Illness perceptions - or in our case injury perceptions - are defined as organized representations patients have about their condition (injury).9 Health threats may elicit these cognitive and emotional representations and further influence a patient’s behavior. Cognitive representations are central mechanisms to control danger and emotional representations are central mechanisms to control fear.9,10 If the central neural system (CNS) decides a person is in danger, pain may be processed. Pain is a neurophysiological phenomenon and one of the most powerful and sophisticated constructs from the human’s sensitive CNS to protect us from danger.11,12
So, should we ask patients how they perceive their injury when they are scheduled for surgical rotator cuff repair (RCR)? Maybe they worry that their rotator cuff (RC) tear may have a serious impact on their financial situation or on how people perceive them. Does this affect the outcome of surgery?
Recent research on psychosocial factors challenges the big body of literature that tendon integrity is crucial for a beneficial outcome post RCR, as patient satisfaction was reported to be high despite a low grade of tendon healing 1-year post RCR.1,2 Not only psychosocial factors move into the spotlight, also the fact that 89% of RC tear patients suffer from sleep disturbance3,4 should awaken our sensors and urge us to reflect on mechanisms that may influence shoulder pain despite the torn tendon(s). Sleep disturbance and central sensitization (the underlying mechanism for nociplastic pain5) seem to have a bidirectional relationship where sleep deprivation may alter the endogenous nociceptive inhibitory system.6-8 This again may lead to delayed recovery from (shoulder) pain6, but we don’t know enough about the effect of these mechanisms on the post RCR outcomes.
Our research team hypothesizes that modifiable factors in the categories psychosocial factors, sleep, and central pain processing do affect the outcome pre and post RCR. To answer the question - Do psychosocial factors such as pain catastrophizing, perceived stress, injury perceptions, patients’ expectations of surgery, sleep related variables, and measures of CPP obtained pre RCR (baseline) influence baseline shoulder function, disability, pain, and quality of life and their evolution over time (1-year post-surgery)? – we set up a longitudinal study design in 2019 and recently finished data collection after 3 years (May 2022).13 The outcomes of interest were the Western Ontario Rotator Cuff index (WORC) for pain, disability, and disease specific quality of life, the Subjective Shoulder Value (SSV), a Numeric Rating Scale for the highest intensity of Pain, and the EQ-5D-5L for Quality of Life and health status. The injury perceptions were measured by the Illness Perception Questionnaire – Revised (IPQ-R) adapted to Injury (IPQ-I).
Our results are yet to be interpreted and published, but it seems that injury perceptions do play a role in the outcome after RCR.
More details on our study are going to be out soon.
Ariane Schwank is a PhD student at University of Antwerp Belgium conducting research in the field of rotator cuff related shoulder pain in patients undergoing a repair and on physiotherapists working with these patients. Next to the academic work, she continues her clinical work at the acute care hospital Kantonsspital Winterthur in Switzerland, where she exclusively treats upper extremity patients (with or without neck problems).
2022 Pain in Motion
References and further reading:
Further reading on the study and the topic is provided here: https://bmjopen.bmj.com/content/bmjopen/12/8/e0588...
1. Nabergoj M, Bagheri N, Bonnevialle N, et al. Arthroscopic rotator cuff repair: Is healing enough? Orthop Traumatol Surg Res 2021; 107(8S): 103100.
2. 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(4): 251-6.
3. Cho CH, Song KS, Hwang I, Warner JJ. 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.
4. Austin L, Pepe M, Tucker B, et al. Sleep disturbance associated with rotator cuff tear: correction with arthroscopic rotator cuff repair. Am J Sports Med 2015; 43(6): 1455-9.
5. Kosek E, Cohen M, Baron R, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain 2016; 157(7): 1382-6.
6. Nijs J, Mairesse, O., Neu, D., Leysen, L., Danneels, L., , Cagnie B, Meeus, M., Moens, M., Ickmans, K. & Goubert, D. sleep disturbances in chronic pain neurobiology assessment and treatment in physical therapy. 2018.
7. Cho CH, Jung SW, Park JY, Song KS, Yu KI. Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance? J Shoulder Elbow Surg 2013; 22(2): 222-8.
8. Nijs J, George SZ, Clauw DJ, et al. Central sensitisation in chronic pain conditions: latest discoveries and their potential for precision medicine. The Lancet Rheumatology 2021.
9. Hale ED, Treharne GJ, Kitas GD. The common-sense model of self-regulation of health and illness: how can we use it to understand and respond to our patients' needs? Rheumatology (Oxford) 2007; 46(6): 904-6.
10. de Raaij EJ, Ostelo RW, Maissan F, Mollema J, Wittink H. The Association of Illness Perception and Prognosis for Pain and Physical Function in Patients With Noncancer Musculoskeletal Pain: A Systematic Literature Review. J Orthop Sports Phys Ther 2018; 48(10): 789-800.
11. Moseley GL, & Butler, D. S. - NOI. Explain pain supercharged Book 2017.
12. Moseley GL, Vlaeyen JWS. Beyond nociception. Pain 2015; 156(1): 35-8.
13. Schwank A, Struyf T, Struyf F, et al. Are psychosocial variables, sleep characteristics or central pain processing prognostic factors for outcome following rotator cuff repair? A protocol for a prospective longitudinal cohort study. BMJ Open 2022; 12(8): e058803.
14. Figure 1: https://medium.com/humanite/perception-on-social-i...