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 Table of Contents  
Year : 2018  |  Volume : 32  |  Issue : 2  |  Page : 76-80

Assessment and correlation of perceived harmfulness with psychological variables in patients with chronic shoulder pain

School of Physiotherapy, D. Y. Patil University, Nerul, Navi Mumbai, Maharashtra, India

Date of Web Publication31-Aug-2018

Correspondence Address:
Dr. Tejashree Ajit Dabholkar
School of Physiotherapy, D. Y. Patil University, Nerul, Navi Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_5_18

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Background: Chronic pain can provoke emotional reactions, such as fear or even terror, depending on what we believe about the pain signals. Chronic pain can be difficult to treat, affecting the patients psychologically causing fear avoidance in them. Patients with chronic condition often suffer catastrophizing pain and perceived harmfulness. Thus, assessing perceived harmfulness in chronic shoulder pain is utmost important. Methods: Patients (N = 48) with chronic shoulder pain (duration more than 3 months) were enrolled for the study. They were administered Photograph series of daily activities-upper extremity (PHODA-UE-110), Tampa scale of kinesiophobia (TSK-11), Pain catastrophizing scale (PCS-4), Shoulder pain and disability index (SPADI). Their responses were statistically analyzed using Pearson's co-efficient. Results: The mean scores of the outcome studied were, PHODA-UE scores were 42 ± 8.43, 95% CI [40.41, 45.32], TSK scores were 28.77 ± 3.70, 95% CI [27.69, 29.84], PCS scores were 8.39 ± 2.54, 95% CI [7.65, 9.13], SPADI (Pain) scores were 81 ± 9.5, 95% CI [78.22, 13.32] and SPADI (Disability) scores were 79 ± 13.32, 95% CI [75.12, 82.87]. Following correlations were found to be significant: PHODA-UE with TSK (r = −0.32, p = 0.02, 95% CI [−0.56, −0.04]), PHODA-UE with PCS (r = −0.49, p = <0.0003, 95% CI [−0.68, 0.24]), TSK with SPADI (Disability) (r = −0.41, p = 0.003, 95% CI [−0.62, 0.15]) and TSK with PCS (r = +0.40, p = 0.004, 95% CI [0.13, 0.61]). Conclusions: The present study reveals that the patients evaluated demonstrated low perceived harmfulness in spite of the chronic pain. Correlations between perceived harmfulness and psychological variables showed weak correlations.

Keywords: Chronic, kinesiophobia, perceived harmfulness, shoulder pain

How to cite this article:
Dabholkar AS, Shah IK, Dabholkar TA. Assessment and correlation of perceived harmfulness with psychological variables in patients with chronic shoulder pain. Indian J Pain 2018;32:76-80

How to cite this URL:
Dabholkar AS, Shah IK, Dabholkar TA. Assessment and correlation of perceived harmfulness with psychological variables in patients with chronic shoulder pain. Indian J Pain [serial online] 2018 [cited 2020 Apr 2];32:76-80. Available from: http://www.indianjpain.org/text.asp?2018/32/2/76/240289

  Introduction Top

Numerous studies suggest that pain-related fear is one of the strongest predictors of pain disability in patients with chronic musculoskeletal pain.[1]

The increasing evidences prove that pain-related fear influences the development and maintenance of pain disability, poorer performance, and disability in performing activities of daily living (ADL).[2] This disability then leads to more chronic conditions often lowering the conditioning levels of the patients. The patients with chronic conditions often have catastrophizing pain and perceived harmfulness. Pain-related fear is also associated with perceived harmfulness of activities, signifying the degree to which performing various activities is believed to be harmful.[3] Compromised shoulder movements because of pain, stiffness, or weakness can cause actual disability and affect a person's ability to carry out daily activities and work. Physical factors such as lifting heavy loads, repetitive movements in awkward positions, and vibrations influence the level of symptoms and disability.[4]

It is necessary to understand the psychological factors influencing chronic pain for better and faster recovery. Therefore, the study aimed at assessing perceived harmfulness and its association with various psychological variables.

  Materials and Methods Top

This cross-sectional study comprised the patients with chronic shoulder pain (N = 48). The protocol of the study was approved by the institutional ethics committee.

Before administration of the scales, the consent for voluntary participation was obtained from the patients.

  Patient Selection Criteria Top

Inclusion criteria: The patients with pain on numerical rating scale, that is, 3 or more, were recruited for the study. The duration of shoulder pain should be more than 3 months (chronic) [Table 1].
Table 1: Demographic profile

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Exclusion criteria: The patients having pain for less than 3 months, undergone any shoulder surgeries, with neck pain radiating to shoulder, or any other musculoskeletal pathology were excluded from the study. Demographic data and brief medical history were recorded to scrutinize for the inclusion and exclusion criteria. Permission to use the PHODA-UE scale (photograph series of daily activities–upper extremity) was obtained from the author, Sir Jeroen R de Jong.

PHODA-UE, Tampa Scale of Kinesiophobia (TSK),[5] Pain Catastrophizing Scale (PCS),[6] and Shoulder Pain and Disability Index (SPADI) were the outcome measures assessed in chronic shoulder pain patients.

PHODA-UE[7] scale comprises 110 images. The patients were asked to rate each image on the scale of 0–100. Then, the total sum of all the scores was calculated and divided by 110. The final score thus obtained showed the level of perceived harmfulness in the patients. This score is interpreted as higher the score, higher the harm perceived by them.

Tampa Scale of Kinesiophobia (TSK),[5] Pain Catastrophizing Scale (PCS),[6] and Shoulder Pain and Disability Index (SPADI)[8] were also administered to each subject.

TSK (11 items) assesses kinesiophobia in the patients. PCS (4 items) assesses the catastrophizing pain felt by the patients. SPADI assesses the pain and disability experienced by the patients. PHODA-UE scale was correlated with the other scales such as TSK, PCS, and SPADI. Statistical analysis was carried out using Statistical Package for the Social Science (SPSS) Software (IBM Corp. in Armonk, NY, Chicago), version 16.0. To correlate PHODA-UE with other parameters such as TSK, PCS, and SPADI and to intercorrelate with each other, Pearson's correlation was measured. Significant correlation conceded the test criteria of P value less than 0.05.

  Results and Analysis Top

The assessed outcome parameters of this study are as follows: the mean scores of PHODA-UE was 42 (standard deviation [SD] = 8.43), TSK was 28.77 (SD = 3.70), PCS was 8.39 (SD = 2.54), SPADI (pain) was 81 (SD = 9.5), and SPADI (disability) was 79 (SD = 13.32) [Table 2]. The correlation between PHODA-UE and TSK showed significant negative weak correlation (r = –0.32, P = 0.02), signifying the reduction in the activities carried out by the patients because of higher kinesiophobia. The correlation between PHODA-UE and PCS showed extremely significant negative weak correlation (r = –0.49, P = <0.0003), signifying the reduction in the patient's ADLs owing to catastrophization of pain. The correlation between TSK and SPADI (disability) showed very significant negative weak correlation (r = –0.41, P = 0.003), signifying the reduction in the patients' ADLs because of greater kinesiophobia. The correlation between TSK and PCS showed very significant positive correlation (r = +0.40, P = 0.004), signifying that as the pain catastrophizes more, it will cause more kinesiophobia in the patients [Table 3]. It was observed that 62.73% of the images of PHODA-UE scores were in the range of 40–50. This implies that most of the patients with chronic shoulder pain were having low perceived harmfulness, and only 10.91% had a range of 50–60 indicating high perceived harmfulness [Table 4].
Table 2: Mean scores of PHODA-UE, TSK, PCS, SPADI (pain), and SPADI (disability)

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Table 3: Correlation between PHODA-UE scale and other psychological scales

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Table 4: Percentage of PHODA-UE images in following range

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  Discussion Top

Pain is one of the most powerful aversive drives, which is closely associated with fear. The fear of pain is an important aspect in the patients' disability, which needs to be addressed to achieve a positive outcome.[9]

In our study, we found that the mean score of PHODA-UE was 42 ± 8.43 [Table 2].

According to [Table 4], it was found that 62.73% of the images showed PHODA-UE scores in the range between 40 and 50. This shows that the patients with chronic shoulder pain had low perceived harmfulness.

In our study, the patients with chronic shoulder pain were undergoing regular physiotherapy sessions. This implies that exercise can influence perceived harmfulness and fear. It is also evident from the study that the SPADI scores were higher. This can imply that the patients were not functionally affected because of regular physiotherapy. This exercise regime may have also influenced their psychological variables such as fear and augmentation of pain.

It is also evident from the studies that the reduction in movement-related fear and anxiety predicts improvements in functioning, reduced affective distress, pain, and interference with daily activity.[10],[11],[12]

The patients receiving physiotherapy treatment may also have good coping strategies and acceptance to the pain. This may have caused low perceived harmfulness and low fear in our patients.

Various studies put forward the message that greater acceptance of chronic pain is associated with better emotional, physical, and social functioning, less health care and medication use, and better work status.[13]

Low levels of pain-related fear and pain catastrophizing are associated with a confrontation behavioral response, which is believed to be a precursor to resuming normal activities.[14],[15],[16]

Exercise therapy is frequently encountered as a central component in the treatment of patients with chronic musculoskeletal pain. Exercise is an effective treatment for various chronic musculoskeletal pain disorders.[17]

Interventions such as supervised or individualized exercise therapy and self-management improve self-efficacy, which is one of the main predictors of treatment outcome for the patients with chronic musculoskeletal pain.[18]

In our study, according to [Table 3] and [Graph 1],[Graph 2],[Graph 3],[Graph 4], the weak correlations in our study suggested that as pain catastrophizing increases, kinesiophobia will increase, leading to reduction in functioning, causing disability in the patients with shoulder pain.

In summary, this study shows the low perceived harmfulness and weak correlations among the psychological variables studied. This study needs to be replicated in a larger sample.

Exercise is an important approach to limit perceived harmfulness and pain-related fear. This can contribute in better coping and better functional outcomes.

PHODA-UE scale assesses perceived harmfulness, which can lead to fear of movement in the patients with chronic pain. It is suggested that perceived harmfulness requires to be evaluated as various treatment strategies need to be implemented to decrease the patients' fear and improve functioning through coping strategies, neuroeducation, and graded exposure for better therapeutic outcomes.

It is recommended that good-quality trials should be performed on how providing information and education can reduce pain-related fear-avoidance beliefs and improve coping in the prevention of chronic pain. However, understanding of the relationship between beliefs about pain, movement, pain-related fear and avoidance, and behavior is needed.

  Conclusion Top

We conclude that the patients with chronic shoulder pain evaluated and showed low perceived harmfulness. In addition, a weak correlation was obtained on statistical analysis between PHODA-UE scale and other scales such as TSK, PCS, and SPADI. It can be further concluded that low perceived harmfulness can be attributed to exercise sessions that the patients were undergoing. The patients with chronic shoulder pain were following routine physiotherapy sessions and hence were having less disability, and therefore scored low on perceived harmfulness. This study supports the idea that perceived harmfulness can be influenced by exercise, and thus deserves more research attention.


We express our gratitude to Sir Jeroen R de Jong who gave us the permission to use the PHODA-UE scale for this research study. We also extend our thanks to our statistician Mr. Pratap Jadhav for his expert guidance in the statistical part of this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

de Jong JR, Vlaeyen JW, de Gelder JM, Patijn J. Pain-related fear, perceived harmfulness of activities, and functional limitations in complex regional pain syndrome type I. J Pain 2011;12:1209-18.  Back to cited text no. 1
de Jong JR, Vlaeyen JW, van Eijsden M, Loo C, Onghena P. Reduction of pain-related fear and increased function and participation in work-related upper extremity pain (WRUEP): effects of exposure in vivo. Pain 2012;153:2109-18.  Back to cited text no. 2
Leeuw M, Goossens ME, van Breukelen GJ, Boersma K, Vlaeyen JW. Measuring perceived harmfulness of physical activities in patients with chronic low back pain: the photograph series of daily activities–short electronic version. J Pain 2007;8:840-9.  Back to cited text no. 3
Mitchell C, Adebajo A, Hay E, Carr A. Shoulder pain: diagnosis and management in primary care. BMJ 2005;331:1124-8.  Back to cited text no. 4
Woby Steve R, Roach Neil K, Urmston M, Watson Paul J. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain 2005;117:137-44.  Back to cited text no. 5
McWilliams LA, Kowal J, Wilson KG. Development and evaluation of short forms of the pain catastrophizing scale and the pain self-efficacy questionnaire. Eur J Pain 2015;19:1342-9.  Back to cited text no. 6
Dubbers AT, Vikstrom MH, De Jong JR. The photograph series of daily activities (PHODA-UE): cervical spine and shoulder. CD-ROM version 1.2: Hogeschool Zuyd. Maastricht, The Netherlands: University Maastricht and Institute for Rehabilitation Research (iRv); 2003.  Back to cited text no. 7
Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res 1991;4:143-9.  Back to cited text no. 8
Chung EJ, Hur YG, Lee BH. A study of the relationship among fear-avoidance beliefs, pain and disability index in patients with low back pain. J Exerc Rehabil 2013;9:532-5.  Back to cited text no. 9
Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Psychol 2002;70:678-90.  Back to cited text no. 10
Wideman TH, Sullivan MJ. Differential predictors of the long-term levels of pain intensity, work disability, healthcare use, and medication use in a sample of workers’ compensation claimants. Pain 2011;152:376-83.  Back to cited text no. 11
Crombez G, Eccleston C, Van Damme S, Vlaeyen JW, Karoly P. Fear-avoidance model of chronic pain: the next generation. Clin J Pain 2012;28:475-83.  Back to cited text no. 12
McCracken LM, Eccleston C. A prospective study of acceptance of pain and patient functioning with chronic pain. Pain 2005;118: 164-9.  Back to cited text no. 13
Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007;30:77-94.  Back to cited text no. 14
Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85:317-32.  Back to cited text no. 15
Lethem J, Slade PD, Troup JD, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception–I. Behav Res Ther 1983;21:401-8.  Back to cited text no. 16
van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol 2010;24:193-204.  Back to cited text no. 17
Miles CL, Pincus T, Carnes D, Homer KE, Taylor SJ, Bremner SA, et al. Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs. Eur J Pain 2011;15:775.e1-11.  Back to cited text no. 18


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


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