The Effect of Body Awareness Level on Shoulder Functionality and Psychological Factors in Rotator Cuff Pathologies

Overview

Rotator cuff syndrome is a prevalent musculoskeletal condition and the most common cause of shoulder pain. It typically begins with tendonitis and may progress to partial or complete tendon rupture due to subacromial space narrowing or overuse. Its incidence increases with age and is more common in women, often resulting in significant functional loss, reduced shoulder mobility, and lower quality of life. Shoulder pain leads to limitations in daily activities and can trigger kinesiophobia, or fear of movement, further exacerbating physical and psychological impairments. In addition to physical limitations, individuals with rotator cuff syndrome often experience psychological challenges such as stress, anxiety, and depression. Psychological resilience-a factor influencing general well-being-plays a critical role in coping with chronic pain. High psychological resilience is associated with reduced pain severity, better shoulder functionality, and lower levels of kinesiophobia. Kinesiophobia, in turn, can lead to movement avoidance, muscle disuse, and further deterioration in function. Basic body awareness (BBA), defined through both experiential and movement dimensions, involves understanding how the body functions and interacts with the environment. It is shaped by multiple sensory systems including proprioception, interoception, and exteroception. Body awareness is linked to pain perception, functional movement, and health-related quality of life. Although BBA has been studied in stroke, mental health, and chronic pain, its role in shoulder rehabilitation has not been sufficiently explored. This study aims to investigate the relationship between basic body awareness, shoulder functionality, and psychological factors in individuals with rotator cuff syndrome.

Rotator cuff syndrome is one of the musculoskeletal system disorders that covers a wide area. It is the most common cause of shoulder pain. The acute process begins with tendonitis of the tendons and can lead to partial rupture, degenerative changes, and eventually complete rupture. Its etiology is multifactorial, with the narrowing of the subacromial space or excessive use of the tendon being the main mechanisms. The lifetime incidence of shoulder pain observed in the general population is reported to be 67%, occurring more frequently in women than in men. Aging or other factors may be related to intrinsic degeneration associated with tendinopathy. The frequency of occurrence increases with age, leading to significant social participation and healthcare costs. Shoulder pain and progressively increasing restriction of shoulder joint movement cause a reduction in shoulder joint positional awareness, upper extremity function, and quality of life. Losses in shoulder function affect individuals in many daily life skills, especially activities of daily living. The pain phenomenon that occurs during shoulder movements is the primary reason for these losses. Following this pain phenomenon, fear of movement or avoidance of movement may occur, leading to kinesiophobia. In individuals with rotator cuff syndrome, there are not only functional impairments but also psychological impairments. The concept of "Psychological Resilience," which is among the psychological factors, is known to affect overall well-being. Especially in cases of persistent chronic shoulder pain, thoughts such as hopelessness and stress have a significant impact on psychosocial status. Psychosocial factors are thought to be quite effective in the severity of patients' pain and restrictions in joint range of motion. The literature indicates that individuals with high musculoskeletal pain have a high prevalence of anxiety and depression, particularly in chronic pain patients, and that psychological factors should be addressed. The fear of movement and injury created by kinesiophobia is often followed by movement disorders and depression. It has been reported that individuals with high levels of kinesiophobia will avoid movement due to expecting the disease's course to worsen or for new symptoms to arise. Excessive avoidance of movement will lead to physical limitations in the individual's daily life. Consequently, a reduction in the patient's functionality will be observed. High psychological resilience has been found to be associated with lower pain severity, reduced joint limitations, and lower levels of kinesiophobia. In physiotherapy, the dual definition of basic body awareness has been made. The first is the experience of the body (experiential dimension), and the second is movements and behaviors (movement dimension). In the context of physiotherapy, another definition of body awareness is the awareness of how the body is used in terms of its function, behavior, self, and interaction with others. Various sensory systems such as proprioception, interoception, exteroception, and the vestibular system are significant in the foundation of body awareness. For body awareness, the processing of interoceptive (sensory inputs coming from within the body) and exteroceptive (processing of inputs coming from outside the body) senses is necessary. Individuals' body awareness is related to movement capacity in daily life activities, health-related quality of life, body image, and pain severity findings. While chronic basic body awareness has been studied in conditions like mental health, stroke, and chronic musculoskeletal problems, there are no studies examining basic body awareness in shoulder rehabilitation. Considering that psychological factors also affect the etiology of shoulder pain, our study aims to investigate the effect of basic body awareness level on shoulder functionality and psychological factors.