Editor’s Spotlight/Take 5: How Does Shame Relate to Clinical and Psychosocial Outcomes in Knee Osteoarthritis?

If you have not yet had the opportunity to dip into the selected proceedings section of this month’s Clinical Orthopaedics and Related Research®, I hope this Spotlight feature will get you to do so.

These proceedings come from the 2024 meeting of the International Consortium for Musculoskeletal Mental and Social Health (I-MESH), a CORR® affiliate. According to its founders, I-MESH “brings together clinicians and researchers with a passion for reducing the global toll of musculoskeletal disorders. United by a desire to break down the silos between those who care for people with musculoskeletal conditions, we developed I-MESH in 2020 to share knowledge and resources and develop actionable strategies to transition musculoskeletal care toward a biopsychosocial model” [7].

An inspiring mission, to be sure, and the papers are great reading. The topics they’ve covered in their last three CORR proceedings, which derived from their meetings in '21, '22, and '23, have been fascinating and unusual. Those papers covered themes we just don’t see written about very much in orthopaedic surgery. Some of my favorites studied how surgeons can better “tune in” to language cues that patients offer us about their emotional distress [1], the frequency and severity of food insecurity among the patients we treat [3], the factors that are most on patients’ minds as they recover from injury [4], and the fears that surgeons have when it comes to addressing patients’ psychosocial concerns [6]. There even was a paper on how much work-related disability orthopaedic surgeons—that’s us—might experience over the spans of our careers [8].

Likewise, the papers in this month’s I-MESH selected proceedings are diverse, engaging, and fun. Perhaps the most unusual among them were two papers that looked at emotional factors I’d never seen explored before in an orthopaedic journal: loneliness [5] and shame [10]. The latter article on shame is the topic of discussion in this Editor’s Spotlight/Take 5 feature.

Its authors—led by Bryan Yijia Tan MBBS, MRCS(Edin), MMed(Ortho), FRCS(Ortho), from Singapore—identified a modest association between patients’ increasing levels of self-reported shame and poorer scores on validated outcomes tools among people with osteoarthritis of the knee [10]. Although the magnitude of the observed association wasn’t overwhelmingly large, one can suspect that it’s underestimated (because of the nature of what they’re measuring). The fact that it was as large as it was got my attention, mainly because shame just hasn’t been very much on my mind as I've cared for patients with arthritis other than in unusual or outlier presentations, such as patients with large and visible deformities (and often not even then).

Bryan Yijia Tan MBBS, MRCS(Edin), MMed(Ortho), FRCS(Ortho)

As you’d imagine, when reading a paper on an important topic that I had essentially missed for years, all sorts of questions came to mind. And this one, in particular, has some practical treatment-related implications that can be used by any surgeon in the real world, as you might also imagine.

This is one of the main reasons I enjoy reading journals as much as I do: If we are open to the possibility that we’ve missed something, no matter how experienced we might be, we can continue to improve.

You’ll want to read this paper, even if you don’t treat patients with knee osteoarthritis. As with so many things that come up in I-MESH proceedings, it’s really less about the achy joint and more about the human heart, mind, and soul to which the achy joint is attached.

Let’s go deep together in the Take 5 interview that follows with Bryan Yijia Tan MBBS, MRCS(Edin), MMed(Ortho), FRCS(Ortho), senior author of “How Does Shame Relate to Clinical and Psychosocial Outcomes in Knee Osteoarthritis?” [10]. Read that, and then check out the rest of the 4^th I-MESH meeting papers in this issue of CORR.

Take 5 Interview with Bryan Yijia Tan MBBS, MRCS(Edin), MMed(Ortho), FRCS(Ortho), senior author of “How Does Shame Relate to Clinical and Psychosocial Outcomes in Knee Osteoarthritis?”

Seth S. Leopold MD: Congratulations on this thought-provoking study. What specifically do you think surgeons should do differently with patients in the office given the associations that you found, and what are you doing differently?

Bryan Yijia Tan MBBS, MRCS(Edin), MMed(Ortho), FRCS(Ortho): The aim of this study was primarily to raise awareness about this little-known issue of shame that patients with knee osteoarthritis often feel and how it can affect clinical outcomes. I don’t think we are at the stage of advocating for widespread screening for shame, but if surgeons were a little more aware of this issue, it would facilitate more open and constructive conversations between them and their patients.

Dr. Leopold: Let’s say we identify a patient who is struggling with this issue. Even if we can get patients in for counseling or support—which is not a sure thing, given how swamped psychologists and psychiatrists still are in the wake of COVID—getting to the root of someone’s shame presumably takes time. If a surgeon wants to help someone with knee pain by (let’s say) doing a knee replacement, how should we “sequence” the counseling and surgical intervention? Or is there a more efficient way to address this?

Dr. Tan: I think the key here is to try to identify the root of the problem so we can deliver the right solutions. Considering the many studies that have shown discordance between radiographic severity and patient-reported pain and disability levels, we need to look past the mechanical problems and mechanical solutions, since those may not achieve the results that we are looking for. Shame may be a missing part of the puzzle.

One old adage that is often quoted is that “good surgeons know how to operate, better ones know when to operate, and the best know when not to operate.” I think many senior surgeons have that “gut feeling” when the patient is not going to do well with surgery and, perhaps on a subconscious level, they recognize that there are other factors (arguably most often psychosocial) at play. Those experienced surgeons then steer patients away from surgery. Much of the research work that we are doing on psychosocial factors in musculoskeletal conditions is trying to unpack and explain what is often instinctively developed by experienced surgeons over decades of clinical practice.

Dr. Leopold: Studies like this can comment only on association, not causation. But underlying studies like this is always the sense, even if speculative, that there is a cause-effect relationship somewhere to be found. So let’s explore some possible relationships. As one reviewer suggested, the most obvious one is that shame diminishes capability, increases pain intensity, and perhaps makes other kinds of emotional distress (symptoms of anxiety or depression) worse. But there are plausible alternative explanations, like how shame might be one of several general mental health factors (including symptoms of anxiety, depression, and self-efficacy) that decrease capability and worsen pain. Or even that poorer general mental health increases shame, which then may decrease capability and increase pain intensity. Your paper seems mainly to presuppose that the most obvious relationship (of shame being the causative actor here) is the right way to think about it. We know that emotional distress is key to the expression of somatic symptoms like pain and function; how confident can we be that shame is as important a factor, and why do you think so?

Dr. Tan: Our study shows that shame only has a mild to moderate association with clinical outcomes, which is consistent with other similar studies we have been doing about psychosocial factors. What we are seeing as a general trend is that while psychosocial factors are undoubtably important, there may not be one dominant psychosocial factor at play, but rather the interaction of multiple, interrelated factors that, individually, have small to moderate associations that add up in meaningful ways. For example, there may be interactions among a patient’s sociodemographic factors that could increase that patient’s financial, social, and emotional distress (including symptoms of depression or anxiety), along with other feelings and conditions, like shame, kinesiophobia, and social isolation. These things may come together as a package deal. Psychologists, sociologists, and other experts working in this field have long acknowledged the “fuzziness” of these factors and have created many complex frameworks over the years to try to explain the various relationships, yet uncertainty remains about the “chicken or egg” question. In addition, there is a continuum for each psychosocial factor, and the point where a particular factor becomes clinically relevant can be difficult to pin down.

This is an exciting, growing field, but one with many remaining “unknowns.” So I can’t say that shame is the key factor, but I would advocate that we should consider the role of shame as part of the larger, holistic biopsychosocial profile of any patient.

Dr. Leopold: Your study was performed in Singapore, and all of the patients were Asian (though there were several Asian ethnic groups represented). Obviously, shame is a universal human emotion, but it’s equally true that culture influences how people experience and express it. How should readers outside of Asia think about your findings? How should we use them?

Dr. Tan: Shame is a universal human emotion, and it exists in every culture. Shame can be defined as an unpleasant self-conscious emotion that is often associated with negative self-evaluation; motivation to quit; and feelings of pain, exposure, distrust, powerlessness, and worthlessness. It is a complex emotion that carries considerable overlap with guilt and embarrassment, and several subtypes of shame have been described [2]. However, I do feel that quite a bit of it can be culture-specific. For example, some of our previous qualitative work [9] suggested that the shame our knee osteoarthritis patients felt often stemmed from external physical manifestations, like unusual gait patterns, slow walking speed, and the use of walking aids. In Asian countries, walking aids are often disguised as umbrellas to make it less obvious. In other cultures where the concept of shame is understood and manifested differently, using assistive devices may be more (or less) accepted.

Dr. Leopold: Orthopaedic surgeons treat many conditions, some being much more visible than others. I would say that knee osteoarthritis is sort of an intermediate condition between some very visible ones (like profound spinal deformities) and essentially invisible ones (like shoulder arthritis). Speculate a bit: Do you think it’s the visibility of a condition or other factors related to it (for example, the level of incapacity imposed by a condition) that influences the level of shame patients feel, and how might we use that to change how we think about the problem?

Dr. Tan: The visibility of a condition certainly contributes to the level of shame someone might feel as a result of their condition, but I believe that is only part of the equation. More important, I think, would be other psychosocial factors, such as one’s resilience level, the way one handles difficulties, and one’s overall perception and outlook on life. This explains how two patients with the exact same condition can perceive and react so differently.