factors associated with shoulder scores after rotator cuff surgery? Clin Orthop Relat Res. 2018;476(10):2062–73. https://doi.org/10.1097/CORR.0000000000000389.
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(9):775–86. https://doi.org/10.1097/AJP.0000000000000029.
Woollard JD, Bost JE, Piva SR, Kelley Fitzgerald G, Rodosky MW, Irrgang JJ. The ability of preoperative factors to predict patient-reported disability following surgery for rotator cuff pathology. Disabil Rehabil. 2017;39(20):2087–96. https://doi.org/10.1080/09638288.2016.1219396.
Yeoman TFM, Wigderowitz CA. The effect of psychological status on pain and surgical outcome in patients requiring arthroscopic subacromial decompression. Eur J Orthop Surg Traumatol. 2012;22(7):549–53. https://doi.org/10.1007/s00590-011-0886-7.
Niknejad B, Bolier R, Henderson CR Jr, Delgado D, Kozlov E, Lockenhoff CE, et al. Association between psychological interventions and chronic pain outcomes in older adults: a systematic review and meta-analysis. JAMA Intern Med. 2018;178(6):830–9. https://doi.org/10.1001/jamainternmed.2018.0756.
Gagnier JJ, Robbins C, Bedi A, Carpenter JE, Miller BS. Establishing minimally important differences for the American shoulder and elbow surgeons score and the Western Ontario rotator cuff index in patients with full-thickness rotator cuff tears. J Shoulder Elb Surg. 2018;27(5):e160–e6. https://doi.org/10.1016/j.jse.2017.10.042.
Chaudhury S, Gwilym SE, Moser J, Carr AJ. Surgical options for patients with shoulder pain. Nat Rev Rheumatol. 2010;6(4):217–26. https://doi.org/10.1038/nrrheum.2010.25.
Wertli MM, Rasmussen-Barr E, Held U, Weiser S, Bachmann LM, Brunner F. Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review. Spine J. 2014;14(11):2658–78. https://doi.org/10.1016/j.spinee.2014.02.033.
Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014;14(5):816–36 e4. https://doi.org/10.1016/j.spinee.2013.09.036.
Nisenzon AN, George SZ, Beneciuk JM, Wandner LD, Torres C, Robinson ME. The role of anger in psychosocial subgrouping for patients with low Back pain. Clin J Pain. 2014;30(6):501–9. https://doi.org/10.1097/AJP.0000000000000019.
The authors did not receive any funding for this project.
Ethics approval and consent to participate
Consent for publication
The authors report no conflicts of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
1 A: Embase Search July 3, 2019.
Elsevier© 2019 RELX Intellectual Properties SA.
Part B. Medline July 3, 2019.
SIGN Quality Assessment. Bold font indicates high quality studies based on the SIGN review.
-, low quality, few or no criteria fulfilled.
Columns 1–14 in Appendix 2A are in response to the following questions:
1. Study question focused? 2. Included groups selected from source population that are comparable. 3. The study indicate how many who were asked to take part did so. 4. The likelihood that some eligible subjects might have the outcome at the time of the enrolment is assessed and taken into consideration. 5. What are the percentage of individuals recruited that dropped out before the study was completed. 6. Comparison is made between full participants and those lost to follow-up. 7. Outcomes clearly defined. 8. The assessment of outcome is made blind to exposure status. 9. Where blinding was not possible, there is some recognition that knowledge of the exposure status could have influenced the assessment of outcome. 10. The method of assessment of exposure is reliable? 11. Evidence from other sources is used to demonstrate that the method of outcome assessment is valid and reliable. 12. Exposure or prognostic factor assessed more than once? 13. Main potential confounders identified and taken into account in analysis. 14. Have confidence intervals been provided. 15. Overall assessment of risk of bias (++/+/−/0).
2 B: Randomized clinical trials.
Columns 1–10 reflect the SIGN questions listed in the legend below the Appendix.
-, low quality, few or no criteria fulfilled.
Columns 1–10 in Appendix 2B are in response to the following questions:
1. Clearly and focused question. 2. The assignment of subjects to treatment groups are randomized? 3. An adequate concealment method is used? 4. The design keeps subjects and investigators ‘blind’ about treatment allocation? 5. The groups are similar at start of the trials? 6. The only difference between the groups is the treatment under investigation? 7. All relevant outcomes are measured in a standard, valid and reliable way? 8. What percentage of the subjects recruited into each treatment arm dropped out before the study was completed? 9. All the subjects are analysed in the groups to which they were allocated (Intention to treat analysis)? 10. Where the study is carried out at more than one site, results are comparable for all sites? Overall quality of the study? (++/+/−/0).
About this article
Cite this article
Sheikhzadeh, A., Wertli, M.M., Weiner, S.S. et al. Do psychological factors affect outcomes in musculoskeletal shoulder disorders? A systematic review. BMC Musculoskelet Disord 22, 560 (2021). https://doi.org/10.1186/s12891-021-04359-6
- Conservative intervention
- Surgical intervention
- Modifiable psychological factors
- Treatment outcome