Rotator cuff tears are associated with significant psychiatric problems

doi:10.21203/rs.3.rs-1969822/v1

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Rotator cuff tears are associated with significant psychiatric problems

https://doi.org/10.21203/rs.3.rs-1969822/v1

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Questions/Purpose: In this prospective study of patients who underwent rotator cuff (RC) repair, we aimed to evaluate the pre- and post-operative rates of depression, anxiety, and sleep disturbances, investigate the impact of psychological health and sleep disturbances on the surgical outcomes, and identify the preoperative predictors for surgical outcomes.

Methods: Patients who underwent RC repair after failed non-operative treatment were included in this study. All patients were evaluated using the visual analogue scale, American Shoulder and Elbow Surgeons Shoulder Score, constant score, the abbreviated World Health Organization Quality of Life questionnaire, Beck depression inventory, Beck anxiety inventory, and the Pittsburgh sleep quality index preoperatively and postoperatively at the 6-month follow up.

Results: Eighty-two patients (20 males and 62 females) with a mean age of 67 years were included in this study. Depression was observed in 48% (mean score = 10.83), anxiety in 51% (mean score = 10.11), and sleep disturbance in 69% (mean score = 6.00) of patients pre-operatively.

Conclusions: Shoulder function, depression, and anxiety scores significantly improved, while sleep disturbance decreased, after RC repair. RC tears are associated with significant psychiatric problems.

Rotator cuff (RC) tears are a common disease and cause pain, weakness, and loss of function of the shoulder joint.[1] The currently available non-surgical treatment options for patients with rotator cuff tears have limited efficacy. Surgery is frequently recommended for patients with ınsuffıcıent healing after non-surgical treatments.[2] Repairing an RC tear reduces the pain of the shoulder joint and increases its functional ability. [3, 4]

Many studies for rotator cuff tears have suggested that clinical outcomes should include physical, psychological, and social factors.[5, 6]. The effects of psychiatric disorders, such as depression, anxiety, and insomnia on clinical outcomes for RC repair have been reported previously. It is unclear whether RC repair is associated with mood in depressed patients.The most frequent psychological distress among patients with RC tears are increased nighttime pain and sleep disturbances.Painful status often disrupt sleep and, in severe cases, hand out the ability to perform daily activities. Cho et al.[7] reported that stress has negative effects on the outcome measures after RC repair shoulder diseases are associated with nocturnal pain, insomnia, and reduced sleep duration owing to the pain.[8, 9]. Sleep disturbances are a frequent complaint among patients with rotator cuff diseases. Sufficient sleep is important for the treatment of RC diseases and patient satisfaction. Sleep disorders are often accompanied with pain and loss of function, which motivates the patients to investigate treatment. However, many patients continue to experience sleep disturbances after rotator cuff repair. [10–13]

Sleep disorders in chronic shoulder painful patients have been reported associated with depression and anxiety be able to initiate or rekindle that painful status.[7, 14] The complex interactions between pain and sleep disorders affect the health and well-being of patients by creating a cycle of continuous pain perception leading to sleep disturbances, daytime dysfunction and psychological or emotional problems.[15] Shoulder pain usually get worse at night and patients with shoulder pain have a low sleep quality.[16, 17] Increased production of inflammatory cytokines be able to responsible for sleep disorders.[12] While RC repair improves the mood, physical activity, and general health of patients, the patients continue to experience sleep disturbances(7). Various factors, including loss of function, fixed shoulder posture, and shoulder stiffness, negatively affect sleep quality.[11] Sleep disorders have been reported to be associated with neck diseases and chronic neck pain, knee pain, carpal tunnel syndrome, long bone fractures and shoulder diseases, including shoulder impingement syndromeand RC tears.^{[8,11, 12,18–20,22−24]}

To the best of our knowledge, only one previous study has reported the effects of severity of pain among patients with shoulder impingement syndrome on sleep quality.[8] However, previous studies have reported that sleep disturbances are strongly associated with symptom severity, functional ability, poor mood, and poor coping strategies.[24, 25]

RC tear size is proportional to pain. However, previous studies have reported conflicting results. Three recent studies[26–28] of patients with RC tears reported lower pain in patients with larger tears. Conversely, two short-term studies[29, 30] reported no significant associations between the behavioral symptoms and pain in patients with full-thickness RC tears.

A wide range of psychological problems may occur with muscle diseases. In particular, depression may have a significant effect on the severity of shoulder pain during recovery. Some studies have reported better outcomes in patients without dementia compared to those with dementia.[31, 32] Psychological problems in patients with RC tears are strongly correlated with the tear size, comorbidities, and social status of patients.[33] To improve the outcomes for shoulder surgery, the injury as well as the cognitive and emotional problems need to be addressed.

In the current study, we evaluated the recovery of physical performance and resolution of mental and sleep disturbances in patients who underwent RC repair. The objectives of this study were to investigate the frequency and severity of depression, anxiety, and sleep disturbances among patients with RC tears as well as the effects of RC repair on the sleep quality and health of patients. In addition, we evaluated the effects of various factors related to the shoulder joint on improvement in neuropsychiatric and sleep disorders. We also assessed the effects of preoperative depression, anxiety, and insomnia on clinical outcomes after RC repair.

2.1 Study subjects: We prospectively collected the data for all the patients who underwent RC repair at a tertiary care institution between January 2016 and February 2020. Patients were included in this study if they had (1) a full-thickness RC tear and underwent arthroscopic repair; (2) failed non-operative treatment with either non-steroidal anti-inflammatory drugs or physiotherapy for at least 3 months before the surgical intervention; (3) no history of shoulder surgeries or psychiatric disorders (4) follow- up for at least 6 months post-operatively.

Patients were excluded if they had (1) a partial repair for irreparable RC tear; (2) undergone additional procedures or previous shoulder surgery; (3) history of any psychiatric disorder; (4) severe glenohumeral arthritis, adhesive capsulitis, sleep apnea disorder, or neuropsychiatric diseases; (5) history of medication use for sleep disorders; or (6) follow-up shorter than 6 months.

2.2 Measurements: All measurements were recorded preoperatively and postoperatively at the 6-month follow-up. The data included patient age, sex, medical history, shoulder symptoms, affected side, body mass index (BMI), duration of symptoms, and impact of the symptoms on activities of daily living. The preoperative and postoperative conditions of the involved shoulder and general health were evaluated. The patients were assessed using the visual analogue scale (VAS)[34] for pain, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score,[35] and the constant score (CS) for shoulder movements.[36]

The VAS for pain intensity ranged from "no pain" (score of 0) to "pain as bad as it could be" or "worst imaginable pain" (score of 100). The ASES is used to assess the shoulder function (range: 0–100; higher score correlates with better function and less pain). CS is considered the gold standard for the evaluation of shoulder movements in Europe (score < 30: unsatisfactory; 30–39: fair; 40–59: good; 60–69: very good; and ≥ 70: excellent).[37]

A psychiatrist performed a neuropsychiatric evaluation for all patients, using the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire,[38] Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the Pittsburgh Sleep Quality Index (PSQI).[39]

WHOQOL-BREF is used to evaluate the quality of life and psychometric properties of the patients. The quality of life is evaluated in different domains (range for each domain: 4–20). Higher scores on this questionnaire correlate with a higher quality of life.

BDI is a 21-item questionnaire used to assess the emotional status, somatic symptoms, and behavioral changes (score < 10: minimal; 10–18: moderate; 19–29: moderate to severe; and > 30: severe depression). BAI is a questionnaire used to assess anxiety (score 8–15: mild; 16–25: moderate; and 26–63: severe anxiety).

The PSQI evaluates several parameters of sleep quality, including subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, and daytime dysfunction (range: 0–3 points for each parameter; 0: no current issues; 3: most negative quality; summed score: 0–21; scores > 5: significantly disturbed sleep).

2.3 Procedures and standardization: All arthroscopic RC repairs were performed by an orthopedic surgeon trained in shoulder surgery with more than 10 years of experience, and the same surgical team. All procedures were performed arthroscopically with the patient in a beach chair position. Postoperative pain control and rehabilitation procedures were similar for all patients.

The following data were recorded postoperatively: size of the RC tear (small: < 1 cm; medium: 1–3 cm; large: 3–5 cm; massive: > 5 cm), number of sutures, intraoperative complications, and need for biceps tenotomy, subacromial decompression, or clavicle excision.

2.4 Interscalene block and postoperative pain control: Interscalene block was performed preoperatively on all patients under ultrasound (Stimuplex HNS 11; B. Braun, Melsungen, Germany) guidance with a 5–10-MHz linear probe. A total of 20 mL local anaesthetic was administered as 10 mL of 0.5% bupivacaine, 5 mL of 2% lidocaine, and 5 mL of 0.9% sodium chloride. The same protocol was applied to all patients for pain control. After discharge from the hospital, Acemetacin (90 mg) was administered for pain relief. For patients who required further pain relief, paracetamol (1 g) was administered. No patient required opioids postoperatively.

2.5 Postoperative rehabilitation: In the early postoperative period, pendulum exercises were begun, as tolerated by the patients. The same rehabilitation protocol was applied to all patients, including a three-week period of immobilization with a shoulder sling. Limited passive movements were begun after 3 weeks and active movements after 6 weeks of surgery. Three months after the surgery, progressive resistance exercises (up to 1 kg) were allowed, with an increase in the maximum weight limit to 2 kgs from the fourth month and full movements from the sixth month.

2.6 Ethical issues: We obtained written, informed consent from all patients. This study was conducted in accordance with the Declaration of Helsinki, and was approved by the local ethics committee.

2.7 Statistical analysis: The descriptive statistics are presented as means with standard deviations, medians with interquartile ranges, or frequencies with percentages. The distribution of data was assessed using the Kolmogorov-Smirnov test. Because our data were not normally distributed, we used the non-parametric Mann-Whitney U test for the analysis of independent quantitative data and Wilcoxon test for the dependent quantitative data. For the correlation analysis, we used the Spearman’s rank correlation coefficient. We used SPSS Statistics software (version 26.0; IBM Corp., Armonk, NY, USA) for the analysis.

Ninety-six RC repairs were performed during the study period. Some of these patients were excluded from the study because the tear could not be repaired (n = 5); patients were using medications for sleep (n = 7); or serial data were missing (n = 2). After the exclusion of these patients, 82 were included in the study.

3.1 Demographic features

The study population consisted of 62 (76%) female and 20 (24%) male patients, with a mean age of 67 ± 5.5 years (range = 54–78 years). The repair was performed on the dominant side in 66 (81%) patients and non-dominant side in 16 (19%) patients. A partial RC tear was present in nine (11%) patients, small tear in 13 (16%), medium tear in 42 (51%), large tear in 11 (13%), and massive tear in seven (9%) patients. No atrophy was present in 53 (65%), mild in 16 (20%), medium in eight (10%), and severe in five (6%) patients. The mean duration of symptoms was 5.9 ± 2.3 months (range = 3–12 months). The mean BMI of the patients was 28.1 ± 4.1 (range = 22.0–37.0). Table 1 summarizes the demographic characteristics of the study participants.

Table 1

Demographics of study participants
		Min-Max			Median	Mean ± sd/n-%
Age (years)		54,0	-	78,0	67,0	67,15	±	5,59
Sex	Male					20		24,4%
Sex	Female					62		75,6%
BMI		22,0	-	37,0	27,5	28,10	±	4,18
Affected Side	Dominant Arm					66		80,5%
Affected Side	Non-dominant Arm					16		19,5%
Size of the Tear	Partial					9		11,0%
	Small					13		15,9%
	Medium					42		51,2%
	Large					11		13,4%
	Massive					7		8,5%
Atrophy	No					53		64,6%
	Mild					16		19,5%
	Medium					8		9,8%
	Severe					5		6,1%
Duration of the Tear		1,0	-	12,0	6,0	5,94	±	2,34

3.2 Functional outcomes after RC repair

There were statistically significant improvements in the VAS, ASES, and CS scores after the RC repair. The post-operative scores for VAS and ASES improved, and the CS scores correlated with excellent function. Figure 1 demonstrates the preoperative and postoperative VAS, ASES, and CS scores. Table 2 summarizes the results of the Wilcoxon test for differences in the functional outcomes between pre and postoperative assessments.

Table 2

Assessment of changes in the functional outcomes of the RCR procedure pre‑ and post‑operatively
	Pre-operatively				Post-operatively			p
	Mean ± sd			Median	Mean.±sd		Median
VAS	49,88	±	7	50	16,4	4,53	15	0
ASES	72,44	±	8	72	49,89	7,45	49	0
CS	51,33	±	7	51	74,55	8,07	77	0

The postoperative VAS (p < .05) and ASES scores decreased (p ˂ .05), and CS score increased (p < .05) compared to the preoperative scores.

3.3 Psychological and mental outcomes after RC repair

There was a significant improvement in the psychological and mental health after RC repair, as assessed using the WHOQOL-BREF, BDI, and BAI scores. Physical and psychological quality of life significantly improved, and symptoms of depression and anxiety decreased after RC repair. Figure 2 demonstrates the preoperative and postoperative WHOQOL-BREF, BDI, and BAI scores.

Table 3 summarizes the results of the Wilcoxon test for differences in the psychological and mental outcomes between pre- and post-operative assessments. There was a significant increase in the WHOQOL-BREF score (p < .05) and decrease in BDI and BAI scores postoperatively (p ˂ .05).

Table 3

Assessment of changes in the psychological and mental outcomes of the RCR procedure pre‑ and post‑operatively
	Preoperative (mean)	Postoperative (mean)
WHO-Physical	46.9	75.8
WHO-Psychological	50.6	62.2
BDI	10.8	7.01
BAI	10.1	4.26

3.4 Sleep quality after the RC repair

The individual sleep quality parameters of PSQI showed significant improvement postoperatively, but there was no significant improvement in the total PSQI score. Figure 3 demonstrates the preoperative and postoperative PSQI subgroup (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, and daytime dysfunction) scores. Table 4 summarizes the results of the Wilcoxon test for differences in the sleep quality outcomes between pre- and post-operative assessments.

Table 4

Assessment of changes in the sleep quality outcomes of the RCR procedure pre‑ and post‑operatively
	Preoperative (mean)	Postoperative (mean)	p
Sleep quality	1.55	1.22	0.000
Sleep latency	1.44	1.22	0.004
Sleep duration	1.09	2.37	0.000
Habitual sleep efficiency	1.24	0.95	0.000
Sleep disturbance	0.98	0.77	0.024
Daytime dysfunction	0.60	0.30	0.000
PSQI total	6.87	6.78	0.971

Sleep quality, sleep latency, habitual sleep efficiency, sleep disturbance, and daytime dysfunction significantly decreased (p < .05), while sleep duration increased (p < .05), after the RC repair. However, the total PSQI score was not different between the pre and postoperative periods (p = .971).

3.5 Effects of demographic and surgical variables on the functional, psychological, and sleep quality outcomes after RC repair

We evaluated the effects of shoulder symptoms (atrophy, tear size, and duration of tear) and demographic variables (BMI) on the functional, psychological, and sleep quality outcomes after the RC repair.

Tear duration had a negative correlation with procedural success, as demonstrated by lower postoperative CS scores for patients with longer duration of symptoms (p = .010) (Table 5). The tear duration did not have any significant associations with other outcomes (p > .05).

Table 5

Spearman correlation coefficient analysis for duration of the tear
	Duration of the Tear
	r	p
Postop-Preop
VAS	0,038	0,733
ASES	0,128	0,250
CS	-0,284	0,010
WHO-Physical	-0,055	0,625
WHO-Psychological	0,079	0,479
BDI	-0,039	0,728
BAI	0,107	0,338
PSQI Total	-0,045	0,688
Sleep Quality	0,076	0,498
Sleep Latency	0,051	0,651
Sleep Duration	-0,098	0,379
Habitual Sleep Efficiency	-0,108	0,333
Sleep Disturbance	0,018	0,872
Daytime Dysfunction	0,067	0,550

Tear size had a strong negative correlation with procedural success, as demonstrated by lower postoperative VAS and ASES scores (p = .047 and p = .030, respectively) for patients with larger tears (wide and massive tears) (Table 6). The tear size did not have any significant associations with other outcomes (p > .05).

Table 6

Mann-whitney u test analysis results for the size of the tear
	The size of the tear												p
	¹Partial-Small				²Medium				³Large-Massive
	Mean.±sd			Med.	Mean.±sd			Med	Mean.±sd			Med
Postop-Preop
VAS	29,8	±	7.1²³	30,0	34,5	±	7,7	35,0	35,6	±	8,6	35,0	0,047
ASES	16,9	±	10.4²³	18,9	24,6	±	10,8	22,9	24,7	±	10,4	26,4	0,030
CS	19,6	±	9,3	20,0	24,3	±	8,9	24,0	25,1	±	10,0	25,0	0,177
WHO-Physical	29,5	±	6,8	29,0	29,0	±	8,9	28,0	27,8	±	9,0	27,0	0,691
WHOPsychological	11,8	±	7,7	12,0	11,2	±	6,8	10,0	12,2	±	8,8	10,0	0,816
BDI	-4,2	±	3,6	-3,5	-4,0	±	4,0	-3,0	-2,9	±	2,8	-2,0	0,438
BAI	-7,7	±	7,2	-5,5	-5,5	±	3,3	-5,0	-4,4	±	4,2	-4,0	0,212
PSQI Total	-0,5	±	1,9	-0,5	-0,1	±	2,0	0,0	0,3	±	1,6	0,5	0,391
Sleep Quality	-0,3	±	0,5	0,0	-0,4	±	0,6	0,0	-0,3	±	0,8	0,0	0,841
Sleep Latency	-0,3	±	0,6	0,0	-0,2	±	0,7	0,0	-0,1	±	0,7	0,0	0,753
Sleep Duration	1,2	±	1,0	1,0	1,3	±	0,8	1,0	1,3	±	1,0	1,5	0,932
Habitual Sleep Efficiency	-0,5	±	0,7	-1,0	-0,2	±	0,5	0,0	-0,3	±	0,6	0,0	0,082
Sleep Disturbance	-0,3	±	0,6	0,0	-0,2	±	0,9	0,0	-0,1	±	0,7	0,0	0,776
Daytime Dysfunction	-0,4	±	0,5	0,0	-0,3	±	0,6	0,0	-0,2	±	0,6	0,0	0,313

No significant associations were observed for atrophy and postoperative functional outcomes, psychological health, anxiety, depression, or sleep quality (Table 7).

Table 7

Mann-whitney u test analysis results for atrophy
	Atrophy (-)				Atrophy (+)				p
	Mean.±sd			Median	Mean ± sd			Median
Postop-Preop
VAS	-33,8	±	7,4	-35	-32,9	±	9,1	-35	0,463
ASES	-22,3	±	11	-22,2	-23,1	±	11	-22,2	0,981
CS	24,6	±	8,7	24	20,8	±	10	20	0,111
WHO-Physical	29,3	±	8,8	28	28,2	±	7,5	28	0,683
WHOPsychological	11,8	±	7,9	11	11,3	±	6,6	10	0,834
BDI	-3,66	±	3,7	-3	-4,1	±	3,6	-3	0,485
BAI	-6	±	4,5	-5	-5,59	±	5,6	-4	0,426
PSQI Total	-0,11	±	1,8	0	-0,03	±	2,2	0	0,63
Sleep Quality	-0,3	±	0,5	0	-0,38	±	0,8	0	0,906
Sleep Latency	-0,19	±	0,6	0	-0,28	±	0,7	0	0,641
Sleep Duration	1,19	±	1	1	1,45	±	0,7	2	0,222
Habitual Sleep Efficiency	-0,32	±	0,6	0	-0,24	±	0,7	0	0,583
Sleep Disturbance	-0,26	±	0,7	0	-0,14	±	0,9	0	0,367
Daytime Dysfunction	-0,23	±	0,5	0	-0,41	±	0,6	0	0,213

No significant associations were observed for BMI and postoperative functional outcomes, psychological health, anxiety, depression, or sleep quality (Table 8) (p > .05).

Table 8

Spearman correlation coefficient analysis for the BMI
	BMI
	r	p
Postop-Preop Değişim
VAS	-0,059	0,598
ASES	0,064	0,565
Constant	-0,100	0,373
WHO-Physical	0,011	0,920
WHO-Psychological	0,206	0,064
BDI	0,008	0,940
BAI	-0,123	0,272
PSQI Total	-0,067	0,551
Sleep Quality	-0,028	0,803
Sleep Latency	0,009	0,937
Sleep Duration	-0,133	0,232
Habitual Sleep Efficiency	0,057	0,614
Sleep Disturbance	-0,012	0,914
Daytime Dysfunction	-0,123	0,270

Pain is the most common complaint of patients with RC tears. Shoulder pain affects the activities of daily living, mental health, and sleep quality of patients, which in turn increase the perception of pain. The aims of this study were to investigate the frequency and severity of depression, anxiety, and sleep disturbances among patients with RC tears, evaluate the effects of RC repair on the sleep quality and mental health of the patients, and determine the factors that predict the response of neuropsychiatric symptoms and sleep disturbances to RC repair.

The VAS, ASES, and CS scores demonstrated improvement in physical and functional measures after the RC repair. The physical and psychological quality of life improved and symptoms of depression and anxiety decreased postoperatively. Various sleep quality parameters improved postoperatively, as evidenced by an increase in the PSQI subgroup scores. However, there was no significant change in the total PSQI score postoperatively. The width and duration of RC tear significantly affected the functional outcomes after RC repair, but not the psychological or sleep quality outcomes.

Depression was more common among patients in our study (40 patients; 48.7%) compared to previous studies. In a ten-year national analysis, Mollon et al. [40] reported that 12.4% of patients had depression preoperatively. The average preoperative BDI score for our patients was 10.83 (range = 0–46), correlating with moderately depressed mood, while the postoperative score was 7.00, correlating with minimally depressed mood. Depression was seen in only 21.9% of the patients after RC repair, with severe depression in 2.4%. Therefore, RC repair significantly improved depression in our patients. The BDI scores positively correlated with functional improvements. Similar to previous studies, the current study results have demonstrated that psychological factors influence symptom severity. Preoperative assessment and treatment of depression may increase the postoperative satisfaction of patients and surgical outcomes.

There was a high prevalence of anxiety preoperatively in our patients (42 patients, 51.2% for all anxiety symptoms; four patients, 4.8% for severe anxiety). The average preoperative BAI score was 10.11 (range = 0–46), correlating with mild anxiety, while the mean postoperative BAI score was 4.26, correlating with no anxiety. None of the patients had severe anxiety after the RC repair. Resolution of anxiety symptoms had a positive correlation with the functional improvement. Cho et al. reported the baseline anxiety score to be an independent and significant predictor of worse functional and health-related quality of life scores in 107 patients who underwent RC repair.[41] Our data suggest that anxiety scores could provide important information during the preoperative assessment.

However, some studies have reported conflicting results. Potter et al. reported that the prevalence of psychological distress decreased postoperatively, but anxiety did not have a negative effect on clinical outcomes.[33]

Preoperative sleep disturbance was observed in a large proportion of our patients (57 patients; 69.5%), which improved postoperatively (39 patients; 47.5%). Previous studies have reported sleep disturbance at a frequency similar to our study in patients with chronic shoulder pain. The frequency of disturbed sleep among patients with RC tears was reported as 84–89% in previous studies.[7, 11] The average PSQI scores were 6.00 preoperatively and postoperatively, correlating with a mild sleep disorder. However, the individual PSQI subgroup scores significantly improved postoperatively. Several studies have reported a significant improvement in sleep disturbance after shoulder arthroplasty[13, 42], which is similar to our results. Because sleep disturbance is present in 30% of the general population,[43] it is possible that other conditions may have contributed to the sleep disturbance seen in our patients, which may explain a lack of improvement after RC repair.

The width and duration of RC tears predicted a poor functional outcome. None of the other variables related to the shoulder pathology or demographics had any significant associations with surgical outcomes. Weinberg et al. reported that BMI predicts poor surgical and sleep quality outcomes in patients undergoing total shoulder arthroplasty.[13] Wylie et al.[44] and Potter et al.[33] reported that psychological factors are stronger predictors of patient-reported outcomes, as compared to tear size. Based on the results of our study, we suggest that clinicians should evaluate the various factors identified in this study to achieve better patient satisfaction and surgical outcomes, and a shorter duration of hospitalization. There were a few limitations to our study. There was no control group in this study. Therefore, we could not compare the psychosocial and sleep quality outcomes of our patients with controls. Additionally, a 6-month follow-up period is relatively short. Future studies should include more frequent patient assessments and longer follow-up duration.

As a result, in this study, shoulder pain, depression, anxiety and sleep quality improved after RC repair. The size and duration of the tear negatively affected the postoperative functional outcomes. With an increasing shift to value-based care that is measured by health quality (and often patient satisfaction), surgeons must consider the effects of psychological factors on treatment outcomes. There are complex relationships between RC tear severity, psychological disorders, and sleep disturbances, and further studies are needed to explore these relationships.

rotator cuff (RC)

body mass index (BMI)

visual analogue scale (VAS)

American Shoulder and Elbow Surgeons (ASES)

constant score (CS)

World Health Organization Quality of Life (WHOQOL-BREF)

Beck Depression Inventory (BDI)

Beck Anxiety Inventory (BAI)

Pittsburgh Sleep Quality Index (PSQI)

Acknowledgements

The authors thank Ertan for her assistance in database search and table editing.

Authors’ contributions

Fatih Karaaslan and Özgül Karaaslan. designed the model and the computational framework and analysed the data. Emre Yurdakul,Fatih Karaaslan and Mehmet Yalvaç carried out the implementation. Turan Cihan Dülgeroğlu performed the calculations. and Serhat Aydoğan wrote the manuscript withinput from all authors.

Funding

This research received no specifc grant from any funding agency in the public, commercial or not-for-proft sectors.

Availability of data and materials

All data relevant to the study are included in the article or are available as digital Content at supplementary material. Only de-identifed individual participant data is provided.

Ethics approval and consent to participate

The study was approved by the Dünyam hospital Turkey ethical approve and prospectively registered in 2020/20-A/1/2 22/01/2020. This study was conducted in accordance with the approved guidelines. All patients were informed about the purpose and procedures ofthe study and provided informed consent.

Consent for publication

Not applicable.

Competing interests

There is not any competing interest

Conflict of interest

The authors received no financial support and have no competing interest with regard to this manuscript.

Chung, S.W., et al., Quality of life after arthroscopic rotator cuff repair: evaluation using SF-36 and an analysis of affecting clinical factors. Am J Sports Med, 2012. 40(3): p. 631-9.
Mohtadi, N.G., et al., A randomized clinical trial comparing open to arthroscopic acromioplasty with mini-open rotator cuff repair for full-thickness rotator cuff tears: disease-specific quality of life outcome at an average 2-year follow-up. Am J Sports Med, 2008. 36(6): p. 1043-51.
Baysal, D., et al., Functional outcome and health-related quality of life after surgical repair of full-thickness rotator cuff tear using a mini-open technique. Am J Sports Med, 2005. 33(9): p. 1346-55.
Hultenheim Klintberg, I., J. Karlsson, and U. Svantesson, Health-related quality of life, patient satisfaction, and physical activity 8-11 years after arthroscopic subacromial decompression. J Shoulder Elbow Surg, 2011. 20(4): p. 598-608.
Vranceanu, A.M., A. Barsky, and D. Ring, Psychosocial aspects of disabling musculoskeletal pain. J Bone Joint Surg Am, 2009. 91(8): p. 2014-8.
Cho, C.H., et al., Does Rotator Cuff Repair Improve Psychologic Status and Quality of Life in Patients With Rotator Cuff Tear? Clin Orthop Relat Res, 2015. 473(11): p. 3494-500.
Cho, C.H., et al., Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance? J Shoulder Elbow Surg, 2013. 22(2): p. 222-8.
Tekeoglu, I., et al., The relationship between shoulder impingement syndrome and sleep quality. Eur Rev Med Pharmacol Sci, 2013. 17(3): p. 370-4.
Zenian, J., Sleep position and shoulder pain. Med Hypotheses, 2010. 74(4): p. 639-43.
Khazzam, M.S., et al., Sleep Quality in Patients With Rotator Cuff Disease. J Am Acad Orthop Surg, 2018. 26(6): p. 215-222.
Austin, L., et al., Sleep disturbance associated with rotator cuff tear: correction with arthroscopic rotator cuff repair. Am J Sports Med, 2015. 43(6): p. 1455-9.
Mulligan, E.P., et al., Sleep quality and nocturnal pain in patients with shoulder disorders. J Shoulder Elbow Surg, 2015. 24(9): p. 1452-7.
Weinberg, M., et al., Improvement in sleep quality after total shoulder arthroplasty. Phys Sportsmed, 2019: p. 1-5.
Badcock, L.J., et al., Chronic shoulder pain in the community: a syndrome of disability or distress? Ann Rheum Dis, 2002. 61(2): p. 128-31.
Alsaadi, S.M., et al., Prevalence of sleep disturbance in patients with low back pain. Eur Spine J, 2011. 20(5): p. 737-43.
Horneff, J.G., 3rd, et al., Long-term Correction in Sleep Disturbance Is Sustained After Arthroscopic Rotator Cuff Repair. Am J Sports Med, 2017. 45(7): p. 1670-1675.
Gumina, S., et al., Sleep quality and disturbances in patients with different-sized rotator cuff tear. Musculoskelet Surg, 2016. 100(Suppl 1): p. 33-38.
Artner, J., et al., Prevalence of sleep deprivation in patients with chronic neck and back pain: a retrospective evaluation of 1016 patients. J Pain Res, 2013. 6: p. 1-6.
Kelly, G.A., et al., The association between chronic low back pain and sleep: a systematic review. Clin J Pain, 2011. 27(2): p. 169-81.
Marin, R., T. Cyhan, and W. Miklos, Sleep disturbance in patients with chronic low back pain. Am J Phys Med Rehabil, 2006. 85(5): p. 430-5.
Murase, K., et al., Knee Pain and Low Back Pain Additively Disturb Sleep in the General Population: A Cross-Sectional Analysis of the Nagahama Study. PLoS One, 2015. 10(10): p. e0140058.
Patel, A., et al., The negative effect of carpal tunnel syndrome on sleep quality. Sleep Disord, 2014. 2014: p. 962746.
Patel, J.N., S.J. McCabe, and J. Myers, Characteristics of sleep disturbance in patients with carpal tunnel syndrome. Hand (N Y), 2012. 7(1): p. 55-8.
Shulman, B.S., et al., Sleep disturbance after fracture is related to emotional well-being rather than functional result. J Orthop Trauma, 2015. 29(3): p. e146-50.
Peters, R.M., et al., Sleep Disturbance and Upper-Extremity Disability. Arch Bone Jt Surg, 2016. 4(1): p. 35-40.
Keener, J.D., et al., A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears. J Bone Joint Surg Am, 2015. 97(2): p. 89-98.
Mall, N.A., et al., Symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables. J Bone Joint Surg Am, 2010. 92(16): p. 2623-33.
Moosmayer, S., et al., The natural history of asymptomatic rotator cuff tears: a three-year follow-up of fifty cases. J Bone Joint Surg Am, 2013. 95(14): p. 1249-55.
Curry, E.J., et al., Structural Characteristics Are Not Associated With Pain and Function in Rotator Cuff Tears: The ROW Cohort Study. Orthop J Sports Med, 2015. 3(5): p. 2325967115584596.
Dunn, W.R., et al., Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am, 2014. 96(10): p. 793-800.
Gerhart, J.I., et al., Relationships Between Sleep Quality and Pain-Related Factors for People with Chronic Low Back Pain: Tests of Reciprocal and Time of Day Effects. Ann Behav Med, 2017. 51(3): p. 365-375.
Gil, J.A., A.D. Goodman, and M.K. Mulcahey, Psychological factors affecting outcomes after elective shoulder surgery. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 2018. 26(5): p. e98-e104.
Potter, M.Q., et al., Psychological distress negatively affects self-assessment of shoulder function in patients with rotator cuff tears. Clin Orthop Relat Res, 2014. 472(12): p. 3926-32.
Crichton, N., Visual analogue scale (VAS). J Clin Nurs, 2001. 10(5): p. 706-6.
Michener, L.A., P.W. McClure, and B.J. Sennett, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. Journal of shoulder and elbow surgery, 2002. 11(6): p. 587-594.
Constant, C. and A. Murley, A clinical method of functional assessment of the shoulder. Clinical orthopaedics and related research, 1987(214): p. 160-164.
Booker, S., et al., Use of scoring systems for assessing and reporting the outcome results from shoulder surgery and arthroplasty. World journal of orthopedics, 2015. 6(2): p. 244.
Organization, W.H., The world health organization quality of life (WHOQOL)-BREF. 2004, World Health Organization.
Buysse, D.J., et al., The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry research, 1989. 28(2): p. 193-213.
Mollon, B., et al., The influence of a history of clinical depression on peri-operative outcomes in elective total shoulder arthroplasty: a ten-year national analysis. Bone Joint J, 2016. 98-b(6): p. 818-24.
Cho, C.H., et al., 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(9): p. 1160-6.
Morris, B.J., et al., Sleep disturbance and anatomic shoulder arthroplasty. Orthopedics, 2017. 40(3): p. e450-e454.
Hinz, A., et al., Sleep quality in the general population: psychometric properties of the Pittsburgh Sleep Quality Index, derived from a German community sample of 9284 people. Sleep Medicine, 2017. 30: p. 57-63.
Wylie, J.D., et al., Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears. J Bone Joint Surg Am, 2016. 98(4): p. 251-6.

No competing interests reported.

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Rotator cuff tears are associated with significant psychiatric problems

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Abstract

Figures

1. Introduction

2. Patients And Methods

3. Results

3.1 Demographic features

3.2 Functional outcomes after RC repair

3.3 Psychological and mental outcomes after RC repair

3.4 Sleep quality after the RC repair

3.5 Effects of demographic and surgical variables on the functional, psychological, and sleep quality outcomes after RC repair

4. Discussion

5. Conclusions

Abbreviations

Declarations

References

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