Heterogeneity of Pain-Related Psychological Distress in Patients Seeking Care for Shoulder Pathology.

BACKGROUND Psychological distress is associated with disability and quality of life for patients with shoulder pain. However, uncertainty around heterogeneity of psychological distress has limited the adoption of shoulder care models that address psychological characteristics. In a cohort of patients with shoulder pain, our study sought to: 1) describe the prevalence of various subtypes of psychological distress, 2) evaluate associations between psychological distress and self-reported shoulder pain, disability, and function, and 3) determine differences in psychological distress profiles between patients receiving non-operative versus operative treatment. METHODS The sample included 277 patients who were evaluated in clinic by a shoulder surgeon and completed the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Assessment Tool (OSPRO-YF) from 2019 to 2021. This tool categorizes maladaptive and adaptive psychological traits, and the number of yellow flags ranges from 0-11, with higher yellow flag counts indicating higher pain-related psychological distress. Operative and nonoperative cohorts were compared using Chi-square test and student t-test. Linear regression was used to evaluate the association between pain, disability, and YFs, while Poisson regression evaluated the association between operative treatment and psychologic distress. K-means cluster analysis was performed to propose potential psychological distress phenotypes. RESULTS Two hundred and fifty-one patients (91%) had at least one YF on the OSPRO-YF tool, with a mean number of 6 +/- 3.5 YFs. Yellow flags in unhelpful coping (85%) and helpful coping domains (78%) were most prevalent. The number of YFs was significantly associated with baseline shoulder pain (p<0.001), SANE (p<0.001), and ASES (p<0.001) scores. Comparing operative and nonoperative cohorts, the operative cohort had significantly higher mean number of YFs (6.5 vs. 5.6, p=0.035), presence of any YF (94.3% vs. 85.7%, p=0.015), and presence of YFs within the unhelpful coping domain (91.8% vs 75.6%, p<0.001). Three phenotypes were described, corresponding to low, moderate, and severe psychological distress (p<0.001), with females (p=0.037) and smokers (p=0.018) associated with higher psychological distress phenotypes. CONCLUSIONS Yellow flags, particularly within the unhelpful coping and helpful coping domains, were highly prevalent in a cohort of patients presenting to a shoulder surgeon's clinic. Additionally, operative patients were found to have a significantly higher rate of YFs across multiple dimensions of psychologic distress. These findings stress the importance of routine attentiveness to multiple dimensions of pain-related psychological distress in shoulder populations, which can provide an opportunity to reinforce healthy interpretation of pain while minimizing distress in appropriately identified patients.