Restricted accessResearch articleFirst published online 2025
Association between pain intensity,range of motion,disability,and mental health-related quality of life variables in frozen shoulder: A cross-sectional study
No studies have highlighted the impact of mental health-related quality of life, disability, range of motion (ROM), and pain in patients with frozen shoulder. The aim of this study was to analyze the association between such variables during the first physiotherapy consultation.
Methods
This cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Participants were recruited between January and October 2024. Each participant anonymously filled out the Shoulder Pain and Disability Index-pain subscore (dependent variable). The Disabilities of the Arm, Shoulder, and Hand questionnaire, the 36-Item Short Form Health Survey, measurement for flexion (FL), abduction, and external rotation ROM (independent variables) were further collected. Statistical analysis was performed using multivariable linear regression-modeling all independent variables simultaneously and adjusting for confounding factors.
Results
Were included 149 subjects (53% female). Significant association was found between pain and disability (standardized coefficient = 13.65, 95%CI 10.38 to 16.92, p < 0.01), and between pain and FL (standardized coefficient = −3.95 95%CI −7.43 to −0.47, p = 0.03).
Discussion
Pain resulted as primary determinant of disability. A significant association between pain and FL was also observed, with FL being the most sensitive movement to pain. While pain limits physical function, its psychological impact, assessed through such outcome measures used, may not yet be evident.
LewisJ. Frozen shoulder contracture syndrome - aetiology, diagnosis and management. Man Ther2015; 20: 2–9.
2.
MillarNLMeakinsAStruyfF, et al.Frozen shoulder. Nat Revs Dis Primers2022; 8: 59.
3.
DyerBPRathod-MistryTBurtonC, et al.Diabetes as a risk factor for the onset of frozen shoulder: a systematic review and meta-analysis. BMJ Open2023; 13: e062377.
4.
AbudulaXMaimaitiPYashengA, et al.Factors associated with frozen shoulder in adults: a retrospective study. BMC Musculoskelet Disord2024; 25: 493.
5.
BrindisinoFTurgutEStruyfF. Frozen shoulder: exploration of terminology and classification. Front Rehabil Sci2024; 5: 1498263.
6.
KraalTLübbersJvan den BekeromMPJ, et al.The puzzling pathophysiology of frozen shoulders – a scoping review. J Exp Orthop2020; 7: 91.
7.
ChoCHSongKSKimBS, et al.Biological aspect of pathophysiology for frozen shoulder. Biomed Res Int2018; 2018: 7274517.
8.
ChalloumasDBiddleMMcLeanM, et al.Comparison of treatments for frozen shoulder: a systematic review and meta-analysis. JAMA Netw Open2020; 3: e2029581.
9.
CucchiDDi GiacomoGCompagnoniR, et al.A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: the SIAGASCOT consensus. Knee Surg Sports Traumatol Arthrosc2024; 32: 37–46.
LinHWTamKWLiouTH, et al.Efficacy of platelet-rich plasma injection on range of motion, pain, and disability in patients with adhesive capsulitis: a systematic review and meta-analysis. Arch Phys Med Rehabil2023; 104: 2109–2122.
12.
BernerJENicolaidesMAliS, et al.Pharmacological interventions for early-stage frozen shoulder: a systematic review and network meta-analysis. Rheumatology (Oxford)2024; 63: 3221–3233.
13.
BrindisinoFGirardiGCrestaniM, et al.Effectiveness of electrophysical agents in subjects with frozen shoulder: a systematic review and meta-analysis. Disabil Rehabil2024; 46: 3513–3534.
14.
LyneSAGoldblattFMShanahanEM. Living with a frozen shoulder – a phenomenological inquiry. BMC Musculoskelet Disord2022; 23: 318.
15.
Balasch-BernatMDueñasLAguilar-RodríguezM, et al.The spatial extent of pain is associated with pain intensity, catastrophizing and some measures of central sensitization in people with frozen shoulder. J Clin Med2022; 11: 154.
16.
BrindisinoFSciscioneSAndriesseA, et al.Frozen shoulder: subjects’ needs and perspectives and clinicians’ beliefs and management strategies: do they align? A cross-sectional study. BMC Musculoskelet Disord2024; 25: 745.
17.
RajaSNCarrDBCohenM, et al.The revised international association for the study of pain definition of pain: concepts, challenges, and compromises. Pain2020; 161: 1976–1982.
18.
NijsJGoubertDIckmansK. Recognition and treatment of central sensitization in chronic pain patients: not limited to specialized care. J Orthop Sports Phys Ther2016; 46: 1024–1028.
19.
NijsJTorres-CuecoRvan WilgenCP, et al.Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician2014; 17: 447–457.
20.
DarioABKamperSJO'KeeffeM, et al.Family history of pain and risk of musculoskeletal pain in children and adolescents: a systematic review and meta-analysis. Pain2019; 160: 2430–2439.
21.
Luque-SuarezAMartinez-CalderonJFallaD. Role of kinesiophobia on pain, disability and quality of life in people suffering from chronic musculoskeletal pain: a systematic review. Brit J Sports Med2019; 53: 554–559.
22.
Martinez-CalderonJZamora-CamposCNavarro-LedesmaS, et al.The role of self-efficacy on the prognosis of chronic musculoskeletal pain: a systematic review. J Pain2018; 19: 10–34.
23.
Martinez-CalderonJFlores-CortesMMorales-AsencioJM, et al.Pain-related fear, pain intensity and function in individuals with chronic musculoskeletal pain: a systematic review and meta-analysis. J Pain2019; 20: 1394–1415.
24.
RiskowskiJL. Associations of socioeconomic position and pain prevalence in the United States: findings from the National Health and Nutrition Examination Survey. Pain Med2014; 15: 1508–1521.
25.
KingWVHebronC. Frozen shoulder: living with uncertainty and being in “no-man's land”. Physiother Theory Pract2023; 39: 979–993.
26.
HirataJTomiyamaMKoikeY, et al.Relationship between pain intensity, pain catastrophizing, and self-efficacy in patients with frozen shoulder: a cross-sectional study. J Orthop Surg Res2021; 16: 542–554.
27.
BrindisinoFSilvestriEGalloC, et al.Depression and anxiety are associated with worse subjective and functional baseline scores in patients with frozen shoulder contracture syndrome: a systematic review. Arthrosc Sports Med Rehabil2022; 4: e1219–e1234.
28.
CrestaniMCookCLeuciC, et al. “I Cannot Recognize My Body": experiences and perceptions of patients living with frozen shoulder: a qualitative systematic review with meta-synthesis and meta-summary. J Orthop Sports Phys Ther2025; 55: 1–16.
29.
MertensMGStruyfFVerborgtO, et al.Exploration of the clinical course and longitudinal correlations in frozen shoulder: the role of autonomic function, central pain processing, and psychological variables. A longitudinal multicenter prospective observational study. Musculoskelet Sci Pract2023; 67: 102857.
30.
PoserABrindisinoFLotS, et al.Is disability associated with range of motion, pain and mental health-related quality of life in subjects with frozen shoulder? A cross-sectional study. Physiother Theory Pract2025; 9: 1–12.
31.
BrindisinoFMinnucciSSergiG, et al.Does the psychological profile of a patient with frozen shoulder predict future outcome? A systematic review. Physiother Res Int2024; 29: e2056.
32.
BrindisinoFGirardiGPulinaF, et al.Prognostic factors for upper limb and shoulder-specific disability and quality of life in participants suffering from frozen shoulder. A multicentric prospective single-cohort study. Musculoskelet Sci Pract2025; 80: 103417.
33.
von ElmEAltmanDGEggerM, et al.The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg2014; 12: 1495–1499.
34.
World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA2013; 310: 2191–2194.
35.
KelleyMJShafferMAKuhnJE, et al.Shoulder pain and mobility deficits: adhesive capsulitis. J Orthop Sports Phys Ther2013; 43: A1–A31.
36.
SchumaierAAbboudJGraweB, et al.Evaluating glenohumeral osteoarthritis: the relative impact of patient age, activity level, symptoms, and Kellgren-Lawrence grade on treatment. Arch Bone Jt Surg2019; 7: 151–160.
37.
WainnerRSFritzJMIrrgangJJ, et al.Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine2003; 28: 52–62.
38.
VenturinDGiannottaGPellicciariL, et al.Reliability and validity of the Shoulder Pain and Disability Index in a sample of patients with frozen shoulder. BMC Musculoskelet Disord2023; 24: 212.
39.
BrindisinoFVenturinDBartoliM, et al.Psychometric properties of the Disability of Arm Shoulder and Hand (DASH) in subjects with frozen shoulder: a reliability and validity study. BMC Musculoskelet Disord2024; 25: 260.
40.
ApoloneGMosconiP. The Italian SF-36 health survey: translation, validation and norming. J Clin Epidemiol1998; 51: 1025–1036.
41.
RoachKEBudiman-MakESongsiridejN, et al.Development of a shoulder pain and disability index. Arthritis Care Res1991; 4: 143–149.
42.
HudakPLAmadioPCBombardierC. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med1996; 29: 602–608.
43.
RoyJSMacDermidJCWoodhouseLJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum2009; 61: 623–632.
44.
PaduaRPaduaLCeccarelliE, et al.Italian version of the disability of the arm, shoulder and hand (DASH) questionnaire. Cross-cultural adaptation and validation. J Hand Surg Br2003; 28: 179–186.
45.
McHorneyCAWareJEJrLuJF, et al.The MOS 36-item short-form health survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care1994; 32: 40–66.
46.
HobartJFreemanJLampingD, et al.The SF-36 in multiple sclerosis: why basic assumptions must be tested. J Neurol Neurosurg Psychiatry2001; 71: 363–370.
47.
HarrellF. Ordinal logistic regression. In: Regression modeling strategies. Series in Statistics. New York, USA: Springer, 2015, pp.311–325.
48.
BrindisinoFGarzonioFTurollaA, et al.Perspectives, perceptions, and expectations of subjects with frozen shoulder: a web-based Italian survey. Arch Physiother2024; 14: 116–130.
49.
MertensMMeeusMNotenS, et al.Understanding the clinical profile of patients with frozen shoulder: a longitudinal multicentre observational study. BMJ Open2022; 12: e056563.
50.
JonesSHanchardNHamiltonS, et al.A qualitative study of patients’ perceptions and priorities when living with primary frozen shoulder. BMJ Open2013; 3: e003452.
51.
ItoiEArceGBainGI, et al.Shoulder stiffness: current concepts and concerns. Arthroscopy2016; 32: 1402–1414.
52.
JainTKSharmaNK. The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: a systematic review. J Back Musculoskelet Rehabil2014; 27: 247–273.
53.
RyanVBrownHMinns LoweCJ, et al.The pathophysiology associated with primary (idiopathic) frozen shoulder: a systematic review. BMC Musculoskelet Disord2016; 17: 340.
54.
SuhCHYunSJJinW, et al.Systematic review and meta-analysis of magnetic resonance imaging features for diagnosis of adhesive capsulitis of the shoulder. Eur Radiol2019; 29: 566–577.
55.
de la SernaDNavarro-LedesmaSAlayónF, et al.A comprehensive view of frozen shoulder: a mystery syndrome. Front Med (Lausanne)2021; 8: 663703.
56.
De BaetsLMatheveTDierickxC, et al.Are clinical outcomes of frozen shoulder linked to pain, structural factors or pain-related cognitions? An explorative cohort study. Musculoskelet Sci Pract2020; 50: 102270.
57.
BagheriFEbrahimzadehMHMoradiA, et al.Factors associated with pain, disability and quality of life in patients suffering from frozen shoulder. Arch Bone Jt Surg2016; 4: 243–247.
58.
BrindisinoFRizzoVDejacoB, et al.Association between pain, stiffness, mood, catastrophizing, and perceived social support, in subjects with frozen shoulder: a cross-sectional study. Shoulder Elbow2025; 11: 17585732251338652.
59.
VangsgaardGKMKrogsgaardMRHansenCF. A systematic review of patient-reported outcome measures for idiopathic adhesive capsulitis - recommendations based on analyses of 16 existing questionnaires. BMC Musculoskelet Disord2025; 26: 452.
