The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain: a systematic review

Key points

1. 01Positive treatment expectations and higher self-efficacy predict better pain and disability outcomes after physiotherapy
2. 02Fear-avoidance beliefs at baseline predict worse outcomes after surgery, but not after physiotherapy
3. 03Baseline depression, anxiety, coping, somatization, and distress do not predict treatment outcome across any shoulder treatment type
4. 04Optimism moderates the relationship between pain catastrophizing and disability in physiotherapy, reducing the harmful effect of catastrophizing
5. 05Catastrophizing is not predictive for physiotherapy outcomes but results after conservative medical treatment are inconclusive

How it was conducted

Design

Systematic review with best-evidence synthesis (no meta-analysis due to study heterogeneity)

Databases searched

PubMed, Web of Science, Embase, PsycINFO, searched until 14 January 2019

Included studies

23 articles describing 21 studies; 3 had high risk of bias, 9 low, 11 moderate

Participants

3769 participants across 21 studies

Shoulder diagnoses

Subacromial pain, rotator cuff tears, mixed shoulder diagnoses, and shoulder arthroplasty for osteoarthritis

Primary outcomes

Pain and disability assessed via multiple validated scales including SPADI, DASH, ASES, QuickDASH, and VAS

What they found

• 23 articles (21 studies, 3769 participants) were included; 3 studies had high risk of bias, 9 low, 11 moderate
• No predictive role of baseline depression, anxiety, coping, somatization, or distress was found across any type of shoulder treatment
• Fear-avoidance beliefs predicted pain and disability after surgical treatment (e.g., odds ratio 1.01 (95% CI 1.03-1.17), P=0.00 at one year in one study, though noted as clinically irrelevant magnitude) but not after physiotherapy
• Catastrophizing was not predictive of outcome after physiotherapy; results after mixed conservative treatments were inconsistent
• Treatment expectations and self-efficacy predicted pain and disability in physiotherapy cohorts (Chester et al. at 6 weeks and 6 months on SPADI and QuickDASH; Kvalvaag at 1 year on SPADI)
• Optimism moderated the relationship between pain catastrophizing and shoulder disability following physiotherapy, reducing the negative influence of catastrophizing on disability (Coronado et al.)
• Optimism did not moderate the relationship between catastrophizing and pain, or between fear-avoidance and disability or pain

Limitations

• No meta-analysis was possible due to heterogeneity in populations, treatments, and psychological measures across studies
• Most studies did not assess psychological factors at follow-up, only at baseline, which may miss how these factors change during treatment
• Studies specifically targeting distinct psychological factors often had few participants with elevated scores, reducing power to detect predictive associations
• Measurement tools for depression and anxiety varied widely in quality, including single-item scales with potentially low specificity

Why it matters

For patients

Patients with shoulder pain should know that having positive expectations about recovery and confidence in self-managing exercises may meaningfully improve their physiotherapy outcomes.

For clinicians

Screening for self-efficacy and treatment expectations before physiotherapy, and for fear-avoidance beliefs before surgery, can help identify patients at risk for poor outcomes who may benefit from targeted psychological support.

For readers

This review clarifies which psychological factors matter by treatment type, distinguishing the physiotherapy context from surgical care and providing a framework for multidimensional shoulder assessment.