Avoidance behavior after proximal humerus fracture: implications for rehabilitation and a clinically relevant cutoff for the Avoidance of Daily Activities Photo Scale (ADAP Shoulder Scale).

Abstract

Avoidance behavior contributes to disability after proximal humerus fracture (PHF), yet its psychosocial determinants and clinical identification remain unclear. This study examined biopsychosocial correlates of avoidance and developed a clinically relevant cutoff for the Avoidance of Daily Activities Photo Scale (ADAP Shoulder Scale). In this cross-sectional study, 105 adults with PHF completed measures of avoidance (ADAP Shoulder Scale), shoulder disability (SPADI), kinesiophobia (TSK-17), pain-related self-efficacy (PSEQ-10), resilience (Connor-Davidson Resilience Scale, CD-RISC-25), depressive symptoms (Patient Health Questionnaire, PHQ-9), and catastrophizing (PCS). Multiple regression and receiver operating characteristic (ROC) analyses were performed. Avoidance (mean ADAP = 58.0) was most strongly associated with lower pain-related self-efficacy (<i>β</i> = -0.46, <i>p</i> < 0.001). Additional associations included female sex (<i>β</i> = 0.22, <i>p</i> = 0.008), shorter time since injury (<i>β</i> = -0.29, <i>p</i> = 0.001), and greater social support (<i>β</i> = 0.17, <i>p</i> = 0.049). The ADAP showed good discrimination of disability (AUC = 0.86). A cutoff score ≥61 may indicate relevant avoidance. Avoidance behavior, a significant contributor to disability after PHF, is strongly associated with lower pain-related self-efficacy. The ADAP cutoff may help clinicians identify patients with relevant avoidance, enabling early, targeted interventions to enhance confidence and engagement in rehabilitation.