1 Pain-related beliefs influence arm function in persons with frozen shoulder De Baets L, a,* Matheve T, a Traxler J, b, c . Vlaeyen JWS, b, c Timmermans A, a a REVAL Rehabilitation Research, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium b Health Psychology Research, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Belgium c Experimental Health Psychology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands *Corresponding author: Liesbet De Baets [email protected]Hasselt University, Agoralaan Building A, 3590 Diepenbeek, Belgium Sources of funding: none Acknowledgements: None to declare Category: original article Paper is not based on a previous communication to a society or meeting
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Pain-related beliefs influence arm function in persons with frozen
shoulder
De Baets L,a,* Matheve T,a Traxler J,b, c. Vlaeyen JWS,b, c Timmermans A,a
aREVAL Rehabilitation Research, Faculty of Rehabilitation Sciences, Hasselt
University, Diepenbeek, Belgium
bHealth Psychology Research, Faculty of Psychology and Educational
Sciences, KU Leuven, Leuven, Belgium
cExperimental Health Psychology, Faculty of Psychology and Neuroscience,
Maastricht University, Maastricht, The Netherlands
23 of DASH which asks whether limitations at work or during other regular daily
activities were experienced as a result of arm, shoulder or hand problems, is
potentially similarly interpretable as item 5 of PSEQ, measuring the confidence
to do some work, despite the pain. In order to explore the potential effect of the
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item overlap between DASH and PSEQ, we removed items 2 and 5 from the
PSEQ and calculated the explained variance in arm function by the control
variables, TSK-11 scores, PCS scores and the adjusted PSEQ score again. R²
was in this case 55% instead of 57%, and the same standard Beta for PSEQ
was found, indicating that the item overlap had only a limited effect on the
explained variance in function.
Limitations
Since the exact etiology of FS is still unknown, there is no gold standard for the
diagnosis of this condition which is, therefore, primarily based on clinical
criteria.2, 39 Moreover, the differentiation of FS from other shoulder disorders is
difficult in the initial stage.1 Since we only included patients with a gradual onset
of symptoms, which were stable or got worse, and were present for longer than
2 months, it is unlikely that we recruited persons with a shoulder condition other
than FS. Furthermore, we did not use any physical tests for the assessment of
arm functioning, but relied on self-report (DASH). Since perceived and actual
functioning may diverge significantly in different musculoskeletal complaints,40
the results of the effects of pain-related beliefs on reported function should be
interpreted with caution. Furthermore, given the lack of physical variables in the
reported prediction model, the reported explained variance in perceived arm
function should be interpreted with care as this might overestimate the role of
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pain beliefs in this population. Given the cross-sectional design of this
observational study, no conclusions can be drawn with regard to how pain-
related beliefs evolve during the clinical course of persons with FS. Therefore,
the cause – consequence relationship between pain intensity, pain-related
beliefs and potential persistent disability is not clear at this moment.
Clinical implications and future research
Healthcare professionals need to acknowledge the value of pain-related fear
and pain self-efficacy in the assessment of persons with FS, as these pain-
related beliefs may be associated with disability. Therefore, these constructs
should be included in the regular assessment of persons with FS in medical and
physiotherapy care. Screening tools which support a multidimensional
examination such as the modified version of the STarT Back Screening Tool,41
the Örebro Musculoskeletal Pain Screening Questionnaire-short version,42 or
the OSPRO (Optimal Screening for Prediction of Referral and Outcome) Yellow
Flag Assessment Tool can be used.43 Other validated questionnaires recording
one or several pain-related beliefs that can be used in clinical practice are the
TSK, the PCS, the PSEQ or the recently developed fear-avoidance component
scale (FACS),23, 27, 28, 44 which assesses all cognitive, emotional and behavioral
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components related to the updated version of the fear-avoidance model.44 Apart
from the relation between pain-related beliefs and perceived arm function, it
would be of interest to assess the relation between objectively measured arm
function and pain-related beliefs in future studies, in order to limit the possible
confounding effect of similarities in the questionnaires on perceived arm
function and self-efficacy. Furthermore, investigating the association between
maladaptive pain-related beliefs and effective avoidance behavior in terms of
adapted motor behavior (i.e. adapted glenohumeral and scapulothoracic range
of motion, and altered muscle activation patterns) in persons with FS might
additionally explain the relationship between pain-related beliefs and reduced
arm function.
Regarding the management options for persons with FS, a recent systematic
review indicated a gap in the literature towards the non-surgical management of
FS.45 In other musculoskeletal pain conditions, such as nonspecific low back
pain, pain-related beliefs are identified as mediating factors for treatment
success.46 Therefore, it is of interest to assess the value of management
strategies accompanied by biopsychosocial interventions which create
awareness for the association between pain-related beliefs and perceived arm
function, and to prepare patients with inadequate pain-related beliefs for what
they can expect regarding their recovery (understanding pain, unhelpful
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thoughts, coping styles, and goal setting).47-49 It is furthermore relevant to
assess the value of self-management support and well guided physical activity
in the management of FS, as an important effect of self-management support
and supported physical activity interventions is assumed to be the improvement
of an individual’s pain-related beliefs and a patient’s independence to manage
his/her complaints.50.51 From that point of view, it is advisable to additionally
investigate the effect of physical activity interventions, based on individual goal-
setting and preferences, as a reinforcement strategy in the (self-)management
of pain and function in persons with FS. In this context, it is of additional
importance to acknowledge the value of behavioral change techniques to
improve self-efficacy beliefs.52, 53
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CONCLUSION
This is the first study assessing pain-related beliefs in a sample of persons with
FS. In addition to pain intensity, pain-related fear and pain self-efficacy were
shown to significantly explain variance in perceived arm function in persons with
FS. These results indicate that the assessment of persons with FS should take
these constructs into account, in order to optimize the medical, psychological,
and physiotherapeutic management of FS.
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