Patients With Functional Somatic Syndromes—Fibromyalgia, Irritable Bowel Syndrome, Chronic Headaches, and Chronic Low Back Pain—Have Lower Outcomes and Higher Opioid Usage and Cost After Shoulder and Elbow Surgery
To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and patient-reported outcome measures (PROMs), postoperative opioid consumption, and hospitalization costs after shoulder and elbow surgery.
Methods
A systematic review of the PubMed and Web of Science databases was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies evaluating the effect of having at least 1 FSS (fibromyalgia, irritable bowel syndrome, chronic headaches, chronic low back pain) on outcomes after shoulder and elbow surgeries. Outcomes of interest included postoperative analgesic use, PROMs, and hospitalization costs.
Results
The review identified a total of 320 studies, of which 8 studies met the inclusion criteria. The total number of participants in our 8 included studies was 57,389. Three studies (n = 620) reported PROMs. These studies demonstrated that the presence of at least 1 FSS is predictive of significantly greater pain scores and lower quality of recovery, Disability Arm Shoulder and Hand, American Shoulder and Elbow Surgeons Shoulder Score, and Single Assessment Numeric Evaluation scores postoperatively. Although scores were inferior in among patients with FSS, 2 of the 3 studies showed improvement in PROMs in this group of patients. Seven studies (n = 56,909) reported postoperative opioid use. Of these, 5 reported that a diagnosis of at least 1 FSS was a strong risk factor for long-term opioid use after surgery. One study (n = 480) found that time-driven activity-based costs were significantly greater in patients with FSSs.
Conclusions
Patients with functional somatic syndromes have less-favorable PROMs postoperatively, consume more opioids postoperatively, and have greater health care costs after elective shoulder and elbow procedures. Although PROMs among patients with FSSs are inferior compared with those without FSSs, PROMs still improved compared with baseline.
Level of Evidence
Level III, systematic review of Level II-III studies.
described functional somatic syndromes (FSSs) as “several related syndromes that are characterized more by symptoms, suffering, and disability than by disease specific, demonstrable abnormalities of structure or function.” These conditions involve chronic pain and include fibromyalgia (FM), chronic fatigue syndrome, chronic whiplash, interstitial cystitis, tension headaches, irritable bowel syndrome (IBS), and others.
Although the pathophysiology of FSSs is unclear, patients with FSSs have worse health outcomes, greater health care costs, less satisfaction, and greater reported pain than those without FSSs.
Fibromyalgia as a predictor of increased postoperative complications, readmission rates, and hospital costs in patients undergoing posterior lumbar spine fusion.
In addition, patients with chronic fatigue syndrome, an FSS, have a worse functional status and well-being compared with patients with other conditions such as congestive heart failure and multiple sclerosis.
The relationship between FSSs and outcomes after shoulder and elbow surgery has not been systematically reviewed and is currently unclear. Increasing evidence suggests patients with FM and low back pain report less satisfaction, worse outcomes, and increased opioid use following knee and hip arthroplasty procedures.
However, these previous studies examined the association between 1 FSS condition and postoperative outcomes versus considering FSSs as a cluster of conditions. Patients with different FSS conditions have similar symptoms and prognosis, so many have reasoned that these conditions should be clustered together and viewed on a continuum of disease severity.
The purpose of this study was to perform a systematic review assessing the relationship between FSSs and patient-reported outcome measures (PROMs), postoperative opioid consumption, and hospitalization costs after shoulder and elbow surgery. Our hypothesis was patients with at least 1 of these 4 FSSs would have worse outcomes following shoulder and elbow surgery.
Methods
This study includes a systematic review of literature conducted according to guidelines from the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis statement.
Online databases PubMed and Web of Science were used to identify clinical studies examining the relationship between at least 1 FSS and orthopaedic clinical outcomes after shoulder/elbow surgery. The databases were queried on August 10, 2021. Two reviewers (R.M. and K.M.) independently completed the search of the literature published through August 2021 that examined the relationship between at least 1 FSS and orthopaedic clinical outcome after shoulder and elbow–related surgeries. The inclusion and exclusion criteria were determined a priori. The search terms (“functional somatic syndrome” OR “fibromyalgia” OR “irritable bowel syndrome” OR “chronic headaches” OR “chronic migraines” OR “chronic low back pain”) AND (“shoulder arthro∗” OR “elbow arthro∗” OR “rotator cuff” OR “shoulder”) were used. In conjunction, the bibliographies of relevant systematic reviews were examined for additional relevant studies. Any discrepancies pertaining to the inclusion/exclusion of a given study during the selection process were to be resolved by the senior author (M.J.S.); however, no discrepancies occurred.
Titles, abstracts, and full text were screened for inclusion. Studies were included if they reported on outcomes of patients with pretreatment diagnosis of at least 1 of 4 well-recognized FSSs undergoing shoulder or elbow surgery. FM, IBS, chronic headaches, and chronic low back pain were chosen as the 4 FSSs, given the substantial literature on these specific conditions. Studies were excluded if they were not written in the English language and/or if they were a systematic review.
Evaluation of risk of bias was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. The MINORS criteria are a validated tool that contains 12 items, each scored from 0 to 2.
Two reviewers (R.M. and K.M.) independently abstracted data into a Microsoft Excel 2021 spreadsheet (Microsoft, Redmond, WA). Data pertaining to patient demographics (age, sample size, sex, etc.), type of procedure, follow-up, loss to follow-up, pre- and post-operative PROMs, postoperative analgesic use, and hospitalization costs were recorded. If mean age was not reported, study authors were contacted and mean age was included if the study authors replied within 2 weeks.
Results
Study Identification
The search identified a total of 320 studies, of which 6 studies met the inclusion criteria. Two additional studies were identified through citation searching, resulting in a total of 8 studies that met the inclusion criteria. A Preferred Reporting Items for Systematic Review and Meta-Analysis flow diagram is shown in Figure 1.
Fig 1The PRISMA flow diagram depicts the methodology of identifying the studies (n = 8) used in the review. (FSS, functional somatic syndrome; PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analysis.)
The included studies had a mean MINORS score of 18.1 of 24 for comparative studies. Seven studies were conducted in the United States, and 1 was conducted in Spain. Sample sizes ranged from 40 to 35,155 subjects, with all but 1 study having a sample size of at least 100 subjects. Two studies were Level II evidence, and the other 6 studies were Level III evidence. A summary of study characteristics is presented in Table 1.
Any type of shoulder arthroscopy, including rotator cuff repairs, subacromial decompressions, labral repairs, stabilizations, debridements, and biceps tenodesis
FM using survey scores
24 patients had a moderate FMSS and 68 had low and very low FMSS
Preoperatively greater FMSS associated w/ higher depressive and anxiety symptoms
POD 2 opioid consumption; POD 2 pain (brief pain inventory, widespread pain using Michigan Body Map, neuropathic pain using painDETECT); POD 2 physical functioning (PROMIS); POD 2 QoR-9 score; POD 14 opioid consumption; POD 14 pain
ACR, American College of Rheumatology; ASES, American Shoulder and Elbow Surgeons; CS, Constant score; DASH, Disability Arm Shoulder and Hand; FM, fibromyalgia; FMSS, fibromyalgia survey score; FSS, functional somatic syndrome; N/A, not available; POD, postoperative day; PROMIS, Patient-Reported Outcomes Measurement Information System; rCS, relative constant score; SANE, Single Assessment Numeric Evaluation; TDABC, time-driven activity-based costs; TSA, total shoulder arthroplasty; VAS, visual analog scale.
All 8 studies assessed FM, 3 assessed chronic low back pain, 2 assessed chronic headaches/migraines, and 1 assessed IBS. Determination of FM was made using medical records (5), American College of Rheumatology criteria (1), and survey scores (1), whereas low back pain, chronic headaches, and IBS determination was made using medical records only. Seven studies reviewed outcomes after shoulder procedures (3 shoulder arthroplasty, 3 arthroscopic, 1 arthroscopic or open) whereas 1 reviewed outcomes after elbow arthroscopy. In total, 10,626 patients had FM, 19 had IBS, 19,263 had chronic back pain, and 145 had chronic headaches/migraines. Using the 4 papers that reported mean age, we found that the weighted mean age of patients was 68.6 years. In total, 48.6% (n = 27,906) of subjects were female. The mean time to follow-up was 15.2 months.
Outcomes
Preoperative PROMs
Three studies (n = 620) reported preoperative PROMs among patients with FSSs after total shoulder arthroplasty, shoulder arthroscopy, and steroid injections/opioids/pregabalin/nonsteroidal anti-inflammatory drugs treatment (Table 2).
found that preoperative American Shoulder and Elbow Surgeons Shoulder Score (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores were not significantly different between patients with at least 1 FSS and patients without an FSS.
demonstrated that patients with a greater Fibromyalgia Survey Score (FMSS) had significantly lower physical functioning and Quality of Recovery 9 (QoR-9) scores. Lastly, Lopiz et al.
showed mixed results with respect to PROMs. Patients with FM had significantly greater Disability Arm Shoulder and Hand (DASH) questionnaire scores preoperatively compared with patients without FM but did not have significantly different VAS, mean Constant, or relative Constant scores.
NOTE. Data are given as means and represent the statistical difference between an FSS-group and control group. The results of Cheng et al. are stratified by Fibromyalgia Survey Score: very low, low, and moderate.
ASES, American Shoulder and Elbow Surgeons; CS, Constant Score; DASH; Disabilities of the Arm, Shoulder, and Hand; FSS, functional somatic syndrome; N/A, not available; PF, Physical Functioning; PROMIS, Patient-Reported Outcomes Measurement Information System; PROMs, patient-reported outcome measures; QOR-9, Quality of Recovery 9; rCS, Relative Constant Score; SANE, Single Assessment Numeric Evaluation; VAS, visual analog scale.
Three studies (n = 620) reported postoperative PROMs (Table 3) among patients with FSSs after total shoulder arthroplasty, shoulder arthroscopy, steroid injections/opioids/pregabalin/nonsteroidal anti-inflammatory drugs treatment.
the only study that included all 4 FSSs, demonstrated that the presence of at least 1 FSS was independently predictive of lower ASES, SANE, and pain scores 2 years after shoulder arthroplasty, with an increasing number of FSS associated with a stepwise increase in pain and decrease in functional outcomes. One study looked at postoperative physical functioning and QoR-9 suggested that physical functioning is lower among patients undergoing shoulder arthroscopy with moderate FMSS compared with those with very low FMSS, and that FMSS is independently predictive of lower QoR-9.
demonstrated significantly greater postoperative DASH scores (P = .009) and significantly lower postoperative satisfaction (P = .03) among patients with FM undergoing isolated arthroscopic subacromial decompression compared with control patients.
NOTE. Data are given as means and represent the statistical difference between an FSS group and control group.
The results of Cheng et al. are stratified by FM Survey Score: very low, low, and moderate.
ASES, American Shoulder and Elbow Surgeons; CS, Constant Score; DASH; Disabilities of the Arm, Shoulder, and Hand; FSS, functional somatic syndrome; N/A, not available; PF, Physical Functioning; PROMIS, Patient-Reported Outcomes Measurement Information System; PROMs, patient-reported outcome measures; QOR-9, Quality of Recovery 9; rCS, Relative Constant Score; SANE, Single Assessment Numeric Evaluation; VAS, visual analog scale.
showed PROMIS, Patient-Reported Outcomes Measurement Information System–Physical Functioning and QOR-9 decreased among patients with moderate, low, and very low FMSS at 2 days postoperatively. Lopiz et al.
Seven studies (n = 56,909) reported postoperative opioid use at various time points. Of these, 5 reported that a diagnosis of at least 1 FSS was a strong risk factor for long-term opioid use among patients undergoing shoulder stabilization surgery, shoulder arthroplasty, elbow arthroscopy, and arthroscopic rotator cuff repair.
One study (n = 480) looked at hospitalization costs and found that time-driven activity-based costs were significantly greater in patients with FSSs undergoing shoulder arthroplasty, with a stepwise rise in costs with an increasing number of disorders (P < .001).
The most important findings of this systematic review are patients with FSSs have more intense and long-lasting pain after shoulder and elbow procedures, as well as less-favorable PROMs.
Fibromyalgia as a predictor of increased postoperative complications, readmission rates, and hospital costs in patients undergoing posterior lumbar spine fusion.
Although the contribution of physiologic, psychological, and environmental factors to risk of developing FSSs is unclear, patients with FSSs have similar clusters of symptoms, case definitions, and prognosis.
In one study that looked at FSS collectively and postoperative outcomes, a diagnosis of more than one of these disorders leads to worse postoperative outcomes in a stepwise manner.
Similarly, the literature has demonstrated that having additional somatic symptoms is associated with worse outcomes after knee and hip arthroplasty, increased health care use, and functional impairment.
This finding is consistent with previous literature, which found that having at least 1 FSS is associated with less pain improvement and prolonged postoperative opioid use.
Prolonged opioid use after primary total knee and total hip arthroplasty: Prospective evaluation of risk factors and psychological profile for depression, pain catastrophizing, and aberrant drug-related behavior.
Preoperative opioid usage, male sex, and preexisting knee osteoarthritis impacts opioid refills after isolated arthroscopic meniscectomy: A population-based study.
In light of the growing body of evidence demonstrating an association between FSSs and prolonged opioid use, orthopaedic surgeons can minimize the risk of misusing opioids through exploring alternative analgesics, discussing ways to minimize pain postsurgery with patients, and monitoring opioid use in these patients.
In our systematic review, one study also suggests patients with FSSs have greater hospitalization costs than patients without FSSs, with a stepwise increase in costs with each additional FSS.
Studies in other specialties also demonstrate that patients with FSSs have increased health care expenditures. For example, patients with FM have increased primary care costs compared with patients without FM.
In addition, patients with IBS are more likely to undergo cholecystectomy and colon resection even if these procedures are not effective in treating their IBS.
Thus, we should investigate ways to mitigate these increased expenditures.
Across many types of orthopaedic surgeries, such as hip arthroplasty and lumbar arthrodesis, there is considerable literature suggesting patients with FSSs report worse pain postoperatively.
Prolonged opioid use after primary total knee and total hip arthroplasty: Prospective evaluation of risk factors and psychological profile for depression, pain catastrophizing, and aberrant drug-related behavior.
Freshman R, Oeding JF, Anigwe C, et al. Pre-existing mental health diagnoses are associated with higher rates of postoperative complications, readmissions, and reoperations following arthroscopic rotator cuff repair [published online August 23, 2022]. Arthroscopy. doi: 10.1016/j.arthro.2022.06.040.
Even after controlling for anxiety and depression, pain catastrophizing, “a set of negative emotional and cognitive processes” is associated with increased reported pain experienced among patients with FM.
Thus, although there is a psychological component to FSS presentation, there are likely biological aspects as well that are still unclear.
Although our systematic review demonstrated patients with at least 1 FSS have worse postoperative PROMs, it is important to note patients with FSSs also generally had worse PROMs preoperatively. For example, Lopiz et al.
showed patients with FSSs have significantly greater DASH scores preoperatively and significantly lower scores postoperatively. However, scores improved among both groups after undergoing surgery. Interestingly, Moverman et al.
showed that although there was no significant difference between patients with and without FSSs preoperatively with respect to ASES, SANE, and VAS scores, these scores were significantly worse in patients with FSSs postoperatively at 2 years, although still improved compared with preoperatively. Although Cheng et al.
did not show an improvement in PROMs among either group of patients, this could be due to the short follow-up time of 2 days.
Addressing FSSs preoperatively may result in improved postoperative outcomes. Since studies have shown patients who score greater on the pain catastrophizing scale have worse outcomes after arthroscopic procedures, perhaps this scale can be used to screen for at-risk patients.
This approach includes recommending a healthy lifestyle, encouraging positive thinking, prescribing antidepressant medications, and referring to mental health specialists depending on FSS severity.
Another review recommended treating FSSs with a multicomponent approach comprising maintaining good communication between patient and physician, more general interventions, and more specific interventions.
Experts’ opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials.
Examples of more general interventions are regularly scheduled office visits and motivational interviewing, and examples of more specific interventions are prescribing antidepressant medications and cognitive behavioral therapy.
Experts’ opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials.
Efforts to manage biopsychosocial determinants preoperatively, via multimodal approaches, may improve postoperative outcomes and these interventions should be evaluated in future studies.
Limitations
We recognize the limitations to our review. For example, most studies included in this review were of low quality according to the MINORS criteria. In addition, many of the included studies had a retrospective study design, so misclassification bias could have occurred. Another limitation is the included studies were heterogenous. Further, not all the included studies controlled for potential confounders. In addition, we chose to include 4 well-recognized FSSs in our review and did not include other FSSs, such as interstitial cystitis. Another limitation is most subjects are from 4 of the 8 included studies. Finally, although we used 2 online databases to systematically identify records, it is possible that studies that met our inclusion criteria were missed.
Conclusions
Patients with FSSs have less favorable PROMs postoperatively, consume more opioids postoperatively, and have greater health care costs after elective shoulder and elbow procedures. Although PROMs among patients with FSSs are inferior compared with those without FSSs, PROMs still improve compared with baseline.
Fibromyalgia as a predictor of increased postoperative complications, readmission rates, and hospital costs in patients undergoing posterior lumbar spine fusion.
Prolonged opioid use after primary total knee and total hip arthroplasty: Prospective evaluation of risk factors and psychological profile for depression, pain catastrophizing, and aberrant drug-related behavior.
Preoperative opioid usage, male sex, and preexisting knee osteoarthritis impacts opioid refills after isolated arthroscopic meniscectomy: A population-based study.
Freshman R, Oeding JF, Anigwe C, et al. Pre-existing mental health diagnoses are associated with higher rates of postoperative complications, readmissions, and reoperations following arthroscopic rotator cuff repair [published online August 23, 2022]. Arthroscopy. doi: 10.1016/j.arthro.2022.06.040.
Experts’ opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials.
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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