Journal Club November 2016: Older Age as a Prognostic Factor of Attenuated Pain Recovery After Shoulder Arthroscopy

Article Title: Older Age as a Prognostic Factor of Attenuated Pain Recovery After Shoulder Arthroscopy


Author: Simon CB, Riley III JL, Coronado RA, Valencia C, Wright T, Moser M, Farmer K, George SZ


Journal: PM R. 2016 Apr;8(4):297-304. doi: 10.1016/j.pmrj.2015.09.004. Epub 2015 Sep 12.




Shoulder injuries, pain, and subsequent shoulder surgeries are common among the older adults.   It is estimated that up to 30% of adults older than 50 years of age have been affected by shoulder pain, a major indicator for shoulder surgery and in particular, arthroscopic rotator cuff repair.  Due to the widespread prevalence of shoulder pain and surgery in the community, Simon conducted a prospective cohort study looking at the variance between postoperative outcomes in younger, middle-aged, and older adults.  The article was originally published in the American Journal of Physical Medicine and Rehabilitation in April 2016 and obtained via the online journal for review.


Inclusion criteria included age (between 20 to 79 years of age), pain in the anterior, lateral, or posterior shoulder, a diagnosis of musculoskeletal dysfunction based on imaging and clinical assessment, and having been scheduled for an arthroscopic shoulder procedure.  Exclusion criteria included pain for more than 3 months in other regions, prior shoulder surgery in the past year, shoulder-related fractures, tumor, or infections, and current or previous chronic pain disorders, psychiatric management or gastrointestinal or renal diseases.  A total of 139 participants were recruited with 30 older adults, 57 younger adults, and 52 middle aged adults.


The study observed both subjective and objective measures of dysfunction and pain utilizing self-reported pain duration and intensity, disability levels, and current medications together with movement-evoked pain and experimental pain response physical testing.  Each utility was assessed pre-operatively, and three and six months post-operatively.  Univariate analysis was used to examine the difference between preoperative physical testing with 3 and 6 month measures postoperatively.  Influence of age group on pain outcomes were performed using a multivariate regression analyses, accounting for prognostic factors preoperative (movement-evoked pain, pain duration, and pain catastrophizing), intraoperatively (arthroscopic procedure), and postoperatively (analgesic use).


Results revealed that older adults had significantly higher movement-evoked pain intensity and experimental pain response at 3 months postoperatively compared to young and middle-aged adults.  Older age is a positive predictor for movement-evoked pain at 3 and 6 months and experimental pain at 3 months.  However, there were no age-group related differences in outcomes.  These results provide data for older age contributing to poorer pain outcomes after shoulder arthroscopy and further age-related studies on managing pain among older adults were recommended.


Discussion Points:


  1. What is the study’s objective?
  2. What is the main rationale behind investigating the objective?
  3. What methodological approach (statistical analysis, design) was used and why was it used?
  4. Was the sample size adequate?
  5. Are there any other factors that can be considered for inclusion or exclusion criteria in the study?
  6. What were the main results of the study?
  7. What were the strengths and weakness of the study?
  8. What biologic factors do you think accounts for the variance in movement-evoked pain intensity between older adults and middle age/young adults?
  9. What recommendations can you make to future older age patients who present with shoulder pain?  Would you change your conversation based on the results found in this article?
  10. What OMM techniques could be utilized in the management of shoulder pain and at what stage of the treatment do you think these techniques will benefit the patients, regardless of age?

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Journal Discussion Questions November 2016

Journal Article November 2016