Do preoperative anxiety and depression affect the post ......Subacromial impingement syndrome (SIS) is the most frequent cause of shoulder pain and accounts for 44-65% of all shoulder

International Journal of Advanced Joint Reconstruction ISSN 2385-7900

Introduction

Shoulder pain is a common reason for consultation in outpatient medical practice. It is highly prevalent in the general population (3-7%) (1) and is a cause of major disability in active people with the corresponding occupational and socioeconomic implications (2).

Subacromial impingement syndrome (SIS) is the most frequent cause of shoulder pain and accounts for 44-65% of all shoulder pathology. Moreover, rotator cuff tear and glenohumeral arthropathy are also habitual disorders seen at the shoulder specialist's office. Treatment is traditionally nonoperative in the initial phase with analgesia, physiotherapy, and corticosteroid injection therapy. Surgery is considered when patients fail to improve after these

Do preoperative anxiety and depression affect the post-surgical functional outcome of patients with shoulder pathology?

Renau-Cerrillo M1,2, Ruiz-Macarrilla L1, Pèlach-Nadal M3, Cassart E1

1. Department of Orthopaedic Surgery. Hospital Universitari Germans Trias i Pujol. 2. Department of Orthopaedic Surgery. Hospital Clínic de Barcelona.

3. Department of Orthopaedic Surgery. Hospital Universitari de Girona Doctor Josep Trueta

J

Abstract Introduction. In shoulder pathology, the coexistence of anxiety and depression has been associated with poorer results in preoperative functionality and quality of life as well as in the results of surgery. However, the relationship between preoperative psychological status and post-surgical functional outcome is not well defined. The aim of this study is to assess the influence of preoperative anxiety and depression states on the postoperative functional outcome of patients with shoulder pathology. Methods. 127 consecutive patients were evaluated in the shoulder unit and diagnosed with subacromial impingement syndrome, rotator cuff tear or glenohumeral arthropathy. On the day of the first visit, functionality was assessed using the Constant and DASH scores, and affective status using the Hospital Anxiety and Depression Scale (HADS). The patients who underwent surgery were evaluated one year after the operation, using the Constant, DASH and HADS questionnaires. Results. From the 45 patients that were operated on, 35 were finally analysed, of which 28 were female and 7 were male, with a mean age of 59 years. All patients presented an improvement in the functional outcomes after surgery. No significant differences were obtained between the pre and postoperative results in the HADS questionnaire. Patients with high levels of anxiety and depression (HADS-D and/or HADS-A ≥11) before the surgical intervention presented a worse result in the Constant and DASH scores 1 year after surgery. Nevertheless, no differences were observed in the amount of improvement on the Constant and DASH scores after surgery according to the preoperative psychological status. Conclusion. Although globally all patients affected by chronic shoulder disease have postoperative functional improvement, preoperative anxiety and depression states negatively affected the final functional outcome of patients undergoing shoulder pathology. However, no differences were observed between groups in the amount of improvement on the functional scores. An adequate diagnosis and treatment of these states could contribute to improve the functional state and the outcomes of surgery.

Keywords Shoulder surgery, rotator cuff tear, shoulder arthropathy, subacromial impingement, anxiety and depression, psychosocial

factors.

ORIGINAL

E

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http://orcid.org/0000-0002-6381-9502http://orcid.org/0000-0002-6381-9502https://orcid.org/0000-0003-2260-1117https://orcid.org/0000-0003-2260-1117


conservative measures. The goal of surgery is to reduce pain, improve functionality and therefore enhance the patient’s quality of life. However, some patients have suboptimal postoperative results that cannot be explained entirely by adverse events or surgery itself. Also, in some cases there is a discrepancy between clinician and patient self-reported outcome (3). Shoulder problems can significantly affect patient’s ability to work, perform leisure activities and carry out basic activities of daily life (4). Therefore, it is reasonable to think that these limitations may affect the mental health status of people who suffer them. It has been observed that anxiety and depression frequently coexist in patients with chronic pain (5). A close relationship between psychological symptoms and pain and disability has been described in several orthopedic procedures, such as spine, hip and knee surgery (6-9). With regard to shoulder pathology, Cho et al. (10) demonstrated a high prevalence of depression, anxiety, and sleep disturbance in patients with chronic shoulder pain compared with healthy participants. The same authors also showed that the severity of preoperative psychological distress was associated with worse functionality and worse quality of life in patients scheduled for rotator cuff repair (11). Similar results have been observed in patients with glenohumeral arthritis (12). In addition, recent works have shown a worse surgical outcome in patients with poorer psychological status (13,14). Nevertheless, some authors have detected an improvement in depression and anxiety, as well as pain and functional status after shoulder surgery, without an influence of the preoperative psychological symptoms on surgical outcomes (15,16) . Hence, the role of anxiety and depression as a predictor of poor outcome in shoulder surgery is not so clear. Therefore, it is important to clarify the effect of psychological distress on shoulder pathology. This study aims to assess the impact of preoperative anxiety and depression states on the postoperative functional outcome of patients with shoulder pathology. We hypothesize that depression and anxiety symptoms predict a poor surgical outcome.

Material and Methods Approval for the study was obtained from our hospital Medical Ethics Committee. All patients signed an informed consent before participation in the study. Between October 2015 and June 2017 we prospectively included 127 consecutive patients evaluated in our shoulder outpatient clinic and diagnosed by medical history, physical examination, and imaging with plain radiography and magnetic resonance imaging (MRI) of subacromial impingement syndrome (SIS), rotator cuff tear (RCT) or glenohumeral arthropathy. We usually make the diagnosis of subacromial impingement syndrome in patients with pain on overhead activity, a positive Hawkins test, a positive Neer test with anesthetic subacromial injection, and radiographic exclusion of RCT by MRI. We included patients with a partial or complete RCT in the MRI with concordant physical examination. We consider glenohumeral arthropathy patients with concordant physical examination and radiographic signs of primary glenohumeral arthritis or rotator cuff arthropathy. We include patients over 18 years of age with the aforementioned shoulder pathologies and persistence of symptoms after at least 3 months of conservative treatment. The exclusion criteria were patients with previous shoulder surgery or a history of ipsilateral proximal humerus fracture, patients with major psychiatric disease or psychiatric treatment, patients with other shoulder diagnoses, such us shoulder instability or adhesive capsulitis, and those who did not agree to participate in the study. Patients with non reparable massive rotator cuff tears with no signs of arthropathy were also excluded for the study. All procedures were carried out by 2 shoulder surgeons. For patients with glenohumeral arthropathy a total shoulder arthroplasty was performed in the beach chair position with a deltopectoral approach. In the case of RCT, patients underwent an arthroscopic rotator cuff repair in the lateral decubitus position and with traction applied to the affected arm. For those with SIS, arthroscopic subacromial decompression was done, also in the lateral decubitus position. All patients were operated under general anesthesia with the addition of regional block anesthesia for postoperative pain. After surgery each patient followed the usual postoperative protocol for each pathology.

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On the day of the first visit, a questionnaire with demographic and social information was collected. Functionality was assessed using the Constant and DASH scores, and the affective status using the Hospital Anxiety and Depression Scale (HADS). Of the 127 patients initially included, those who underwent surgery were evaluated at 12 months postoperatively fulfilling again the 3 questionnaires. The Constant-Murley and DASH scores are commonly reported shoulder and upper extremity questionnaires around the world that has been validated into Spanish (17). The minimum clinically important differences have been estimated to be around 10 points in both scores (18-20). The HADS, also validated into Spanish (21,22), is a 14-item self-report scale designed to detect anxiety and depression, independently of somatic symptoms in a hospital outpatient clinic and has been widely used in patients with musculoskeletal disorders. It consists of a 7-item anxiety sub-scale (HADS-A) and a 7-item depression sub-scale (HADS-D). Each item is rated from 0 to 3 according to the severity of distress experienced, with a maximum sub-scale scores of 21 for depression and anxiety, respectively. The HADS data can be categorized quantitatively as: normal (0 to 7 points), mild

(8 to 10), moderate (11 to 15), severe (16 to 21) or also qualitatively where a score equal to or higher than 11 is defined as a possible case of anxiety or depression. The last was the one we used in our study. The HADS does not confirm the diagnosis, but rather detects symptoms to screen for these pathologies. Once all data was collected, pre and postoperative results were statistically analyzed using R version 3.5.2. To determine the changes between preoperative and postoperative results in functional (Constant and DASH) and psychological (HADS) outcomes, a linear mixed model fit by restricted maximum likelihood (REML) was used. To ascertain the effect of preoperative depression and anxiety on postoperative clinical outcome, we used a linear regression test. A p value of


cuff tear and 5 cases of glenohumeral arthropathy. Globally, we obtained 14 patients (40%) with high preoperative anxiety levels (HADS-A ≥11) and 10 patients (28.57%) with high preoperative depression levels (HADS-D ≥11). 10 of these patients showed both anxiety and depressive symptoms. All patients presented an improvement in the functional outcomes after surgery. The mean global result for the Constant score was 35.64 points before surgery and 68 points at the 12 months’ follow-up, with an increase of 32.76 points [Confidence interval 26.56-38.97; p


improvement on the Constant and DASH scores after surgery in absolute numbers and in percentage according to the preoperative psychological state, no differences were observed between groups (Figure 4).

Discussion

In recent years, the interest in the relationship between psychological factors and their effect on musculoskeletal pathology has increased. A close relationship between

Figure 4: Improvement on the Constant and DASH scores after surgery in absolute

numbers according to the preoperative psychological state.

Figure 3: Relationship between preoperative HADS and postoperative DASH score

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psychological symptoms and pain and disability has been described in several orthopaedic procedures. In spine surgery, previous research suggested an association between preoperative depressive symptoms and a poorer surgery outcome (6,7). In spite of this, other authors also expose that global psychological distress improved after spinal surgery (8). In hip and knee pathology, Duivenvoorden et al. (9) found a high preoperative prevalence of anxiety and depressive symptoms. After joint replacement, although a significant decrease of these symptoms was seen, preoperative psychological symptoms predicted a lower patient reported outcome and less satisfaction after surgery. Concerning shoulder pathology, a high prevalence of anxiety and depressive symptoms, as well as, a correlation of preoperative psychological distress with worse functionality and worse quality of life has been observed in patients with RCT and glenohumeral arthritis (11,12). In our study, we obtained 14 patients (40%) with high preoperative anxiety levels and 10 patients (28.57%) with high preoperative depression levels. The prevalence of depression is similar than the one observed by Cho et al. (10) (22.3%), but our prevalence of anxiety is much higher; Cho et al. (10) reported 19.2% of anxiety. According to the Spanish Ministry of health, in general population the prevalence of anxiety has been estimated to 6.7% and 6.6% for depression (23). However, it is important to remark that the HADS questionnaire is a tool for screening on anxiety and depressive symptoms. Having these symptoms is not the same as having an anxiety disorder or depression. Therefore, we presume that our prevalence of anxiety or depressive symptoms is an overestimation of the actual prevalence of anxiety and depression disorders. Our findings showed a general improvement in the functional outcomes assessed by Constant and DASH scores after surgery. We also observed that patients with high levels of anxiety and depression before the surgical intervention presented a worse result in the Constant and DASH scores at the 12 months’ follow-up. These results are consistent with the findings of other recent studies, Ravindra et al. (13) analyzed the correlation of preoperative psychological factors with pain after arthroscopic rotator cuff repair, they demonstrated improvements in pain and functional outcomes

after surgery, but worse preoperative emotional scores were found to be correlated with increased postoperative pain. Dekker et al. (24) also found that the presence of anxiety and depression was strongly correlated with pain and negatively correlated with function in patients with subacromial impingement syndrome, and that patients with high HADS scores had worse overall functional outcomes. On the other hand, we didn’t observe differences in the amount of improvement in the Constant and DASH scores after surgery according to the preoperative psychological state. The same results were identified by Thorpe et al. (14), who revealed that patients with poorer psychologic function before surgery were associated with higher levels of shoulder pain and disability before and one year after shoulder surgery; despite this, all patients showed very similar improvements in functional scores. Comparable results were also observed by Lau et al. (25). This findings, could be explained by a poor initial preoperative functional state in patients with anxiety and depression status. Kennedy et al. (26) performed a systematic review of the effect of psychosocial factors in patients with rotator cuff tears, most studies support that these factors do influence the level of disability and pain preoperatively; however, 3 of 9 studies showed significant improvements in postoperative pain and function even with significant psychosocial confounders. Analogous results were found in another systematic review performed by Vajapey et al. (27) in patients undergoing shoulder arthroplasty. Some previous research has also demonstrated an improvement of the psychologic status after shoulder surgery in patients undergoing a rotator cuff repair and in shoulder arthroplasty (15,16). In contrast, in our study, no significant differences were obtained between the pre and postoperative psychological state measured by the HADS questionnaire. Equivalent results were found in a prospective longitudinal cohort study performed in 315 patients planned for elective shoulder surgery (28). This study has some limitations that need to be addressed. First, we did not have a control group with nonoperative management. Second, we had 20% of patients lost to follow-up. Due to the lost patients, the sample size finally analyzed is small and this is another limitation of the study. Moreover,

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a previous calculation of the number of patients needed would had been desirable. A further limitation must be highlighted, we included a heterogeneous study population with shoulder pain due to three different diagnoses and surgery procedures, and it can lead to a bias and limit our conclusions. Notwithstanding, the aim of this study was to assess whether anxiety and depressive symptoms affect functional outcome of patients undergoing shoulder surgery or not. We did not focus on comparing the pathologies with each other. Additional studies should examine if our results are confirmed in all shoulder surgical procedures. As strengths, we performed a prospective inclusion of the patients with a strict inclusion diagnostic criteria performed by shoulder specialist surgeons. To date, the influence of psychological factors on the post-surgical outcome of patients with shoulder pathology has not been well established. Recent studies in this matter have differed in their findings. In addition, no studies have been made to determine the effect of preoperative screening of psychological conditions, referring them for further evaluation, and following postoperative outcomes (29). Hence, emphasis should be placed on well-designed, randomized controlled studies with long-term follow-up, in order to improve understanding and establishing a comprehensive treatment approach that addresses biological, psychological and social factors.

Conclusions.

In conclusion, according to the results of our research, all patients show functional improvement one year after surgery. However, patients with high levels of preoperative anxiety and depression have a worse functional outcome after surgery, probably due to worse preoperative functionality. We found that the levels of anxiety and depression do not change with surgery. Although poor preoperative psychological state should not contraindicate shoulder surgery, an adequate diagnosis and treatment of anxiety and depression states before surgery could contribute to improve the postoperative functional state in this type of patients.

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Copyright

Copyright © 2020 Renau M et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Conflicts of interest statement

The authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.

Acknowledgement

The authors would like to thank Josep Roca from the Epidemiology department for the support with statistical analysis.

How to cite

Renau-Cerrillo M, Ruiz-Macarrilla L, Pèlach-Nadal M, Cassart E. Do preoperative anxiety and depression affect the post-surgical functional outcome of patients with shoulder pathology? Int J Adv Jt Reconstr. 2020; 7(1): 15-22.

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Do preoperative anxiety and depression affect the post ......Subacromial impingement syndrome (SIS) is the most frequent cause of shoulder pain and accounts for 44-65% of all shoulder