Clinical Orthopaedics and Related Research®

, Volume 470, Issue 12, pp 3470–3477 | Cite as

To What Degree do Shoulder Outcome Instruments Reflect Patients’ Psychologic Distress?

  • Young Hak Roh
  • Jung Ho Noh
  • Joo Han Oh
  • Goo Hyun Baek
  • Hyun Sik Gong
Clinical Research



Psychologic distress contributes to symptom severity in patients with several musculoskeletal disorders. While numerous shoulder outcome instruments are used it is unclear whether and to what degree psychologic distress contributes to the scores.


We asked (1) to what degree shoulder outcome instruments reflect patients’ psychologic distress, and (2) whether patients who are strongly affected by psychologic distress can be identified.


We prospectively evaluated 119 patients with chronic shoulder pain caused by degenerative or inflammatory disorders using the Constant-Murley scale, Simple Shoulder Test (SST), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. To evaluate psychologic distress, we measured depression using the Center for Epidemiologic Studies-Depression (CES-D) scale and pain anxiety using the Pain Anxiety Symptom Scale (PASS). Demographic and clinical parameters, such as pain scores, ROM, and abduction strength, also were measured. We then assessed the relative contributions made by psychologic distress and other clinical parameters to the quantitative ratings of the three shoulder outcome instruments.


Quantitative ratings of shoulder outcome instruments correlated differently with psychologic distress. Constant-Murley scores did not correlate with psychologic measures, whereas SST scores correlated with PASS (r = 0.32) and DASH scores correlated with PASS and CES-D (r = 0.36 and r = 0.32). Psychologic distress contributed to worsening SST and DASH scores but not to Constant-Murley scores. DASH scores were more strongly influenced by pain anxiety and depression than the other two outcome instruments.


Shoulder outcome measures reflected different psychologic aspects of illness behavior, and the contributions made by psychologic distress to different shoulder outcome instruments apparently differed. Physicians should select and interpret the findings of shoulder outcome instruments properly by considering their psychologic implications.

Level of Evidence

Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.



We thank P.G. Jung MD and S.Y. Lee MD for their roles in data collection.


  1. 1.
    Alizadehkhaiyat O, Fisher AC, Kemp GJ, Frostick SP. Pain, functional disability, and psychologic status in tennis elbow. Clin J Pain. 2007;23:482–489.PubMedCrossRefGoogle Scholar
  2. 2.
    Beaton DE, Richards RR. Measuring function of the shoulder: a cross-sectional comparison of five questionnaires. J Bone Joint Surg Am. 1996;78:882–890.PubMedGoogle Scholar
  3. 3.
    Bjelle A. Epidemiology of shoulder problems. Baillieres Clin Rheumatol. 1989;3:437–451.PubMedCrossRefGoogle Scholar
  4. 4.
    Boyd JH, Weissman MM, Thompson WD, Myers JK. Screening for depression in a community sample: understanding the discrepancies between depression symptom and diagnostic scales. Arch Gen Psychiatry. 1982;39:1195–1200.PubMedCrossRefGoogle Scholar
  5. 5.
    Chard MD, Hazleman R, Hazleman BL, King RH, Reiss BB. Shoulder disorders in the elderly: a community survey. Arthritis Rheum. 1991;34:766–769.PubMedCrossRefGoogle Scholar
  6. 6.
    Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160–164.PubMedGoogle Scholar
  7. 7.
    Fishbain D. Evidence-based data on pain relief with antidepressants. Ann Med. 2000;32:305–316.PubMedCrossRefGoogle Scholar
  8. 8.
    Furner SE, Hootman JM, Helmick CG, Bolen J, Zack MM. Health-related quality of life of US adults with arthritis: analysis of data from the behavioral risk factor surveillance system, 2003, 2005, and 2007. Arthritis Care Res (Hoboken). 2011;63:788–799.CrossRefGoogle Scholar
  9. 9.
    Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg. 2007;16:717–721.PubMedCrossRefGoogle Scholar
  10. 10.
    Godfrey J, Hamman R, Lowenstein S, Briggs K, Kocher M. Reliability, validity, and responsiveness of the simple shoulder test: psychometric properties by age and injury type. J Shoulder Elbow Surg. 2007;16:260–267.PubMedCrossRefGoogle Scholar
  11. 11.
    Goldhahn J, Angst F, Simmen BR. What counts: outcome assessment after distal radius fractures in aged patients. J Orthop Trauma. 2008;22(8 suppl):S126–S130.PubMedCrossRefGoogle Scholar
  12. 12.
    Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:11.PubMedCrossRefGoogle Scholar
  13. 13.
    Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand)[corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29:602–608.PubMedCrossRefGoogle Scholar
  14. 14.
    Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002;84:208–215.PubMedGoogle Scholar
  15. 15.
    Junge A, Frohlich M, Ahrens S, Hasenbring M, Sandler A, Grob D, Dvorak J. Predictors of bad and good outcome of lumbar spine surgery: a prospective clinical study with 2 years’ follow up. Spine (Phila Pa 1976). 1996;21:1056–1064; discussion 1064–1065.CrossRefGoogle Scholar
  16. 16.
    Kim KW, Han JW, Cho HJ, Chang CB, Park JH, Lee JJ, Lee SB, Seong SC, Kim TK. Association between comorbid depression and osteoarthritis symptom severity in patients with knee osteoarthritis. J Bone Joint Surg Am. 2011;93:556–563.PubMedCrossRefGoogle Scholar
  17. 17.
    Kirkley A, Griffin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy. 2003;19:1109–1120.PubMedCrossRefGoogle Scholar
  18. 18.
    Lindenhovius AL, Buijze GA, Kloen P, Ring DC. Correspondence between perceived disability and objective physical impairment after elbow trauma. J Bone Joint Surg Am. 2008;90:2090–2097.PubMedCrossRefGoogle Scholar
  19. 19.
    Lippitt SB, Harryman DT, Matsen FA. A practical tool for evaluating function: the Simple Shoulder Test. In: Matsen 3rd FA, Fu FH, Hawkins RJ, eds. The Shoulder: A Balance of Mobility and Stability. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1993:501–530Google Scholar
  20. 20.
    Macfarlane GJ, Hunt IM, Silman AJ. Predictors of chronic shoulder pain: a population based prospective study. J Rheumatol. 1998;25:1612–1615.PubMedGoogle Scholar
  21. 21.
    Masters S, O’Doherty L, Mitchell GK, Yelland M. Acute shoulder pain in primary care: an observational study. Aust Fam Physician. 2007;36:473–476.PubMedGoogle Scholar
  22. 22.
    McCracken LM, Zayfert C, Gross RT. The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain. Pain. 1992;50:67–73.PubMedCrossRefGoogle Scholar
  23. 23.
    Monnin D, Perneger TV. Scale to measure patient satisfaction with physical therapy. Phys Ther. 2002;82:682–691.PubMedGoogle Scholar
  24. 24.
    Oh JH, Jo KH, Kim WS, Gong HS, Han SG, Kim YH. Comparative evaluation of the measurement properties of various shoulder outcome instruments. Am J Sports Med. 2009;37:1161–1168.PubMedCrossRefGoogle Scholar
  25. 25.
    Osman A, Barrios FX, Osman JR, Schneekloth R, Troutman JA. The Pain Anxiety Symptoms Scale: psychometric properties in a community sample. J Behav Med. 1994;17:511–522.PubMedCrossRefGoogle Scholar
  26. 26.
    Perrot S, Maheu E, Javier RM, Eschalier A, Coutaux A, LeBars M, Bertin P, Bannwarth B, Treves R. Guidelines for the use of antidepressants in painful rheumatic conditions. Eur J Pain. 2006;10:185–192.PubMedCrossRefGoogle Scholar
  27. 27.
    Radloff LS. The CES-D Scale: a self teport depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.CrossRefGoogle Scholar
  28. 28.
    Ring D, Kadzielski J, Fabian L, Zurakowski D, Malhotra LR, Jupiter JB. Self-reported upper extremity health status correlates with depression. J Bone Joint Surg Am. 2006;88:1983–1988.PubMedCrossRefGoogle Scholar
  29. 29.
    Romeo AA, Bach BR Jr, O’Halloran KL. Scoring systems for shoulder conditions. Am J Sports Med. 1996;24:472–476.PubMedCrossRefGoogle Scholar
  30. 30.
    Rosenberger PH, Jokl P, Ickovics J. Psychosocial factors and surgical outcomes: an evidence-based literature review. J Am Acad Orthop Surg. 2006;14:397–405.PubMedGoogle Scholar
  31. 31.
    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 (Oxford). 2007;46:508–515.CrossRefGoogle Scholar
  32. 32.
    Schiphorst Preuper HR, Reneman MF, Boonstra AM, Dijkstra PU, Versteegen GJ, Geertzen JH, Brouwer S. Relationship between psychological factors and performance-based and self-reported disability in chronic low back pain. Eur Spine J. 2008;17:1448–1456.PubMedCrossRefGoogle Scholar
  33. 33.
    Szabo RM. Outcomes assessment in hand surgery: when are they meaningful? J Hand Surg Am. 2001;26:993–1002.PubMedCrossRefGoogle Scholar
  34. 34.
    Turk DC, Rudy TE. Neglected topics in the treatment of chronic pain patients–relapse, noncompliance, and adherence enhancement. Pain. 1991;44:5–28.PubMedCrossRefGoogle Scholar
  35. 35.
    van de Ven-Stevens LA, Munneke M, Terwee CB, Spauwen PH, van der Linde H. Clinimetric properties of instruments to assess activities in patients with hand injury: a systematic review of the literature. Arch Phys Med Rehabil. 2009;90:151–169.PubMedCrossRefGoogle Scholar
  36. 36.
    van der Windt DA, Kuijpers T, Jellema P, van der Heijden GJ, Bouter LM. Do psychological factors predict outcome in both low-back pain and shoulder pain? Ann Rheum Dis. 2007;66:313–319.PubMedCrossRefGoogle Scholar
  37. 37.
    Wolf JM, Green A. Influence of comorbidity on self-assessment instrument scores of patients with idiopathic adhesive capsulitis. J Bone Joint Surg Am. 2002;84:1167–1173.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Young Hak Roh
    • 1
  • Jung Ho Noh
    • 2
  • Joo Han Oh
    • 3
  • Goo Hyun Baek
    • 3
  • Hyun Sik Gong
    • 3
  1. 1.Department of Orthopaedic Surgery, Gil Medical CenterGachon University School of MedicineIncheonKorea
  2. 2.Department of Orthopaedic SurgeryNational Police HospitalSeoulRepublic of Korea
  3. 3.Department of Orthopaedic SurgerySeoul National University College of MedicineSeoulKorea

Personalised recommendations