Fear and avoidance of shoulder movement according to the International Code of Functioning: cross-sectional study / Medo e evitação de movimento do ombro segundo o Código Internacional de Funcionalidade: estudo transversal

ABSTRACT BACKGROUND AND OBJECTIVES: Shoulder pain is a limiting condition that has a major impact on daily activities and work. Knowing which specific activities involving the shoulder are associated with the occurrence of higher levels of pain may be of interest to professionals. The use of images of shoulder movements can be an effective tool to check the presence of pain and fear of movement, break down language and cultural barriers, and facilitate communication between professional and patient. The objectives of this study were: (1) to carry out a descriptive analysis of fear responses and movement avoidance based on passive viewing of images of shoulder movements based on the International Classification of Functioning, Disability and Health (ICF) codes; (2) to check whether there is a correlation between fear responses and movement avoidance with the Shoulder Pain and Disability Index (SPADI). METHODS: In this cross-sectional observational study, individuals with chronic shoulder pain were recruited. Participants responded to the Shoulder Pain and Disability Index (SPADI) and the TAMPA Scale of Kinesiophobia (TSK) to measure the intensity of shoulder pain and disability, and fear of movement, respectively. Participants viewed 58 movement images based on codes and descriptors from the third chapter of ICF. In addition, they responded to a numerical scale to judge fear of movement and a second numerical scale to judge movement avoidance. RESULTS: The study included 42 individuals. The activities belonging to the mobility subgroup (chapter 4), which refers to chapter 3 of the ICF, are those that present greater responses of fear and movement avoidance. Multiple regression resulted in a significant model [F(1, 40) = 31.119; p<0.001; R2 = 0.438], when verifying whether fear and movement avoidance responses related to ICF images are associated with SPADI in participants with chronic shoulder pain. The fear response is associated with SPADI (β=0.661; t=5.578; p<0.001), however, the avoidance response did not present a significant result with the scale (β=−0.063; t=-0.160; p=0.874). CONCLUSION: Movements that refer to mobility seem to be the most feared and avoided by people with chronic shoulder pain. Fear of movement is associated with shoulder disability.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor no ombro é uma condição limitante, que apresenta grande impacto nas atividades de vida diárias e no trabalho. Conhecer quais atividades específicas envolvendo o ombro estão associadas à ocorrência de maiores níveis de dor pode ser de interesse dos profissionais. A utilização de imagens de movimentos do ombro pode ser uma ferramenta eficaz para verificar a presença de dor e medo de movimento, quebrar barreiras de linguagem e culturais e facilitar a comunicação entre profissional e paciente. Os objetivos deste estudo foram: (1) realizar a análise descritiva das respostas de medo e evitação do movimento a partir da visualização passiva de imagens de movimentos do ombro baseadas nos códigos da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF); (2) verificar se há correlação das respostas de medo e evitação do movimento com o Índice de dor e Incapacidade do Ombro (SPADI). METODOS: Neste estudo observacional do tipo transversal foram recrutadas pessoas com dor crônica no ombro. Os participantes responderam ao Shoulder Pain and Disability Index (SPADI) e à Escala TAMPA de Cinesiofobia (TSK) para mensurar a intensidade da dor e incapacidade do ombro, e de medo do movimento, respectivamente. Os participantes visualizaram 58 imagens de movimentos baseadas em códigos e descritores do terceiro capítulo de Atividade e Participação da CIF. Além disso, responderam a uma escala numérica para julgar o medo do movimento e a uma segunda escala numérica para julgar a evitação ao movimento. RESULTADOS: Participaram do estudo 42 pessoas. As atividades pertencentes ao subgrupo mobilidade (capítulo 4), referente ao capítulo 3 da CIF, são as que apresentam maiores respostas de medo e evitação do movimento. A regressão múltipla resultou em um modelo significativo [F (1, 40) = 31, 119; p<0,001; R2 = 0,438], ao verificar se as respostas de medo e evitação do movimento referente às imagens da CIF estão associadas ao SPADI dos participantes com dor crônica no ombro. A resposta de medo é associada ao SPADI (β=0,661; t=5,578; p<0,001), porém a resposta de evitação não apresentou resultado significativo com a escala (β=−0,063; t=−0,160; p=0,874). CONCLUSÃO: Os movimentos que se referem à mobilidade parecem ser os mais temidos e evitados por pessoas com dor crônica no ombro. O medo do movimento está associado com a incapacidade do ombro.

Using Machine Learning to Predict Nonachievement of Clinically Significant Outcomes After Rotator Cuff Repair.

Background: Although some evidence suggests that machine learning algorithms may outperform classical statistical methods in prognosis prediction for several orthopaedic surgeries, to our knowledge, no study has yet used machine learning to predict patient-reported outcome measures after rotator cuff repair. Purpose: To determine whether machine learning algorithms using preoperative data can predict the nonachievement of the minimal clinically important difference (MCID) of disability at 2 years after rotator cuff surgical repair with a similar performance to that of other machine learning studies in the orthopaedic surgery literature. Study Design: Case-control study; Level of evidence, 3. Methods: We evaluated 474 patients (n = 500 shoulders) with rotator cuff tears who underwent arthroscopic rotator cuff repair between January 2013 and April 2019. The study outcome was the difference between the preoperative and 24-month postoperative American Shoulder and Elbow Surgeons (ASES) score. A cutoff score was calculated based on the established MCID of 15.2 points to separate success (higher than the cutoff) from failure (lower than the cutoff). Routinely collected imaging, clinical, and demographic data were used to train 8 machine learning algorithms (random forest classifier; light gradient boosting machine [LightGBM]; decision tree classifier; extra trees classifier; logistic regression; extreme gradient boosting [XGBoost]; k-nearest neighbors [KNN] classifier; and CatBoost classifier). We used a random sample of 70% of patients to train the algorithms, and 30% were left for performance assessment, simulating new data. The performance of the models was evaluated with the area under the receiver operating characteristic curve (AUC). Results: The AUCs for all algorithms ranged from 0.58 to 0.68. The random forest classifier and LightGBM presented the highest AUC values (0.68 [95% CI, 0.48-0.79] and 0.67 [95% CI, 0.43-0.75], respectively) of the 8 machine learning algorithms. Most of the machine learning algorithms outperformed logistic regression (AUC, 0.59 [95% CI, 0.48-0.81]); nonetheless, their performance was lower than that of other machine learning studies in the orthopaedic surgery literature. Conclusion: Machine learning algorithms demonstrated some ability to predict the nonachievement of the MCID on the ASES 2 years after rotator cuff repair surgery.

Restrição à atividade física na pandemia está associada com menor autoeficácia para dor na população com dor musculoesquelética: um estudo transversal / La restricción de la actividad física en la pandemia se asocia con menor autoeficacia para el dolor en la población con dolor musculoesquelético: un estudio transversal / Physical activity restriction in the pandemic is associated with lower pain self-efficacy in the population with musculoskeletal pain: cross-sectional study

RESUMO Durante a pandemia de COVID-19, observou-se um menor nível de prática de atividade física pela população, o que pode influenciar o nível de autoeficácia para dor na população com dor musculoesquelética. Neste contexto, o objetivo deste estudo foi analisar se existe associação entre o tempo de prática de atividade física e o nível de autoeficácia para dor na população com dor musculoesquelética durante a pandemia de COVID-19 no estado de São Paulo, controlada por variáveis biopsicossociais. Realizou-se um estudo através de um formulário online com questões sobre aspectos sociodemográficos, tempo semanal de prática de atividade física, níveis de estresse e ansiedade, intensidade de dor e autoeficácia para dor (PSEQ-10 - Pain Self-Efficacy Questionnaire). A análise estatística ocorreu por meio de dois modelos de regressão linear múltipla, com (modelo A) e sem (modelo B) o controle dos dados por fatores psicoemocionais (ansiedade e estresse) em 150 pessoas. Foi encontrada associação entre o tempo de prática de atividade física semanal e o nível de autoeficácia para dor no modelo A (p=0,0271, β=1,914) e no modelo B (p=0,0333, β=1,826). Intensidade de dor durante a pandemia, índice de massa corporal (IMC) e sexo, dentre as variáveis de controle, também foram associadas ao nível de autoeficácia para dor. Maior tempo de prática de atividade física foi associado a maior nível de autoeficácia para dor na população com dor musculoesquelética durante a pandemia de COVID-19. Intensidade de dor durante a pandemia, IMC e sexo também foram associados ao nível de autoeficácia para dor.

RESUMEN Durante la pandemia del COVID-19 se observó un menor nivel de actividad física en la población, lo que puede influir en el nivel de autoeficacia para el dolor en la población con dolor musculoesquelético. En ese contexto, el objetivo de este estudio fue analizar si existe asociación entre el tiempo de práctica de actividad física y el nivel de autoeficacia para el dolor en la población con dolor musculoesquelético durante la pandemia del COVID-19 en el estado de São Paulo, controlado por variables biopsicosociales. Se realizó un estudio mediante un formulario por Internet con preguntas sobre los aspectos sociodemográficos, el tiempo semanal de actividad física, los niveles de estrés y ansiedad, la intensidad del dolor y la autoeficacia del dolor (PSEQ-10 - Pain Self-Efficacy Questionnaire). El análisis estadístico se realizó utilizando dos modelos de regresión lineal múltiple, con (modelo A) y sin (modelo B) control de datos para factores psicoemocionales (ansiedad y estrés) en 150 personas. Se encontró asociación entre el tiempo de práctica de actividad física semanal y el nivel de autoeficacia para el dolor en el modelo A (p=0,0271, β=1,914) y en el modelo B (p=0,0333, β=1,826). La intensidad del dolor durante la pandemia, el índice de masa corporal (IMC) y el sexo, entre las variables de control, también se asociaron con el nivel de autoeficacia para el dolor. La práctica de actividad física durante más tiempo se asoció con un mayor nivel de autoeficacia para el dolor en la población con dolor musculoesquelético durante la pandemia del COVID-19. La intensidad del dolor durante la pandemia, el IMC y el género también se asociaron con el nivel de autoeficacia para el dolor.

ABSTRACT During the COVID-19 pandemic, a lower level of physical activity was observed in the population, which may influence the level of pain self-efficacy in the population with musculoskeletal pain. In this context, this study sought to analyze whether there is an association between the time of physical activity practice and the level of pain self-efficacy in the population with pain during the COVID-19 pandemic in the state of São Paulo, controlled by biopsychosocial variables. This study was conducted via an online form with questions about sociodemographic aspects, weekly physical activity practice, stress and anxiety levels, pain intensity and pain self-efficacy (Pain Self-Efficacy Questionnaire - PSEQ-10). The analysis was determined by two models of multiple linear regression, with (Model A) and without (Model B) the control of data by psycho-emotional factors (anxiety and stress) in 150 subjects. An association was found between weekly physical activity practice time and pain self-efficacy level, Model A (p=0.0271, β=1.914) and Model B (p=0.0333, β=1.826). Pain intensity during the pandemic, body mass index (BMI) and sex, among the control variables, also were associated with the pain self-efficacy level. A higher time of physical activity practice was associated with a higher pain self-efficacy level in the population with musculoskeletal pain during the COVID-19 pandemic. Pain intensity during the pandemic, BMI and sex also were associated with pain self-efficacy level.

Pain self-efficacy and physical activity during COVID-19-related social distancing: cross-sectional study / Autoeficácia para dor e atividade física durante o distanciamento social relacionado à COVID-19: estudo transversal

ABSTRACT BACKGROUND AND OBJECTIVES: The COVID-19 pandemic has impacted the practice of physical activity in the population with musculoskeletal pain, and one of the ways to increase the performance of physical activity is to stimulate pain self-efficacy. However, to date, no study that brought the association between self-efficacy and physical activity in this population has been observed in the literature. The aim of this study was to analyze the association of the level of pain self-efficacy and physical activity weekly time in the population with pain during social distancing related to the COVID-19 pandemic in the states of Ceará and São Paulo. METHODS: This study is characterized as a cross-sectional study with a quantitative approach. Data collection was performed using an electronic form. To identify the association between pain self-efficacy (Pain Self-Efficacy Questionnaire) and physical activity weekly time (dependent variable) in the population with pain, a multiple linear regression was performed. RESULTS: Self-efficacy showed a direct association (ß = 0.015; p = 0.0016) with the time of physical activity practiced during the pandemic. Other variables were associated with longer time of physical activity, such as lower pain intensity during the pandemic (ß = -0.064; p = 0.0223), lower body mass index (ß = -0.036; p = 0.0004), the male gender (ß = -0.441; p<0.0001) and absence of reported comorbidities (ß = -0.297; p = 0.0116). The history of positive diagnosis for COVID-19 was not associated with the physical activity duration (p = 0.5347) in an alternative model. CONCLUSION: A direct association between pain self-efficacy and time of physical activity in the population with musculoskeletal pain during COVID-19-related social distancing was identified.

RESUMO JUSTIFICATIVA E OBJETIVOS: A pandemia de COVID-19 impactou a prática de atividade física da população com dor musculoesquelética (DME), e um dos modos de ampliar a realização da atividade física é estimulando a autoeficácia para dor. Entretanto, até o momento, não se observou na literatura qualquer estudo que trouxesse a relação entre autoeficácia e atividade física nessa população. O objetivo deste estudo foi analisar a associação do nível de autoeficácia e do tempo semanal de prática de atividade física na população com dor durante o distanciamento social relacionado à pandemia de COVID-19 nos estados do Ceará e São Paulo. MÉTODOS: Este estudo se caracteriza como um estudo transversal com abordagem quantitativa. A coleta de dados foi realizada a partir de um formulário eletrônico. Para identificação da associação entre autoeficácia (Pain Self-Efficacy Questionnaire) e tempo semanal de prática de atividade física (variável dependente) na população com dor, foi realizada uma regressão linear múltipla. RESULTADOS: A autoeficácia apresentou relação direta (ß = 0,015; p = 0,0016) com tempo de atividade física praticada durante a pandemia. Outras variáveis apresentaram associação com maior tempo de prática de atividade física, como menor intensidade de dor durante a pandemia (ß = -0,064; p = 0,0223), menor índice de massa corporal (ß = -0,036; p=0,0004), ser do sexo masculino (ß = -0,441; p<0,0001) e relatar ausência de comorbidades (ß = -0,297; p = 0,0116). O histórico de diagnóstico positivo para COVID-19 não apresentou associação com tempo de atividade física (p = 0,5347). CONCLUSÃO: Identificou-se associação direta entre autoeficácia para dor e tempo de prática de atividade física na população com dor musculoesquelética durante o distanciamento social relacionado à COVID-19.

Causal mechanisms of a scapular stabilization intervention for patients with subacromial pain syndrome: a secondary analysis of a randomized controlled trial.

BACKGROUND: Causal mediation analysis is one way to bridge this gap by exploring the causal pathways of a given intervention. The aim of this study was to assess whether scapular motion, position, and periscapular muscle strength are mediators for pain and shoulder disability outcomes following a scapular stabilization intervention for patients with subacromial pain syndrome. METHODS: Sixty patients were randomized into two groups: scapular stabilization or periscapular strengthening exercises. The intervention consisted of three sessions per week for 8 weeks. The primary outcome measures were pain and disability and the following outcome measures were considered as potential mediators: scapular motion, scapular position, periscapular muscle strength, age, duration of symptoms, and side of the complaint. A model-based inference approach with bootstrap simulations was used to estimate the average causal mediation effect, average direct effect, and the average total effect from the data of a randomized clinical trial that evaluated the effect of adding scapular stabilization exercises to a scapulothoracic strengthening program in people with subacromial pain syndrome. RESULTS: The results demonstrated that none of the putative mediators were influenced by the intervention. However, muscle strength of serratus anterior, upper, middle, and lower trapezius muscles was associated with shoulder disability. CONCLUSION: Scapular kinematic and periscapular muscle strength did not mediate the effect of scapular stabilization exercises on shoulder pain or disability scores in subjects with subacromial pain syndrome. Muscle strength of serratus anterior, upper, middle and lower trapezius were associated with shoulder disability scores at 8-weeks follow-up.

Therapeutic approach to pain-related fear and avoidance in adults with chronic musculoskeletal pain: an integrative review and a roadmap for clinicians / Abordagem terapêutica do medo relacionado à dor e da evitação em adultos com dor musculoesquelética crônica: revisão integrativa e roteiro para o clínico

ABSTRACT BACKGROUND AND OBJECTIVES: Cognitive-behavioral approaches have been applied in patients with chronic pain as a treatment strategy to reduce symptoms and disability, since fear related to pain, kinesiophobia and catastrophizing may be important psychosocial barriers for recovery. The relevance of fear and avoidance behaviors in the development and maintenance of processes of disabling chronic pain is already well established in the scientific literature. CONTENTS: The cognitive-behavioral approach defines the relationship of pain with defense behaviors and the contribution to functional disability, assisting clinicians to recognize signs of these defensive behaviors during practice, as well as providing strategies for clinical practice, highlighting approaches that can be used, such as pain neuroscience education and exposure therapy. Therefore, it is possible to provide a guide to facilitate the implementation of these concepts in clinical practice for the management of chronic musculoskeletal pain, helping clinicians to ground the theories of fear learning and avoidance in the context of pain and to address the psychosocial factors of patients who present an association between pain and movement. CONCLUSION: Pain-related fear and catastrophic thoughts influence pain intensity and functional disability. Recognizing pain within a multidimensional context assists in establishing targeted approaches. Cognitive-behavioral approaches based on exposure therapy focus on the view beyond body structures.

RESUMO JUSTIFICATIVA E OBJETIVOS: As abordagens cognitivo-comportamentais têm sido aplicadas em pacientes com dor crônica como estratégia de tratamento para redução de sintomas e incapacidade, uma vez que o medo relacionado a dor, a cinesiofobia e a catastrofização podem representar barreiras psicossociais importantes para a recuperação. A relevância do medo e de comportamentos de evitação no desenvolvimento e manutenção de processos de dor crônica incapacitante já é bem estabelecida na literatura científica. CONTEÚDO: A abordagem cognitivo-comportamental fundamenta a relação da dor com comportamentos de defesa e a contribuição para a incapacidade funcional, auxiliando os clínicos a reconhecer sinais destes comportamentos defensivos na prática, além de fornecer estratégias para prática clínica, destacando as abordagens que podem ser utilizadas, como a educação em neurociência da dor e as terapias de exposição. Dessa maneira, é possível fornecer um guia para facilitar a implementação desses conceitos na prática clínica para a abordagem de pessoas com dor musculoesquelética crônica, ajudando os clínicos a fundamentar as teorias de aprendizado do medo e evitação no contexto da dor e a lidar com fatores psicossociais dos pacientes que apresentam associação entre dor e movimento. CONCLUSÃO: O medo relacionado à dor e os pensamentos catastróficos influenciam na intensidade da dor e na incapacidade funcional. O reconhecimento da dor dentro do contexto multidimensional auxilia no estabelecimento de abordagens direcionadas. As abordagens cognitivo-comportamentais baseadas em terapia de exposição têm como enfoque o olhar para além das estruturas do corpo.

Shoulder pain across more movements is not related to more rotator cuff tendon findings in people with chronic shoulder pain diagnosed with subacromial pain syndrome.

INTRODUCTION: People with chronic shoulder pain commonly report pain during arm movements in daily-life activities. Pain related to movement is commonly viewed as an accurate representation of tissue damage. Thus, when a person reports pain across a variety of movements, this is often understood as indicative of greater damage. OBJECTIVES: We aimed to investigate if movement-related pain that occurs across a wider variety of movements was associated with the number or severity of rotator cuff tendons reported as abnormal on a magnetic resonance imaging (MRI). To answer this question, this study was designed in 3 phases. METHODS: We recruited 130 individuals with chronic shoulder pain diagnosed with subacromial pain syndrome. First, a list of daily functional activities commonly reported as painful by people with chronic shoulder pain was generated from 3 well-established outcome measures with 30 individuals and a measurement tool was developed with data from further 100 individuals, which demonstrated to have acceptable content validity, construct validity, internal consistency, interrater reliability, and structural validity. Multiple linear regression was then used to evaluate the hypotheses of the study. A direct acyclic graph was used to select variables for linear regression modelling. RESULTS: There was no association between movement-related pain occurrence across movements and the MRI findings. CONCLUSION: Our study provides evidence that neither the number of rotator cuff tendons reported as abnormal nor the severity of each tendon imaging finding were associated with pain occurrence across movements and activities commonly perceived as painful by people with chronic shoulder pain.

Pain can be conditioned to voluntary movements through associative learning: an experimental study in healthy participants.

Experimental data suggest that associative learning can influence defensive avoidance behavior and pain perception in humans. However, whether voluntary movements can become conditioned stimuli (CSs) and influence pain responses is yet to be evaluated. Forty healthy volunteers participated in this study. Electrocutaneous stimuli applied to the shoulder at pain threshold level (US) and at pain tolerance level (US) were determined before a movement-conditioning paradigm. First, reaching movements to visual cues shown on one side of a computer screen were associated with the US (CS+ movements) on 80% of trials, whereas reaching movements to visual stimuli shown on the other side were never associated with the nociceptive-US (CS- movements). Next, participants underwent a test phase in which movements to visual cues on both sides were paired with the US on 50% of trials. During the test phase, participants were asked to evaluate whether the movement was painful (yes/no) and to rate pain intensity after each trial. Movement onset and duration as well as skin conductance responses were collected. The US stimuli were more likely to be perceived as painful and were also rated as more painful during CS+ movements. Movement onset latency and skin conductance responses were significantly higher in anticipation of the CS+ movement as compared to the CS- movement. These findings suggest that pain can be conditioned to voluntary movements.