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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 38

The relationship between depression or anxiety symptoms and objective and subjective symptoms of patients with frozen shoulder


1 Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
2 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Hand and Upper Extremity Division, Department of Orthopedic Surgery, Mass General Hospital, Harvard Medical School, Boston, MA, USA
3 Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
4 School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission07-Jun-2017
Date of Acceptance26-Jun-2018
Date of Web Publication15-Mar-2019

Correspondence Address:
Mohammad Hosein Ebrahimzadeh
Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Ahmad-Abad Street, Mashhad
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2008-7802.254186

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  Abstract 


Background: the aim of this study is to evaluate the prevalence and effect of depression and anxiety on the shoulder range of motion, as well as the objective and subjective symptoms in patients suffering from frozen shoulder. Methods: Between 2013 and 2014, in a cross-sectional study, we evaluated 120 patients with idiopathic frozen shoulder. We collected the demographic data for each patient and measured shoulder range of motion in four directions in both limbs. All patients filled out visual analog scale (VAS) for pain and the disabilities of the arm, shoulder, and hand (DASH) questionnaires. Both Hamilton anxiety and depression questionnaires were filled out for each patient. Results: A total of 92 patients (77%) with idiopathic frozen shoulder showed symptoms of depression, while only 32 (27%) of them experienced anxiety. Thirty-two patients (27%) showed symptoms of both depression and anxiety. Although elevation and abduction were not affected by depression, internal and external rotations were more restricted among patients who had symptoms of depression. DASH and VAS scores were higher in patients with symptoms of depression. In terms of anxiety, only VAS and DASH were different between two groups. In multivariable analysis, DASH score was correlated with severity of both anxiety and depression symptoms. Conclusion: While there is no definitive relationship between symptoms of depression or anxiety and shoulder range of motion in patients suffering from frozen shoulder, patients who suffer from depression or anxiety experienced increased pain and limb disability.

Keywords: Adhesive capsulitis, anxiety, DASH, depression, frozen shoulder


How to cite this article:
Ebrahimzadeh MH, Moradi A, Bidgoli HF, Zarei B. The relationship between depression or anxiety symptoms and objective and subjective symptoms of patients with frozen shoulder. Int J Prev Med 2019;10:38

How to cite this URL:
Ebrahimzadeh MH, Moradi A, Bidgoli HF, Zarei B. The relationship between depression or anxiety symptoms and objective and subjective symptoms of patients with frozen shoulder. Int J Prev Med [serial online] 2019 [cited 2019 May 21];10:38. Available from: http://www.ijpvmjournal.net/text.asp?2019/10/1/38/254186




  Introduction Top


Frozen shoulder for the first time was described by Duplay in 1879 as “humeroscapular periarthritis,” and since then, it has remained a controversial topic.[1] The exact etiology of frozen shoulder is unknown; however, diabetes mellitus is one of the major risk factors associated with this disease.[2]

During the recent decades, a scientist has noticed psychological disorders as probable risk factors to explain the musculoskeletal diseases etiology.[3],[4],[5],[6] Regarding the association between psychological parameters and frozen shoulder, the researchers at first focused on personality disorders with the well-known expression of “'frozen' shoulder in a 'frozen' personality.”[7],[8],[9] However, the effect of depression and anxiety on frozen shoulder has not been studied in detail.[10]

In the current study, we tried to evaluate the prevalence and the possible effects of depression and anxiety symptoms on patients suffering from frozen shoulder. Our goal was to find if there is any association between depression and anxiety with range of motion, pain, and disability in these patients.


  Methods Top


Between 2013 and 2014, in a cross-sectional study, we enrolled 120 patients with idiopathic frozen shoulder, who were visited in our referral shoulder clinic in Ghaem Hospital, Mashhad, Iran. All patients were in phase-II of frozen shoulder, which was diagnosed based on history and clinical examination. All patients had shoulder pain for at least 3 months. We excluded patients with a history of psychosis, rotator cuff tear, and previous shoulder surgery or fracture. All patients signed informed consent. The study was approved by the Mashhad University Ethical Board.

We collected demographic data for each patient and measured shoulder range of motion in four directions (elevation, abduction, external and internal rotation) in both limbs. All patients filled out visual analog scale for pain (VAS) and the disabilities of the arm, shoulder, and hand (DASH) questionnaires. Both Hamilton anxiety and depression questionnaires were filled out for each patient individually by a psychiatrist. Internal rotation was defined with a six score scale as the back of hand reached to inter scapular, thoracolumbar junction, mid lumbar, lumbosacral junction, buttock, and lateral thigh, respectively. Hamilton depression questionnaire score was interpreted as normal, mild, moderate, and severe if the scores were 0–7, 8–16, 17–23, and >24, respectively. Anxiety severity was classified as normal, mild, moderate, and severe, according to Hamilton anxiety questionnaire, if the scores were 0–13, 14–17, 18–24, and >24, respectively.

The average age of the patients was 52-year-old (23–88 years) and 69% were women. Twelve patients had bilateral involvement [Table 1]. The most common diseases associated with frozen shoulder were diabetes (24%) and hypothyroidism (7.5%), respectively.
Table 1: Demographic data in patients suffering from idiopathic frozen shoulder (n=120)

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We used SPSS version 16 (SPSS Inc., Chicago IL, USA) for descriptive and statistical analysis. We used independent t-test and ANOVA test to compare two independent means of variables between different subgroups. Nonparametric variables were assessed with Fisher's exact test and Chi-square test. P< 0.05 was deemed to be statistically significant. For interpretation of correlation, we assumed coefficient of <0.4, 0.4–0.7, and >0.7 as weak, moderate, and strong, respectively.


  Results Top


A total of 28 patients (23.3%) did not show any symptoms of depression, 59 (49.2%) showed mild symptoms, 27 (22.5%) showed moderate symptoms, and only six (5%) patients showed sym ptoms of severe depression. Eighty-eight patients (73.3%) had no anxiety, 22 (18.3%) had mild anxiety, eight (6.7%) had moderate anxiety, and two (1.7%) had severe anxiety. Thirty-two patients (27%) experienced symptoms of both depression and anxiety. Pearson's correlation was 0.73 between severity of symptoms of anxiety and depression (P< 0.001).

We divided the patients into two groups based on the presence or absence of symptoms of depression [Table 2]. Although elevation and abduction were not affected by depression, internal and external rotations were more restricted in patients who experienced symptoms of depression. DASH and VAS scores were higher among patients with symptoms of depression. Regarding anxiety, only VAS and DASH differed in two groups [Table 2].
Table 2: Comparison of patients suffering from depression or anxiety signs with normal ones in patients with idiopathic frozen shoulder

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We found weak correlations between severity of depression and all four directions of range of motion, education, VAS, and DASH scores. The correlations between anxiety and range of motion, and DASH were weak [Table 3].
Table 3: Correlation of severity of depression and anxiety with other factors in patients suffering from idiopathic frozen shoulder

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In multivariable analysis, DASH score was correlated with severity of both anxiety and depression symptoms. Education and internal rotation had only relation with depression [Table 4].
Table 4: Multivariable analysis: Independent factors associated with depression and anxiety in patients suffering from frozen shoulder

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  Discussion Top


In this study, more than three-fourth of the patients with idiopathic frozen shoulder showed symptoms of depression, while only a little over one-fourth of them experienced anxiety. Patients with symptoms of depression suffered from more limited internal and external rotations of the shoulder joint, while those who suffered from anxiety experienced more pain and disability in the affected limb. However, multivariable analysis revealed that depression and anxiety have more correlation to subjective symptoms than objective signs.

There are some limitations to this study. We did not have a control group to compare our demographics with them. Furthermore, our study had a cross-sectional design, which prevented us from establishing a causative relationship between frozen shoulder and depression or anxiety.

In contrast with range of motion, which was not affected by anxiety, DASH score was higher in patients who suffered from anxiety. It seems that anxiety aggravates upper extremity disability but not the objective signs such as range of motion. Depression had similar effects; however, unlike anxiety, rotational range of motion, especially internal rotation, was also decreased in patients exhibiting symptoms of depression. Ding et al. in a prospective study, evaluated the effect of anxiety and depression on patients suffering from frozen shoulder.[4] According to their results, patients with symptoms of anxiety and depression experienced more pain and upper limb disabilities compared to patients without those symptoms.[4] Range of motion was similar in both groups; however,[4] Alizadehkhaiyat et al. showed the importance of the depression and anxiety on tennis elbow disability regarding pain and disability.[11] Similarly, Ring et al. have shown that anxiety and depression aggravate disability in different upper extremities diseases.[12]

In our study, patients with symptoms of depression experienced increased shoulder pain. However, we could not find a similar relationship between anxiety and shoulder pain. Cho et al. used Hospital Anxiety and Depression Scale for patients before rotator cuff repair, and they found similar results; namely, in their study, only depression, but not anxiety, was associated with increased VAS score.[10] However, Ding et al. reported higher VAS scores in both groups.[4] Bair et al. evaluated the relationship of pain experience with depression and anxiety in patients with musculoskeletal pain and reported that both depression and anxiety were associated with increased pain.[3]

Depression is a common finding in patients suffering from frozen shoulder.[13],[14] Although depression and anxiety do not have a significant relationship with objective shoulder function in patients suffering from frozen shoulder, it seems that they are associated with increased pain experience and limb disability. Therefore, when managing such patients, not only we should consider physical function but also we should focus on psychological factors as well.

Financial support and sponsorship

The authors have received a research grant from Mashhad University of Medical Sciences for this study.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goldberg BA, Scarlat MM, Harryman DT 2nd. Management of the stiff shoulder. J Orthop Sci 1999;4:462-71.  Back to cited text no. 1
    
2.
Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br 1995;77:677-83.  Back to cited text no. 2
    
3.
Bair MJ, Wu J, Damush TM, Sutherland JM, Kroenke K. Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosom Med 2008;70:890-7.  Back to cited text no. 3
    
4.
Ding H, Tang Y, Xue Y, Yang Z, Li Z, He D, et al. A report on the prevalence of depression and anxiety in patients with frozen shoulder and their relations to disease status. Psychol Health Med 2014;19:730-7.  Back to cited text no. 4
    
5.
Hodkinson B, Maheu E, Michon M, Carrat F, Berenbaum F. Assessment and determinants of aesthetic discomfort in hand osteoarthritis. Ann Rheum Dis 2012;71:45-9.  Back to cited text no. 5
    
6.
Wolkind SN. Psychiatric aspects of low back pain. Physiotherapy 1974;60:75-7.  Back to cited text no. 6
    
7.
Coventry MB. Problem of painful shoulder. J Am Med Assoc 1953;151:177-85.  Back to cited text no. 7
    
8.
Fleming A, Dodman S, Beer TC, Crown S. Personality in frozen shoulder. Ann Rheum Dis 1975;35:456-7.  Back to cited text no. 8
    
9.
Lorenz TH, Musser MJ. Life stress, emotions and painful stiff shoulder. Ann Intern Med 1952;37:1232-44.  Back to cited text no. 9
    
10.
Cho CH, Seo HJ, Bae KC, Lee KJ, Hwang I, Warner JJ. The impact of depression and anxiety on self-assessed pain, disability, and quality of life in patients scheduled for rotator cuff repair. J Shoulder Elbow Surg 2013;22:1160-6.  Back to cited text no. 10
    
11.
Alizadehkhaiyat O, Fisher AC, Kemp GJ, Frostick SP. Pain, functional disability, and psychologic status in tennis elbow. Clin J Pain 2007;23:482-9.  Back to cited text no. 11
    
12.
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;88:1983-8.  Back to cited text no. 12
    
13.
Ebrahimzadeh MH, Moradi A, Pour MK, Moghadam MH, Kachooei AR. Clinical outcomes after arthroscopic release for recalcitrant frozen shoulder. Arch Bone Jt Surg 2014;2:220-4. Epub 2014 Sep 15.  Back to cited text no. 13
    
14.
Bagheri F, Ebrahimzadeh MH, Moradi A, Bidgoli HF. Factors Associated with Pain, Disability and Quality of Life in Patients Suffering from Frozen Shoulder. Arch Bone Jt Surg 2016;4:243-7.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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