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Scoring Systems for the Functional Assessment of the Shoulder
Abstract
A number of instruments have been developed to measure the quality of life in patients with various conditions of the shoulder. Older instruments appear to have been developed at a time when little information was available on the appropriate methodology for instrument development. Much progress has been made in this area, and currently an appropriate instrument exists for each of the main conditions of the shoulder. Investigators planning clinical trials should select modern instruments that have been developed with appropriate patient input for item generation and reduction, and established validity and reliability. Among the other factors discussed in this review, responsiveness of an instrument is an important consideration as it can serve to minimize the sample size for a proposed study. The shoulder instruments reviewed include the Rating Sheet for Bankart Repair (Rowe), ASES Shoulder Evaluation Form, UCLA Shoulder Score, The Constant Score, Disabilities of the Arm, Shoulder and Hand (DASH), the Shoulder Rating Questionnaire, the Simple Shoulder Test (SST), the Western Ontario Osteoarthritis of the Shoulder Index (WOOS), the Western Ontario Rotator Cuff Index (WORC), the Western Ontario Shoulder Instability Index (WOSI), Rotator Cuff Quality of Life (RC-QOL), and the Oxford Shoulder Scores (OSS).
... Patient-reported outcome measures (proms), such as the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST) have been validated to assess shoulder function in patients, pre-and postoperatively. The ASES questionnaire is composed of a series of ten questions, asking patients to indicate the ease with which they can perform everyday tasks, such as putting on a coat or combing one's hair [2]. The questionnaire also assesses the patient's ability to perform strenuous tasks, such as their ability to lift ten pounds over their shoulder [2]. ...
... The ASES questionnaire is composed of a series of ten questions, asking patients to indicate the ease with which they can perform everyday tasks, such as putting on a coat or combing one's hair [2]. The questionnaire also assesses the patient's ability to perform strenuous tasks, such as their ability to lift ten pounds over their shoulder [2]. In contrast, the SST also provides physicians with a validated shoulder outcome score that assesses the ability to perform tasks, such as tossing a softball with their afflicted shoulder [2]. ...
... The questionnaire also assesses the patient's ability to perform strenuous tasks, such as their ability to lift ten pounds over their shoulder [2]. In contrast, the SST also provides physicians with a validated shoulder outcome score that assesses the ability to perform tasks, such as tossing a softball with their afflicted shoulder [2]. Studies have shown that SST scores can distinguish patients with pathological conditions of the shoulder from those who do not [2]. ...
... The American Shoulder and Elbow Surgeons Value Committee has recommended it as a outcomes tool that should be used for all patients with shoulder pathology. 29 The Western Ontario disease-specific shoulder scores were developed by Kirkley et al. 30 using similar methodologies including item reduction and validation using multiple 100-mm visual analog scales anchored by both ends by the extremes of the items being measured. In 2003, the WORC was developed as a tool to measure quality of life in patients with rotator cuff disease and includes 21 questions divided into 5 domains. ...
... In 2003, the WORC was developed as a tool to measure quality of life in patients with rotator cuff disease and includes 21 questions divided into 5 domains. 4,30 The WORC has been shown to be reliable and valid. 30 When examining responsiveness, the minimal clinically important difference of the WORC was 245.26, suggesting that an 11.7% change in the total score will demonstrate an important difference. ...
... 4,30 The WORC has been shown to be reliable and valid. 30 When examining responsiveness, the minimal clinically important difference of the WORC was 245.26, suggesting that an 11.7% change in the total score will demonstrate an important difference. 28,30 The ease of scoring has been considered only moderate, with 10 to 15 minutes required to complete the questionnaire. ...
Purpose
To compare the correlation, responsiveness, and responder and administrator burdens of the American Shoulder and Elbow Score (ASES) with the Western Ontario Rotator Cuff Index (WORC) for patients undergoing arthroscopic rotator cuff repair to determine whether one score is superior to the other to limit the use of multiple scoring measures when tracking patient outcomes.
Methods
A retrospective review of a database of patients undergoing arthroscopic rotator cuff repair was reviewed where the ASES was simultaneously recorded with the WORC. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative outcome and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean and the effect size of both scores. Responder and administrator burden was examined using 50 consecutively scored WORC and ASES scores by determining the number of questions accurately answered and the length of time taken to score each questionnaire.
Results
Correlation was excellent for the ASES and WORC (r = 0.90). The correlation of preoperative scores was strong-moderate (r = 0.69), and the correlation of postoperative scores was excellent (r = 0.86). The standardized response mean WORC = 2.3; ASES = 2.2) and the effect size (WORC = 2.9; ASES = 2.8) demonstrated comparable responsiveness. In total, 71.5% of the WORC questions were able to be scored compared with 93.3% for the ASES (P < .0001). The mean time to score the WORC was significantly greater than the ASES (154 vs 23 seconds; P < .0001).
Conclusions
There is excellent correlation and comparable responsiveness between the ASES and WORC. Since there is greater responder and administrative burden for the WORC score, the authors recommend using the ASES over the WORC in patients undergoing rotator cuff repair.
Level of Evidence
Level IV, diagnostic series.
... The literature search (Table 1) [11][12][13][14][15] was conducted on PubMed/Medline (PubMed Central is a free full-text archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health's National Library of Medicine), Scopus (Scopus is Elsevier's abstract and citation database that was launched in 2004), PEDro (PEDro has been informing physiotherapy practice for over 23 years. It is a free database of over 56,000 trials, reviews and guidelines evaluating physiotherapy interventions), and the Cochrane databases (The Cochrane Database of Systematic Reviews (CDSR) is the leading journal and database for systematic reviews in health care) using the keywords "shoulder impingement" AND "low level laser therapy". ...
... It has one item for each domain. Pain accounts for 10 points, function for 10 points, forward flexion for 5 points, strength for 5 points, and general satisfaction for 5 points; the total score is 35 points [11]. ...
Background: Conservative therapy is currently the elective treatment for shoulder impingement syndrome according to the scientific literature. The success of conservative therapy is due to physiotherapy and the application of its methods. The aim of this systematic review was to evaluate low-level laser therapy, a physiotherapeutic method for pain reduction and increasing the range of motion. Methods: This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The screening of the literature was carried out on the Cochrane, PEDro, PubMed/Medline, and Scopus databases up until December 2021. All studies were randomized controlled trials (RCTs), and five articles met the inclusion criteria and were included in this study. The risk of bias was evaluated with PEDro and Jadad scales. Results: In this study, we reviewed five RCTs that compared low-level laser therapy with other physiotherapy treatments to reduce pain and improve range of motion in patients with shoulder impingement syndrome. Conclusions: Low-level laser therapy for shoulder impingement syndrome requires further investigation in future studies.
... Patient functional clinical outcomes were evaluated pre and postoperatively (6 month follow-up) using the Western Ontario Rotator Cuff Index (WORC) [28], the Oxford Shoulder Score (OSS) [29] and the Constant score [30]. These were all obtained in-person by the same experienced practice nurse and entered into a dedicated software package for score calculation and database storage (Socrates v 3.5, Ortholink, Aus). ...
... These were all obtained in-person by the same experienced practice nurse and entered into a dedicated software package for score calculation and database storage (Socrates v 3.5, Ortholink, Aus). The WORC and Constant scores were normalised within the database software (% of normal) for age and gender as per published recommendations [28,30]. ...
... The Western Ontario Shoulder Instability Index (WOSI), developed by Kirkley et al. in 1998, contains 21 items grouped in four domains concerning the symptoms of instability, everyday functioning and quality of life. The WOSI contains instruction for users clarifying every item [3,7]. High validity and reliability of the WOSI was demonstrated, with better responsiveness than other shoulder measurement tools-the Disabilities of the Arm, Shoulder and Hand tool (DASH), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), UCLA Shoulder Rating Scale, Constant Score, Rowe Rating Scale and a global health instrument-the SF12 [3]. ...
... Total score is in the range between 0 and 2100, with higher scores reflecting extreme limitations in shoulder-related quality of life. Additionally, the score can be expressed as a percentage of normal shoulder function, a score of 2100 corresponding to 0% of normal function and a score of 0 corresponding to 100% [3,7] This self-administered questionnaire is intended to evaluate disability of the upper extremity. It consists of 11 questions: three related to symptoms and eight questions assessing the effects of upper limb problems reflected by limitations at work, in activities of daily living and in social activity. ...
Apart from imaging and physical examination for shoulder instability (SI), medical history with patient feedback should be considered to assess the patient’s condition and recovery. The aim of this study was to evaluate psychometric properties of the Polish version of Western Ontario Shoulder Instability Index (WOSI)—one of the most frequently used patient-reported outcome measures for SI. During examination 1, 74 patients after arthroscopic repair for SI (age x¯ = 30.01 ± 8.98) were tested. Examinations 2 and 3 involved 71 and 51 patients, respectively. They completed the Polish version of the WOSI, the shortened version of the Disabilities of Arm, Shoulder and Hand Questionnaire (QuickDASH), the Short Form-36 version 2.0 (SF-36 v. 2.0) and 7-point Global Rating Change scale (GRC). The WOSI-PL demonstrated high internal consistency (Cronbach’s alpha for total = 0.94), and test–retest reliability (Total ICC2,1 = 0.99). High construct validity was found (89%) as the a priori hypotheses were confirmed. All domains and total scores of WOSI-PL showed a moderate to strong degree of responsiveness (ES = 0.37–0.44; SMR = 0.87–1.26). Minimal clinically important difference (MCID) for the Total WOSI-PL was 126.43 points/6% (95%CI 67.83–185.03) by the anchor-based method and 174.05 points/8% (95%CI 138.61–233.98) by the distribution-based method. The Polish version of the WOSI can be considered a reliable, valid and responsive PROM. It is recommended for assessing the quality of life in patients after arthroscopic repair for SI and can be applied in research and in the clinical setting for monitoring treatment and facilitating patient-centred therapeutic decisions.
... 11 At this time, few recommendations about which of these various scores are appropriate to use to evaluate shoulder-and especially ACJ-pathologies exist; thus, their inclusion in the current literature is limited. However, the European Shoulder and Elbow Society has recommended since 1992 that researchers include the CMS in all shoulder-specific peer-reviewed articles, 14 and as a result, the CMS has been most widely used in the literature, with an observer reliability of 3% (range, 0%-8%). 4 In 2017, however, Charles et al 2 raised questions regarding the applicability of the global CMS to ACJ-specific interventions. ...
... Notably, however, the findings of this study contradict the 1992 stated paradigm of the need to include the CMS in all peer-reviewed shoulderrelated studies. 13,14 The presented data of this study showed a strong correlation between the global examinerspecific objective CMS and the validated ACJ-specific and strictly subjective PROM NCS. ...
Background
Various clinical outcome scores have been described to evaluate postoperative shoulder function after operatively treated acromioclavicular joint (ACJ) instability. Clinical outcome scores can be divided between patient-reported outcome measures (PROMs) and examiner-dependent outcome measures (EDOMs) after a clinical examination by a physician. The correlation between PROMs and EDOMs, and thus their interchangeability with regard to operatively treated ACJ instability, has not yet been evaluated.
Purpose
To investigate whether PROMs are a reasonable substitute for EDOMs. Correlations between global shoulder (GS) and ACJ-specific outcome measures were also investigated.
Study Design
Cohort study (diagnosis); Level of evidence, 3.
Methods
Included in this study were 131 consecutive patients with operatively treated ACJ instability between 2011 and 2017. Postoperative shoulder function was measured using PROMs, including the Subjective Shoulder Value (SSV), Subjective Shoulder Test, and Nottingham Clavicle Score (NCS), and EDOMs, including the Constant-Murley score (CMS), Taft score, ACJ instability (ACJI) score, and SICK Scapula Score (SSS). Associations between PROM and EDOM scores were calculated using the Pearson and Spearman correlation coefficients for linear and nonlinear variables, respectively, and were interpreted using the Cohen classification. The scores were further stratified into GS versus ACJ-specific measures.
Results
A strong correlation was observed between several PROMs and EDOMs (CMS vs SSV [ r = 0.59; P = .02] and CMS vs NCS [ r = 0.79; P ≤ .001]) and between several GS and ACJ-specific scores (CMS vs NCS; CMS vs ACJI [ rs = 0.69; P < .001]; and CMS vs SSS [ r = –0.68; P < .001]).
Conclusion
Based on the results of this study, PROMs such as the SSV (a GS measure) and the NCS (an ACJ-specific measure) can substitute for EDOMs.
Clinical Relevance
PROMs that can be substituted for EDOMs can enable the conduct of clinical studies in circumstances in which in-person clinical follow-up of the patient by a physician is not possible.
... The MCID of WORC has been shown to be 245.26 mm [42]. ...
Introduction
Rotator cuff tendinopathy is a common shoulder disorder in which the primary treatment is resistance exercises. Isometric exercises are being studied for lower limb tendinopathies but not for rotator cuff tendinopathy. This protocol for a randomized clinical trial aims to compare the effects of two types of exercise (isometric and isotonic) on shoulder pain, functioning, muscle strength, and electromyographic activity in individuals with rotator cuff tendinopathy.
Methods
Forty-six individuals (18 to 60 years old) with shoulder pain for more than three months and unilateral supraspinatus and/or infraspinatus tendinopathy will participate in this trial. Individuals will be randomized into two exercise groups: isometric or isotonic. The following outcomes will be evaluated before and after the first session and after six weeks of intervention: shoulder pain and functioning; isometric strength of shoulder elevation and lateral and medial rotation; and electromyographic activity of medial deltoid, infraspinatus, serratus anterior, and lower trapezius. Groups will perform stretching and strengthening of periscapular muscles. The isometric group will perform three sets of 32 s, at 70% of maximal isometric strength. The isotonic group will perform concentric and eccentric exercises (2 s for each phase) in three sets of eight repetitions at a load of eight repetition maximum. The total time under tension of 96 s will be equal for both groups, and load will be adjusted in weeks three and five of the protocol. Treatment effect between groups will be analyzed using linear mixed model.
Trial registration
Trial registration number: Universal Trial Number (UTN) code U1111-1284-7528 and Brazilian Clinical Trials Registry platform–RBR-3pvdvfk.
... 12,13 Internal rotation motion is required for several daily tasks, notably bathing, toileting, and getting dressed. 14,15 However, most patient-reported outcome measures (PROM) assess activities with flexion, abduction, and external rotation motions. 15 This bias toward these activities can lead to "good" outcomes despite poorly performed internal rotation activities. ...
Background
The Functional Internal Rotation Scale is an excellent clinical tool for evaluating patients with shoulder arthroplasty, but it has not been adapted to the Thai version. The objectives of this study were to translate the English version and culturally adapt the Functional Internal Rotation Scale to the Thai version and to examine the psychometric properties of the Thai Functional Internal Rotation Scale among Thai participants having shoulder arthroplasty.
Methods
The Functional Internal Rotation Scale was translated to Thai, including cross-cultural adaptations, following standard guidelines. Psychometric properties were evaluated with shoulder arthroplasty patients. Content validity was evaluated using the content validity index (CVI). Criterion validity was assessed using the Pearson correlation coefficient. An Independent t-test was used to evaluate construct validity. Internal consistency reliability was assessed using Cronbach's alpha coefficient. Intraclass correlation coefficient (ICC) was used to determine test-retest reliability over a 14-day interval.
Results
Of 45 participants, 20 total shoulder arthroplasty (TSA) patients and 25 reverse shoulder arthroplasty (RSA) patients, the majority of participants were female (69%) and retired (91%) with a mean age of 72.9 years (SD 9.1). CVI evaluation was acceptable, with a total CVI of 0.92. The correlation of the Thai Functional Internal Rotation Scale with the Thai version of the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (Thai ASES) and the internal rotation subscale (IR subscale) of the Thai ASES was 0.73 (P < 0.001) and 0.75 (P < 0.001), respectively. For construct validity, TSA patients scored, on average, 10.8 points higher than RSA patients (43.7 vs. 32.9, P < 0.001, 95% confidence interval 6.3–15.3). Cronbach's alpha coefficient of the Thai Functional Internal Rotation Scale was 0.95. The test-retest reliability revealed excellent reliability (ICC 0.99).
Conclusion
The Thai Functional Internal Rotation Scale has good validity and excellent reliability in assessing internal rotation function in Thai shoulder arthroplasty patients.
... Due to difficulty performing free-pain movements, they often develop compensatory scapular movements to maintain a physiologic range of motion [60]. The quantitative evaluation of scapular kinematics with wearable M-IMUs in clinical scenarios represents a valid solution that complements subjective assessments using clinical scales [61][62][63][64]. ...
Monitoring shoulder kinematics, including the scapular segment, is of great relevance in the orthopaedic field. Among wearable systems, magneto-inertial measurement units (M-IMUs) represent a valid alternative for applications in unstructured environments. The aim of this systematic literature review is to report and describe the existing methods to estimate 3D scapular movements through wearable systems integrating M-IMUs. A comprehensive search of PubMed, IEEE Xplore, and Web of Science was performed, and results were included up to May 2023. A total of 14 articles was included. The results showed high heterogeneity among studies regarding calibration procedures, tasks executed, and the population. Two different techniques were described, i.e., with the x-axis aligned with the cranial edge of the scapular spine or positioned on the flat surface of the acromion with the x-axis perpendicular to the scapular spine. Sensor placement affected the scapular motion and, also, the kinematic output. Further studies should be conducted to establish a universal protocol that reduces the variability among studies. Establishing a protocol that can be carried out without difficulty or pain by patients with shoulder musculoskeletal disorders could be of great clinical relevance for patients and clinicians to monitor 3D scapular kinematics in unstructured settings or during common clinical practice.
... Similarly, in terms of ULCA shoulder score, our findings showed that the arthroscopic repair elevated it by about 11 points, with a postoperative mean score of 32.9, indicating better shoulder function. Nonetheless, compared to other outcome measures, the reliability, validity, and responsiveness of the UCLA shoulder score are not well-established [38]. The UCLA shoulder scoring system may be beneficial for some conditions, such as rotator cuff disease or shoulder instability. ...
This study aimed to evaluate the clinical outcomes and the frequency of return to sport after the arthroscopic repair of a humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion. Web of Science, Scopus, and Medline via PubMed and OVID were searched to identify the relevant citations. Screening and data extraction were performed independently. The Comprehensive Meta-Analysis software was used for all statistical analyses (CMA; USA version 3.3.070). A total of 18 articles (n = 832 patients; of whom, 379 patients had HAGL) were included. The fixed-effect estimate showed that the percentage of patients who returned to their sports was 89.1% (95% CI = 85% to 92.2%). The mean duration to return was estimated to be 6.65 months (95% CI = 5.10 to 8.20). Postoperatively, the mean Western Ontario Shoulder Instability Index (WOSI), Oxford Shoulder Instability Score (OSIS), and Subjective Shoulder Value (SSV) scores were 88.60 (95% CI = 86.18 to 90.98), 15.02 (95% CI = 7.42 to 22.63), and 86.90 (95% CI = 80.79 to 93.00), respectively. The Rowe score improved significantly postoperatively with a mean difference (MD) of 54.47 (95% CI = 39.28 to 69.66). The University of California - Los Angeles (UCLA) shoulder score increased significantly post-arthroscopic repair (MD = 10.91, 95% CI = 10.07 to 11.76). The current evidence suggests that arthroscopic repair of HAGL lesions is associated with a high percentage of return to sports and improved Rowe score, WOSI, UCLA shoulder score, OSIS scale, and SSV score. The quality of the included studies is moderate; however, these findings are promising and call for further multicenter, prospective studies.
... The systematic review of Huang of the psychometric properties of PROMs for use in patients with RC disease the WORC index was found to have the best overall quality of psychometric properties such as internal consistency, reliability, content validity, hypothesis testing and responsiveness among all shoulder outcome measures 10 . The WORC index is a disease specific shoulder questionnaire, developed at the University of Western Ontario to measure the health quality of life in patients with RC disease [11][12][13][14] . It is a self-reported questionnaire consisting of 21 visual scales (VAS) items in 5 domains. ...
Patient-reported outcome measures (PROMs) are essential clinical instruments used for assessing patient function and assisting in clinical decision making. The Western Ontario Rotator Cuff (WORC) index is the PROM for shoulder pathology with the most psychometric properties but is very time consuming. The Single Assessment Numeric Evaluation (SANE) method is a PROM that takes less time to answer and to analyze. The aim of the study is to evaluate the intra- class correlation between these two outcome scores in establishing shoulder function in patients with non-traumatic rotator cuff pathologies. Fifty five subjects of both genders and different ages presenting with non-traumatic shoulder pain for more than 12 weeks had a physical examination and ultrasound as well as MRI arthrogram scan findings that were consistent of a non-traumatic rotator cuff (RC) based pathology. On the same moment a WORC index and a SANE score questionnaire were filled in by the subject. The intra class correlation of both PROMs was statistically analyzed. The WORC index score and the SANE score show a moderate correlation with an Intra Class Coefficient (ICC) of r = 0.60 (95% CI:0.40-0.75). This study demonstrates a moderate correlation between the WORC index score and the SANE score in rating the disability of patients with atraumatic RC disease. The SANE score is applicable in research and clinical practice and is for the patient and the researcher an almost no time consuming PROM.
... Among the multiple sources of chronic pain [8], shoulder pain is one of the most frequent reasons for referral to health professionals. Clinicians use multiple tools to assess a patient with shoulder pain [9]. ...
Background:
The Constant-Murley Score (CMS) is a relatively unique shoulder assessment tool because it combines patient-reported outcomes (pain and activity), performance measurement and clinician-reported outcomes (strength and mobility). With these characteristics, the effect of patient-related psychological factors on the CMS remains debated. We aimed to investigate which parameters of the CMS are influenced by psychological factors by assessing the CMS before and after rehabilitation for chronic shoulder pain.
Methods:
This retrospective study screened all patients (18-65 years old) who were admitted for interdisciplinary rehabilitation for chronic shoulder pain (≥ 3 months) between May 2012 and December 2017. Patients with unilateral shoulder injuries were eligible. Exclusion criteria were shoulder instability, concomitant neurological injuries, complex regional pain syndrome (including Steinbrocker syndrome), heavy psychiatric issues, and missing data. The Hospital Anxiety and Depression Scale, Pain Catastrophizing scale, and Tampa Scale of Kinesiophobia were administered before and after treatment. Regression models were used to estimate associations between psychological factors and the CMS.
Results:
We included 433 patients (88% male, mean age 47±11 years) with a median duration of symptoms of 392.2 days (interquartile range: 266.5-583.5). Rotator cuff issue was present in 71% of patients. During interdisciplinary rehabilitation, patients were followed for a mean of 33.6±7.5 days. The mean CMS at entry was 42.8 ±15.5. The mean gain in CMS after treatment was 10.6 ±10.9. Before treatment, psychological factors were significantly associated with only the pain CMS parameter: -0.37 (95% CI: -0.46 to -0.28), p <0.001. After treatment, psychological factors were associated with the evolution of the four CMS parameters: -0.12 (-0.23 to -0.01) to -0.26 (95% CI: -0.36 to -0.16), p<0.05.
Conclusions:
This study raises the question of a distinct assessment of pain when assessing shoulder function with CMS in patients with chronic shoulder pain. The separation of the "pain parameter" from the overall CMS score seems illusory with this tool that is used worldwide. However, clinicians should be aware that psychological factors can negatively influence the evolution of all CMS parameters during follow-up, which argues for a biopsychosocial approach to patients with chronic shoulder pain.
... Zur Beurteilung der Schulter existieren unzählige PROMs, deren uneinheitliche Verwendung den Vergleich zwischen unterschiedlichen Studien erschwert [29]. Daher wurden "core outcome sets" (COS) definiert, welche ein vereinbartes Minimum an Outcomeparametern darstellen, die in allen Studien einer bestimmten Pathologie genutzt werden sollten [32]. ...
Zusammenfassung
In der Orthopädie und Unfallchirurgie hat die Bedeutung von PROMs („patient-reported outcome measures“) nicht nur klinisch und akademisch, sondern auch gesundheitspolitisch enorm zugenommen. Am Schultergelenk existieren zahlreiche solcher Messinstrumente, sodass für den Vergleich in Wissenschaft und Klinik eine einheitliche Verwendung geeigneter PROMs zu empfehlen ist. Ein PROM sollte wissenschaftliche Kriterien (u. a. Reliabilität, Validität, Responsiveness) erfüllen sowie in der jeweiligen Landessprache und nicht nur für die jeweilige Pathologie validiert sein. Zudem sollten Daten zur „minimal clinically important difference“ (MCID) vorliegen, um Ergebnisse nicht nur hinsichtlich ihrer statistischen Signifikanz, sondern auch der klinischen Relevanz beurteilen zu können. Ziel dieser Arbeit war es, für relevante Pathologien des Schultergelenks jeweils einen PROM zu empfehlen, der die o. g. Kriterien am besten erfüllt. Für das Schultergelenk werden dabei vom Research-Komitee der AGA unter Berücksichtigung dieser Kriterien folgende PROMs empfohlen: Constant-Murley-Score (CMS) für die Omarthrose bzw. Schulterendoprothetik, Western Ontario Stability Index (WOSI) für glenohumerale Instabilitäten und Western Ontario Rotator Cuff Index (WORCI) für Pathologien des Subakromialraums bzw. von Rotatorenmanschettenläsionen. Der Nottingham Clavicle Score (NCS) stellt ein geeignetes Instrument für die Klavikula sowie die angrenzenden Gelenke (Akromioklavikular- und Sternoklavikulargelenk) dar. Diese empfohlenen PROMs decken eine große Bandbreite an Schulterpathologien ab, sind bzgl. obiger Kriterien qualitativ hochwertig und für die deutsche Sprache validiert.
... In the assessment of disability, in turn, MarcosMartín et al. (2011) employed the CFPDI method for craniofacial assessment, and NDI for cervical spine assessment [247]. The Neck Disability Index (NDI) is a questionnaire with 10 items referring to the activities of daily living, in which patients rate their subjective experience [272][273][274]. The reliability, construct validity and responsiveness of NDI have been studied. ...
Abstract
Myofascial pain syndrome (MPS) is one of the most common ailments associated with the human musculoskeletal system, characterised by the presence of the so‑called trigger points (TrP – trigger point; MTrPs – myofascial trigger points). The International Association for the Study of Pain indicates that MPS may affect approximately one‑third of people with chronic musculoskeletal pain, and that there is a lack of appropriate classiCication which can be attributed to a misunderstanding and/or misinterpretation of the pathophysiology. Given the diverse causes of pain syndromes in myofascial structures, it is vital to properly select and integrate therapeutic methods. The scienticic literature indicates that treatment programmes should include a variety of manual therapy methods and rehabilitation exercises. Trigger point therapies, such as dry needling or dry cupping, are also widely used. At the heart of the success of rehabilitation programmes, in the opinion of the authors of this publication, is their multimodality, i.e. selection of therapeutic methods based on the cause of the pain, providing for measurable, reproducible diagnostic methods in therapy.
Aim of the study. The aim of this study is to analyse and infer conclusions on multimodal myofascial pain therapy programmes.
Material and methods.
Given the complex research problem set as the aim, the study was carried out through a literature review in terms of two criteria:
Criterion I (C I): analysis of the literature on the etiology and pathogenesis of myofascial pain (i.e. causes and triggers, symptoms, social and environmental factors determining the onset of MPS), diagnostic procedures (initial diagnosis and ongoing monitoring of treatment outcomes), and therapeutic methods used in the course of MPS.
Criterion II (C II): a literature study of research publications addressing multimodal programmes for myofascial pain therapy, with their qualitative evaluation using the
modiCied PEDro scale, and empirical testing of hypotheses based on the literature study and the analysis made in Part I.
Data sources: PubMed, SCOPUS, Science Direct, MEDLINE, PEDro, Cochrane, Embase, Web of Science Core Collection, Google Scholar electronic databases were searched systematically, restricting the languages to English and German only.
Results.
The analysis of the literature showed that the causes, symptoms and associations of myofascial pain have been described in detail. There are also numerous reports on a variety of therapeutic methods, together with a precisely described methodology for their implementation. It is not uncommon to recommend combining methods into multimodal programmes, which unfortunately does not mean that there are many such programmes or that studies on MPS are consistent. The literature study on multimodal treatment programmes for MPS revealed that there is no correlation between its pathogenesis and a purposeful selection of speciCic therapeutic methods. In a small number of cases, a complex etiopathogenesis led to the formation of multidisciplinary teams. This may be associated with the absence of strict recommendations on the diagnostic
methods applicable to the assessment of MPS.
Conclusions.
1. Multimodal programmes for the treatment of musculoskeletal pain, notably MPS and MTrPs, should include a detailed and comprehensive diagnosis (structural,
biochemical, psycho‑emotional) which should serve as the basis for the formation of interdisciplinary rehabilitation teams.
2. Musculoskeletal diagnosis, in addition to
radiological assessment, should include measurable techniques of postural and functional assessment (such as pedobarography, wearable sensors, assisted anthropometry, i.e. photogrammetry, videogrammetry, etc.), aimed primarily at the ongoing assessment of posture.
3. The choice of therapeutic methods and patient education should be based on
the causes of the patient’s pain, taking into account systemic diseases, postural defects, lifestyle and psycho‑emotional state.
4. ScientiCic research in multimodal treatment programmes should be carried out in randomised groups, with due attention to the methodologies of diagnostic and therapeutic procedures and group selection.
Keywords
chronic pain, myofascial pain, manual therapy, exercise, multimodal programmes
... The total score can be expressed as an index, i.e. percentage of the best possible health state [3]. WOSI has been evaluated by the collaborative working group for health outcome measures (consensus based standards for the selection of health measurement instruments, COSMIN) as the most reliable and valid available tool for assessing patient reported outcome in treatment of shoulder instability [5][6][7]. ...
Background
Western Ontario shoulder instability index (WOSI) is a widely used disease-specific self-assessment measurement tool for patients with shoulder instability. The main aim of this study was to translate and cross culturally adapt the WOSI into Finnish language and to test its measurement properties.
Methods
WOSI was translated in Finnish and adapted into an electronic user interface. 62 male patients with traumatic anteroinferior shoulder instability, programmed for stabilizing shoulder surgery, answered the questionnaire twice preoperatively (2 and 0 weeks), and twice postoperatively (3 and 12 months). Additional scoring tools, such as satisfaction to treatment outcome, subjective shoulder value (SSV), Oxford shoulder instability index (OSIS) and Constant score (CS), were used as comparators. The reliability, validity and responsiveness of WOSI were investigated through statistical analysis.
Results
Preoperative test-retest results were available for 49 patients, and 54 patients were available at final follow up. The mean WOSI was 57.8 (SD 20.3), 70.4 (SD 18.9), and 85.9 (SD 15.5), at baseline, 3, and 12 months, respectively. There was a statistically significant mean improvement of 28.8 (SD 24.5) in WOSI between baseline and 12 months (p < 0.0001). The intraclass correlation coefficient for the preoperative WOSI was excellent 0.91. At 12 months WOSI had an excellent Pearson’s correlation coefficient both with SSV (0.69), OSIS (-0.81), and poor with CS (0.25) scores, confirming our a priori hypothesis. There were no detected floor nor ceiling effects for WOSI pre- or postoperatively. The calculated minimal detectable change was 9.2 and the estimated minimal clinically important difference 13.4 to 18.1.
Conclusion
Finnish version of WOSI is a reliable and valid tool for assessing health state and improvement after operative treatment of shoulder instability in young male patients.
... Intervention measures were HA replacement and RSA. Outcome indicators were Constant-Murley Shoulder Outcome Score, Disabilities of Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder score, shoulder range of motion (ROM) and complications (9). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was followed to perform the present meta-analysis (10). ...
The present meta-analysis was conducted to compare the safety and effectiveness of reverse shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in the treatment of osteoporotic proximal humeral fractures in elderly patients. The Embase, Pubmed Central, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses, Cochrane Library and Chinese Biomedical databases were searched between January 2009 and January 2022 to identify relevant studies. According to the search strategy, a total of 210 associated studies were retrieved and 16 were finally included. Review Manager 5.4 software was used for the data analysis. This study indicated that patients in the RSA group had significantly improved treatment outcomes compared with patients in the HA group, as assessed by Constant-Murley Shoulder Outcome Score (95% CI, 1.69-3.76; P<0.001), American Shoulder and Elbow Surgeons score (95% CI, 11.81-24.88; P<0.001) and shoulder range of motion (ROM; 95% CI, 3.41-9.07; P<0.001). However, the HA group was superior to the RSA group in terms of the Oxford Shoulder score (95% CI, 2.89-11.11; P<0.001). There was no significant statistical difference between the two groups in terms of the Disabilities of the Arm, Shoulder and Hand score and complications. Overall, for the treatment of osteoporotic proximal humeral fractures in the elderly, the RSA group had improved postoperative ROM and functional scores compared with the HA group, without significant difference in the incidence of complications. However, HA remains a safe and reliable treatment option.
... 23 The WOOS assessment was created in 2001 to evaluate primary outcome measures for patients with symptomatic primary shoulder osteoarthritis. 16,17 It contains 4 areas including physical symptoms, sport/recreation/work, lifestyle, and emotional functions. Scores range from 0% or raw score 1900 (worst) to 100% or raw score 0 (best quality of life). ...
Background
In performing reverse total shoulder arthroplasty (rTSA), the role of repairing the subscapularis has been debated. Our objective was to determine the effect of subscapularis repair following rTSA on postoperative shoulder range of motion and patient reported outcome scores (PROs).
Methods
A prospective registry was reviewed to establish a cohort of primary rTSA patients with a 135-degree humeral implant with a minimum of 2 years of follow-up. Variables collected included demographics, subscapularis repair information, diagnosis, glenosphere size, and glenoid lateralization information. Outcomes collected were range of motion measurements, subscapularis strength, and multiple generic and shoulder PROs. Multivariable linear regression models were created to predict these 2-year outcomes.
Results
The 143-patient cohort had a mean age of 69 years with 68% of patients undergoing subscapularis repair. After adjustment in the multivariable models, whether the subscapularis was repaired did not significantly predict 2-year forward elevation, external rotation, internal rotation, subscapularis strength, Western Ontario Osteoarthritis of the Shoulder score, VR-12 scores, Constant score, or American Shoulder and Elbow Surgeons Shoulder scores. Increased glenoid lateralization significantly predicted greater internal rotation, higher VR-12 physical score, and higher Constant score. There were no dislocations in either group.
Conclusions
After adjusting for patient and implant factors, subscapularis repair was not associated with 2-year postoperative range of motion, strength, or any PROs suggesting that repairing the subscapularis may not affect functional outcome. Increased glenoid lateralization through the baseplate and glenosphere independently predicted better internal rotation, VR-12 physical score, and Constant scores indicating a benefit to lateralization during rTSA.
... Numerous methods and scoring systems have been implemented to evaluate and quantify the function in normal and diseased shoulders. The constant shoulder score first published as a university thesis in 1986 is widely accepted among shoulder surgeons and has been mandated by the European Shoulder and El-bow Society [1]. Constant score (CS) incorporates both subjective and objective assessment regardless of the diagnosis, rendering it widely applicable. ...
Background:
In the present study, the age- and sex-adjusted Constant score (CS) in a normal Indian population was calculated and any differences with other population cohorts assessed.
Methods:
The study participants were patients who visited the outpatient department for problems other than shoulder and healthy volunteers from the local population. Patients without shoulder pain/discomfort during activity were included in the study. Subjects with any problem that might affect shoulder function (e.g., cervical, thoracic spine, rib cage deformity, inflammatory arthritis) were excluded. Constant scoring of all participants was performed by trained senior residents under the supervision of the senior faculty. Shoulder range of movement and strength were measured following recommendations given by the research and Development Committee of the European Society for Shoulder and Elbow Surgery (2008). A fixed spring balance was used for strength measurement; one end was fixed on the floor and the other end tied with a strap to the wrist of the participant, arm in 90 degree abduction in scapular plane with palm facing down.
Results:
Among the 248 subjects (496 shoulders), the average age was 37 years (range, 18-78 years), 65.7% were males (326 shoulders) and 34.3% females (170 shoulders). The mean CS was 84.6±2.9 (males, 86.1±3.0; females, 81.8±2.9). CS decreased significantly after 50 years of age in males and 40 years of age in females (p<0.05). The mean CS was lower than in previous studies for both males and females. Heavy occupation workers had higher mean CS (p<0.05). A linear standardized equation was estimated for calculating the adjusted CS for any age.
Conclusions:
Mean CS and its change with age differed from previous studies among various population cohorts.
... Furthermore, fixation of dislocations using 3.5mm and 2,7 mm LCP Plates (Depuy Synthes ®) provides an adequate reduction regardless of the anterior or posterior J o u r n a l P r e -p r o o f position of the dislocation, which corresponds to findings reported in literature [14][15][16][17][18][19][20]. ...
Introduction
Sternoclavicular joint dislocations are infrequent among all joint injuries. Conservative management is often described and recommended as a means of closed reduction and immobilization of the affected limb. This study aims to review results of patients affected by this injury who were treated surgically using locking plates.
Materials and methods
A descriptive case series study was carried out. Cases of patients affected with sternoclavicular joint dislocation treated with open reduction and fixation with locking plates between 2009 and 2019 were included. The Constant score was applied to each patient to assess functional outcome.
Results
According to inclusion criteria, 15 patients were included, 12 males and 3 females. Post-operative assessment showed very positive results since the range of Constant scores was consistently over 90 in all cases.
Discussion
Fixation of sternoclavicular joint dislocations using locking plates had a low complication rate and provided good functional results.
Level of evidence
IV.
... The Shoulder Rating Questionnaire (SRQ) is a validated questionnaire used in the assessment of the severity of shoulder symptoms and degree of impairment of shoulder function [21][22][23]. The SRQ comprises 21 items measured in domains: pain, daily activities, recreational or athletic activities, work and satisfaction, and areas for improvement. ...
Sternocostoclavicular hyperostosis (SCCH), the main clinical manifestation of chronic non-bacterial osteomyelitis (CNO) in adults, is associated with various degrees of chronic pain and restricted shoulder girdle function. We evaluated the impact of CNO/SCCH on quality of life (QoL) and its determinants in 136 adult patients with this rare auto-inflammatory bone disorder using the Short Form 36, Brief Pain Inventory, Brief Illness Perception, Utrecht Coping List, and Shoulder Rating questionnaires. Data were compared with those of the general Dutch population, patients with chronic pain, fibrous dysplasia, or osteoarthritis. Eighty-six (64%) predominantly female (85%) patients with completed questionnaires were included in the study. Sixty-four (75%) had isolated CNO/SCCH. Mean delay in diagnosis was 3.0 ± 5.5 (SD) years, 90% had variable pain, and 84% limited shoulder function. Compared to healthy and chronically diseased reference populations, CNO/SCCH patients demonstrated significant impairments in almost all aspects of QoL, maladaptive illness perceptions, and ineffective coping strategies. For patients with >5-year delay in diagnosis, higher pain scores and limited shoulder function were identified as determinants for impaired QoL. Patients with CNO/SCCH reported significant impairments in QoL associated with clinical and psychological determinants. Clinical measures such as shortening delay in diagnosis, effective pain management, and psychosocial interventions targeting these factors should help minimize the negative impact of CNO/SCCH on QoL.
... The WOSI score ranges from 0 to 210, with 0 representing the best possible response in terms of function and stability. 15 The mean preoperative WOSI value was 126.77 (min 118; max 135) and at the end of follow-up was 45.08 (min 37; max 65). The evolution of functional scores over time is shown in Figure 3 and Table III. ...
Background:
Although there is a low incidence of shoulder instability in women, this population is still representative and is often associated with lower rates of return to sports. Few studies have evaluated the results of the Latarjet procedure in this population.
Methods:
This was a prospective cohort study of female athletes who underwent the Latarjet procedure between 2013 and 2018. The participants were followed up for 3 years. The primary outcomes of the study included the visual analog scale for pain; range of motion: active elevation, passive elevation, active external rotation, and passive external rotation. The functional scores were as follows: American Shoulder and Elbow Surgeons score, the Western Ontario Shoulder Instability Index, and the Athletic Shoulder Outcome Rating Scale. Additional data were collected regarding return to sport, complication rates, and patient satisfaction.
Results:
Thirteen female athletes who practice Soccer, Volleyball, Basketball, Handball, Judo, or Weight training were evaluated. There was a significant reduction in the mean range of motion for all movements at 4 weeks after surgery. Patients recovered a range of motion similar to the preoperative values after 6 months. The mean visual analog scale reached 6.39 at the first week after surgery and decreased to values below preop at 8 weeks. The mean preoperative Western Ontario Shoulder Instability Index was 126.77 (min 118; max 135), and at the end of follow-up, the WOSI index was 45.08 (min 37; max 65; P < .05). The mean preoperative American Shoulder and Elbow Surgeons score was 41.61 (min 35; max 46), and at the end of follow-up, the mean ASES score was 84.46 (min 80; max 90; P < .05). The mean Athletic Shoulder Outcome Rating Scale in the preoperative period was 39.38 (min 37; max 42), and at the end of follow-up, the mean ASORS score was 83.15 (min 77; max 85; P < .05). The rate of return to sports was 92.3%, and 84.6% of patients were satisfied with the surgery. The aesthetic satisfaction rate was 76.9%. The complication rate was 15.4% (1 screw failure and 1 dislocation recurrence).
Conclusion:
Latarjet surgery in female athletes showed high rates of return to sports and improved functional scores without impairing range of motion after the procedure. Recurrence and complication rates were low. In addition, treatment was associated with improved functionality and patient satisfaction.
... A researcher blinded to the patient groups assessed all patients for functional status before, immediately after PT, and one month afterward, for a total of three times. The Constant Shoulder Scale (11) , which was established to evaluate the functional recovery of the shoulder, ROM, and its functional condition, was used in our study. It is graded on a scale of 0 to 100, with higher scores signifying better results. ...
... A researcher blinded to the patient groups assessed all patients for functional status before, immediately after PT, and one month afterward, for a total of three times. The Constant Shoulder Scale (11) , which was established to evaluate the functional recovery of the shoulder, ROM, and its functional condition, was used in our study. It is graded on a scale of 0 to 100, with higher scores signifying better results. ...
Background: Physical therapy (PT) is often recommended for patients with frozen shoulder. However, it could be painful for some patients, and this could hinder the rehabilitation programme. Some procedures like joint injection and suprascapular nerve block (SSNB) could alleviate pain during this setting. Objective: The purpose of this study was to compare the effectiveness of continuous SSNB plus PT compared to PT alone in managing frozen shoulder. Patients and methods: A total of 76 patients with frozen shoulder were included in this study. They were divided into two groups: 38 patients in the injection group (IG) received SSNB via catheter before PT, while the remaining 38 participants in the control group (CG) received no block prior to PT (CG). The functional state of the shoulder joint was assessed via the constant shoulder scale before and just after PT, then one month later. Results: General patient characteristics, including age, gender, BMI, comorbidities, and trauma history, were statistically comparable between the two groups. When we examined the constant scores of the two groups, we found that both had low scores before treatment, which increased immediately after treatment and then increased again one month later. Nonetheless, the injection group had a much greater increase than the control group. Conclusion: When used with PT for the treatment of adhesive capsulitis, continuous SSNB is an effective option that enhances the response to PT. It is associated with better improvement in shoulder function.
... This may be because both scoring systems have subjective patient dependent measurements. The fact that one of the main parameters of the ASES scoring system is pain and the VAS scoring system focuses entirely on pain may explain this difference in the early period [24]. Postoperative muscle cramps and the absence of sense of tension in the PE group may have affected the evaluations of pain. ...
Introduction
The optimal position of the elbow and forearm during biceps tenodesis is a debated topic. The aim of our study was to compare two different forearm positions, pronation-extension (PE) or neutral, for fixation of the long head of the biceps tendon (LHB) in biceps tenodesis.
Materials and methods
Fifty patients who underwent shoulder arthroscopy between February 2016 and January 2019 were included in our study. After diagnostic arthroscopy, the LHB was cut from its origin with a thermal ablator. The LHB was then tenodesed beneath the inferior border of the pectoralis major tendon for 25 patients in the PE position and for 25 patients in the neutral position. Patients were evaluated preoperatively and 3rd, 6th and 12th months postoperatively according to the visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) shoulder and Constant scores. Flexion and supination force measurements were made with a digital dynamometer device, compared to the healthy side for both groups.
Results
ASES and VAS scores were statistically better in the PE group compared with the neutral group (p < 0.05), but there was no statistically significant difference between Constant scores at 3 and 6 months (p > 0.05). No significant difference was found in both groups for 3 scores at 12 months. Comparison of the PE group with the contralateral extremity and comparing the neutral group with the contralateral extremity in terms of flexion strength showed no statistically significant difference. No statistically significant difference was found between the supination powers of both comparative groups.
Conclusion
Functional scoring in the PE position is better at 3 and 6 months because patients experience less pain at 3 and 6 months. The simple change of the fixation position causes patients to feel less pain in the early period.
Level of evidence
1.
... -Patients' tendon healing process were closely monitored using ultrasound, evaluated clinically after surgery at the follow-up time of 1 month, 3 months, and finally, before the end of the study. -Postoperative clinical outcomes were evaluated based on the UCLA, ASES scale [18,19](at the end of the study). -This case series has been reported in line with the PROCESS Guideline [20]. ...
Postoperative tendon healing is still a matter of concern after rotator cuff repair. Several techniques have been introduced to help improve this healing process. Among them, the bone marrow is commonly used source and a research subject for methods using stem cells to promote wound healing process. A number of studies have shown that bone marrow stem cells can travel up through the holes on the rotator cuff insertion sites, contributing into the rotator cuff repair process, increasing the efficiency of tendon healing and improving clinical results.
Patients and methods
Cross-sectional descriptive study was performed on 41 rotator cuff tear patients. The microfractures for these patients were calculated beforehand, which have great depth but small diameter, based on the anatomical characteristic of the rotator cuff tear insertions of Vietnamese people. Patients' rotator cuff tendon healing processes were evaluated using ultrasound after surgery. Final tendon healing and clinical results ultimately rely on MRI assessments, classified according to Sugaya's classification, UCLA and ASES scale.
Results
No cases of rupture and fracture of the greater tubercle was recorded. There was a clear progression of tendon healing on ultrasound according to postoperative follow-up time-stamps (1 month, 3 months). MRI images evaluation also reveals at the latest follow-up time, according to Sugaya classification, the ratio of tendon healing was 87.8%, while the percentage of re-rupture was 12.2%. ASES and average UCLA scale were collected at the end of the study, respectively as 95.41 ± 5.45 and 32.36 ± 2.53.
Conclusion
The technique's microfractures characteristics based on the rotator cuff tear insertion anatomy ensures a secure, straightforward approach along with promising results in terms of tendon healing rate and postoperative functional outcomes.
... We evaluated them using the Shoulder-Rating Score Sheet, clinically evaluating them for any evidence of shoulder pathology emphasizing on the impingement sign, abduction and adduction sign, as well as evidence of any functional limitation and regional tenderness. 9 Geriatric healthy participants were volunteers in whom MRI 3.0 T of the rotator cuff showed no signs of edema, calcification, or rupture of tendons. Geriatric patients with rotator cuff tears (22 men and 48 women with an average age of 77.52 ± 8.39 years [range, 69 to 80 years]) were included if they were suffering from sustained shoulder dysfunction and chronic pain and had obvious rotator cuff tears detected by MRI. ...
Introduction
Previous clinical studies have reported associations between the acromion index, lateral acromion angle, and critical shoulder angle and the occurrence of rotator cuff tears. The objective of this study was to analyze the correlations of these different anatomic parameters in geriatric Chinese Population.
Methods
Healthy geriatric Chinese participants (n = 66) and geriatric Chinese patients with rotator cuff tears (n = 70) identified between January 2019 and October 2020 were included in this study. Standardized true anteroposterior radiographs were used to measure the acromion index, lateral acromion angle, and critical shoulder angle in each study participant.
Results
The mean acromion index was significantly larger, the mean lateral acromion angle was significantly smaller, and the mean critical shoulder angle was significantly larger in geriatric patients with full-thickness rotator cuff tears compared with geriatric healthy participants.
Conclusion
There were a negative linear relationship between the acromion index and lateral acromion angle and a positive linear relationship between the acromion index and critical shoulder angle in geriatric patients with rotator cuff tear and geriatric healthy participants; we termed this phenomenon “Hypothesis of Acromion Index.” The acromion index, lateral acromion angle, and critical shoulder angle are independent predictors of rotator cuff tears in a geriatric Chinese population.
... 47 The SPADI Shoulder Score is a reliable and valid tool, also having been shown to be responsive to change over time in a variety of patient populations. 48,49 WOSI is a valid, reliable and sensitive assessment for patients with shoulder problems that are associated with instability. 50,51 Standardization in outcomes and outcome measures in research is highly warranted. ...
This study was designed to identify the most frequent shoulder patient-reported outcome measures (PROMs) reported in high-quality literature. A systematic review was performed to identify shoulder PROMs, and their diffusion within the scientific literature was tested with a subsequent dedicated search in MEDLINE. 506 studies were included in the final data analysis, for a total number of 36,553 patients. The Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), the American Shoulder, Elbow Surgeons Score (ASES) and the Shoulder Pain and Disability Index (SPADI) were the most frequently reported PROMs in the analysed publications, with disease-specific PROMs being used with increasing frequency. A core set of outcome measures for future studies on patients with shoulder pathologies, based on the international acceptance and diffusion of each PROM, is needed. A combination of the DASH score for shoulder outcome assessment with more specific PROMs, such as the ASES for rotator cuff pathology and osteoarthritis and the SPADI for shoulder stiffness and shoulder pain of unspecified origin, is proposed as a recommended set of PROMs.
Cite this article: EFORT Open Rev 2021;6:779-787. DOI: 10.1302/2058-5241.6.200109
... Each patient also completed the WORC and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. 22,23,27,28,33,44 ...
Background
Despite advances in surgical techniques, the use of maximal repair to treat large or massive rotator cuff tears results in a high retear rate postoperatively. Currently, no randomized controlled trials have compared the outcomes of maximal repair with interposition dermal allograft bridging reconstruction.
Hypothesis
We hypothesized that large or massive rotator cuff tendon tears reconstructed using bridging dermal allograft would have better clinical outcomes 2 years postoperatively, as measured using the Western Ontario Rotator Cuff (WORC) index, than would those receiving the current gold standard treatment of debridement and maximal repair alone. We also expected that patients treated via bridging reconstruction using dermal allograft would have fewer postoperative failures as assessed using postoperative magnetic resonance imaging scans.
Study Design
Randomized controlled trial; Level of evidence 1.
Methods
A sample size of 30 patients (determined using a priori sample size calculation) with massive, retracted rotator cuff tears were randomly allocated to 1 of 2 groups: maximal repair or bridging reconstruction using dermal allograft. All patients completed questionnaires (WORC and Disabilities of the Arm, Shoulder and Hand [DASH]) preoperatively and postoperatively at 3 months, 6 months, 1 year, and 2 years. The primary outcome of this study was the WORC index at 2 years. Secondary outcomes included healing rate, progression of rotator cuff arthropathy, and postoperative acromiohumeral distance in both groups.
Results
Patients treated via bridging reconstruction using dermal allograft had better postoperative WORC and DASH scores (23.93 ± 24.55 and 15.77 ± 19.27, respectively) compared with patients who received maximal repair alone (53.36 ± 31.93 and 34.32 ± 23.31, respectively). We also noted increased progression to rotator cuff arthropathy in the maximal repair group with an increased retear rate when compared with the reconstruction group (87% and 21%, respectively; P < .001). The acromiohumeral distance was maintained in the reconstruction group but significantly decreased in the maximal repair group.
Conclusion
Rotator cuff bridging reconstruction using a dermal allograft demonstrated improved patient-reported outcomes as measured using the WORC index 2 years postoperatively. This technique also showed favorable structural healing rates and decreased progression to arthropathy compared with maximal repair.
Trial Registration
ClinicalTrials.gov (NCT01987973)
Background:
Patient-reported outcome measures (PROMs) have transitioned from primarily being used as research instruments to becoming increasingly used in the clinical setting to assess recovery and inform shared decision-making. However, there is a need to develop validated short-form PROM instruments to decrease patient burden and ease incorporation into clinical practice.
Purpose:
To assess the validity and responsiveness of a shortened version of the Western Ontario Shoulder Instability Index (Short-WOSI) when compared with the full WOSI and other shoulder-related PROM instruments.
Study design:
Cohort study (diagnosis); Level of evidence, 2.
Methods:
This study was a secondary analysis of data collected as part of an institutional review board-approved, multicenter cohort of 1160 patients undergoing surgical stabilization for shoulder instability. The following PROMs were captured preoperatively and 2 years after surgery: WOSI, American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and 36-Item Health Survey (RAND-36). The cohort was split into 2 data sets: a training set to be used in the development of the Short-WOSI (n = 580) and a test set to be used to assess the validity and responsiveness of the Short-WOSI relative to the full WOSI, ASES, SANE, and RAND-36.
Results:
The Short-WOSI demonstrated excellent internal consistency before surgery (Cronbach α = .83) and excellent internal consistency at the 2-year follow-up (Cronbach α = .93). The baseline, 2-year, and pre- to postoperative changes in Short-WOSI and WOSI were closely correlated (r > 0.90), with both demonstrating large effect sizes (Short-WOSI = 1.92, WOSI = 1.81). Neither the Short-WOSI nor the WOSI correlated well with the other PROM instruments before (r = 0.21-0.33) or after (r = 0.25-0.38) surgery. The Short-WOSI, WOSI, and SANE scores were more responsive than ASES and RAND-36 scores.
Conclusion:
The 7-item Short-WOSI demonstrated excellent internal consistency and a lack of floor or ceiling effects. The Short-WOSI demonstrated excellent cross-sectional and longitudinal construct validity and was similarly responsive over time as the full WOSI. Neither the Short-WOSI nor WOSI correlated with more general shoulder PROMs, underscoring the advantage of using instability-specific instruments for this population.
The impact of shoulder injuries and treatments on patients is mostly measured during the clinical evaluation. Initially, simple questions inquire about pain, other symptoms, influence on function, and treatment satisfaction. Next, a physical examination assesses the shoulder’s range of motion, strength, and stability before performing different provocative maneuvers evaluating for different pathologies. Finally, diagnostic imaging data are obtained and appraised first for injuries and deformity, and then later for signs of healing and prosthetic alignment and stability. The physician deciphers through all the clinical information to evaluate how the shoulder pathology is affecting the patient, determine treatment, and then gauge the effectiveness of their treatment on the patient.KeywordsRotator cuffMinimal clinically important differenceConstant scoreRotator cuff repairWestern Ontario Rotator Cuff
Background:
Superior capsular reconstruction (SCR) using a tensor fascia lata graft has been performed in patients with irreparable rotator cuff tears and shoulder pseudoparalysis (PPS), and good clinical results have been reported. This procedure can be indicated for younger patients who are highly active in sports and manual labor from the viewpoint of joint preservation. However, this procedure supplements the defect with a graft that has no muscle contractility; therefore, the extent to which shoulder muscle strength is recovered after SCR remains unclear. We hypothesized that the recovery of muscle strength after SCR would not be normalized and would be only approximately 50% of that of the healthy (unaffected) side. This study aimed to evaluate muscle strength after SCR in patients with PPS due to irreparable rotator cuff tears and the extent of recovery by comparing with that of the unaffected side.
Methods:
In total, 20 patients who underwent SCR for PPS using a tensor fascia lata graft with a minimum 2-year follow-up were included. Shoulder muscle strength in abduction, internal rotation, and external rotation was evaluated using a handheld dynamometer. Muscle strength was compared to that on the unaffected side, and the affected/unaffected ratio was measured. Shoulder range of motion (ROM) and acromiohumeral distance (AHD) were also evaluated.
Results:
The postoperative ROMs and AHD (4.0 ± 1.4 mm vs. 8.4 ± 1.9 mm, P < .001) were significantly improved compared to those preoperatively. In external and internal rotation, the muscle strength of the affected side was recovered by approximately 80% compared to that of the unaffected side. However, in abduction, the muscle strength of the affected side (2.9 ± 1.5 kg) could not reach 50% (48.0 ± 15.9%, range: 25.0-76.5%) of that of the unaffected side (5.9 ± 1.8 kg).
Conclusion:
Abduction strength was not sufficiently restored after SCR when compared to that on the unaffected side.
To compare local acupuncture and auricular acupuncture with physiotherapy in the treatment of frozen shoulder. A randomized clinical trial with 3 parallel groups in an outpatient clinic was conducted at a university hospital. In total, 116 participants with frozen shoulder were randomly allocated to 3 groups and underwent physiotherapy or local acupuncture or auricular acupuncture. Shoulder active and passive ranges of motion were assessed, and the Shoulder Pain and Disability Index questionnaire was used to assess pain and disability before and after the treatments. Active and passive ranges of motion were best improved by physiotherapy in abduction and flexion (all P < .001). Passive external rotation was best increased after physiotherapy (P = .030). For active external and internal rotation, and also for passive internal rotation, there were no significant differences among the treatments. Pain reduction was more successful with acupuncture, especially with auricular acupuncture (P < .001). Auricular acupuncture was more effective in improving patients' functional abilities (P < .001). None of the participants reported any side effects resulting from the treatments. Acupuncture, particularly auricular acupuncture, is more effective in relieving pain and decreasing disability than physiotherapy. All the interventions were beneficial in improving range of motion.
Introduction
The aim of this prospective study was to investigate BMD changes in the proximal humerus of the shoulder during a healing period of 12 months after displaced 3- or 4-part proximal humerus fractures treated with open reduction and internal fixation (ORIF) with an anatomic angular stable locking plate and the influence on fracture healing and functional outcomes.
Methods
In a prospective multicenter study, 36 patients (29F and 7M, age range: 38-83) with unilateral displaced 3- or 4-part proximal humerus fractures were included for ORIF. Dual-energy x-ray absorptiometry (DXA) for osteoporosis status was employed. Postoperative and at 6 weeks, 3-, 6-, and 12-months shoulder radiographs and DXA of the shoulder with BMD measures in four templated regions of interest (ROIs) were performed. Functional outcomes: Western Ontario Osteoarthritis of the Shoulder index (WOOS), Constant Score (CS), visual analogue scale pain (VAS), and 36-Item Short Form Survey (SF-36) were collected.
Results
17 of 36 patients had osteoporosis. We found no differences in BMD changes, functional outcomes, radiology or need for revision surgery between the osteoporosis and non-osteoporosis groups. The BMD values gradually declined from baseline to 3 months follow-up in all four ROIs of the operated shoulders. All four ROIs in the operated shoulder presented with a reduction in BMD at 3, 6 and 12 months compared with baseline, while no significant BMD changes were seen in the healthy shoulder during the study period. The functional outcomes displayed an increase in CS score from 3 to 12 months, but a decrease in domains of the SF-36 from pre-injury to 12 months (physical functioning, general health and bodily pain). Preinjury and at 12 months WOOS, VAS pain at rest and activity were comparable.
Conclusion
BMD changes appeared swiftly in the proximal humerus, after treatment of displaced 3- or 4-parts fractures with ORIF, particularly affecting the proximal diaphysis of the humerus. Shoulder function was restored to preinjury levels for most of the patients. Osteoporosis may not be regarded as a contraindication for treatment of displaced 3- or 4-parts fractures with ORIF
Background:
The Western Ontario Shoulder Instability (WOSI) questionnaire is a 21-item questionnaire to evaluate quality of life in patients with shoulder instability. Completing the questionnaire is time-consuming because each item is evaluated on a visual analog scale. Telephone or email versions of the score are appealing alternatives to administering it during the standard in-person patient visit; however, their validity and reliability remain unknown.
Questions/purposes:
(1) Does the numerical scale (NS) version of the WOSI correlate with the original WOSI and Quick-DASH? (2) Do telephone and email administration of the NS-WOSI have good reliability and consistency? (3) Compared with the original WOSI form, does the NS form lead to faster completion for patients and quicker data extraction for researchers?
Methods:
Between 2014 and 2019, 50 patients with a documented history of shoulder dislocation with persistent symptomatic shoulder instability, whether anterior, posterior, or multidirectional; patients scheduled for surgery; and patients with traumatic or nontraumatic injuries were prospectively recruited from the outpatient clinic of two university hospitals acting as Level 1 trauma centers and sports traumatology tertiary referral centers. The median (IQR) age was 28 years (24 to 36), and 80% (40 of 50) were men. Most (52% [26 of 50]) patients had two to five lifetime shoulder dislocations. Validity of the NS-WOSI was assessed using the Pearson correlation coefficient during an in-person visit; the original WOSI questionnaire (or its previously validated French-language version), NS-WOSI, and Quick-DASH questionnaires were administered in a random order. After a minimum 7-day interval, 78% (39 of 50) of patients completed the phone interview, and 74% (37 of 50) of patients completed the email version of the NS-WOSI score to evaluate NS-WOSI's reliability using the intraclass correlation coefficient (ICC), which was interpreted as poor (< 0.5), moderate (0.50-0.75), strong (0.75-0.90), and very strong (> 0.90). The standard error of measurement (SEM) was used to evaluate variability around the true score, with a low value indicating a high reliability. The 95% minimal detectable change (MDC95%) was calculated to evaluate the minimal change in score that was not related to measurement errors. Lastly, the Cronbach alpha was used to assess internal consistency (intercorrelation strength), where a value > 0.70 was considered good. The time needed for the patient to complete the various versions and for researchers to extract data was recorded.
Results:
The NS-WOSI score was very strongly correlated with the original WOSI score (r = 0.96 [95% confidence interval (CI) 0.93 to 0.98]; p < 0.001). Although telephone-acquired and email-acquired data for the NS-WOSI questionnaires were correlated with the NS-WOSI (telephone r = 0.91 [95% CI 0.83 to 0.95]; p < 0.001; email r = 0.84 [95% CI 0.71 to 0.91]; p < 0.001), the ICC was higher for telephone interviews (0.92 [95% CI 0.86 to 0.96] versus email 0.80 [95% CI 0.64 to 0.89]), indicating that although both had good reliability, the phone interview was more suitable. The phone interview was also preferable to email regarding SEM (3% [52 of 2100 points] versus 6% [132 of 2100 points]) and the MDC95% (7% [144 of 2100 points] versus 17% [366 of 2100 points]). The 95% CI of the MDC acquired by email was superior to the reported minimum clinically important difference for the original WOSI (7% [152 of 2100 points]), meaning that an error of measurement could wrongly be interpreted as a clinically significant change in score. Internal consistency was deemed good, with a Cronbach alpha of 0.96 (95% CI 0.92 to 98) and 0.89 (95% CI 0.79 to 0.94) for NS-WOSI telephone and email, respectively. The time to complete the NS-WOSI was reduced compared with the original WOSI (221 ± 153 seconds versus 266 ± 146 seconds, mean difference -45 seconds [95% CI -72 to -12]; p = 0.009). Lastly, data extraction was faster (62 ± 15 seconds versus 209 ± 52 seconds, mean difference -147 seconds [95% CI -164 to -130]; p < 0.001) with the NS-WOSI than with the original WOSI.
Conclusion:
The NS-WOSI in person, by telephone, or by email is a valid, reliable, and timesaving alternative to the original WOSI questionnaire. However, the reliability of data acquisition by telephone interviews was superior to that of email.
Clinical relevance:
Given that there were no important differences in performance for the NS-WOSI, regardless of whether it was administered in person or by phone, we suggest that physicians use both interchangeably based on patient convenience. However, we do not recommend using the email version, especially for research purposes, since it was not as reliable when compared with in-person administration. The responsiveness of the modified NS-WOSI, as well as factors influencing response rates to phone interview, are questions that remain to be explored.
Purpose
The purpose of this study was to explore whether PRP injection can be a viable alternative to CS injection for conservative treatment of rotator cuff disease.
Methods
The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, The Cochrane Library, and Web of Science were searched for English-written randomized controlled trials (RCTs) which compared PRP and CS injections for patients with rotator cuff disease from January 1, 1990, to March 20, 2022. Two evaluators independently screened the literature, extracted data, and assessed the level of evidence and methodological quality of the enrolled studies. The meta-analysis was conducted using RevMan 5.3.3 software.
Results
Thirteen non-surgical RCTs with 725 patients were included. Compared with CS, PRP provided statistically worse short-term (＜2 months) changes (Δ) of the American Shoulder and Elbow Surgeons (ASES) assessment, Δ the Simple Shoulder Test (SST), Δ the Disability of Arm, Shoulder and Hand (DASH) questionnaires but better medium-term (2 to 6 months) Δ DASH, long-term (≥ 6 months) Δ Constant-Murley Score (CMS), Δ ASES and Δ SST. No statistical differences regarding pain reduction were found between the two groups. PRP injections led to worse short-term Δ forward flexion, Δ internal rotation but better medium-term Δ forward flexion and Δ external rotation. PRP had significantly lower rates of postinjection failure (requests for a subsequent injection or surgical intervention prior to 12 months) than CS. No outcome reached the minimal clinically important difference (MCID). After sensitivity analyses by excluding studies with substantial clinical and/or methodological heterogeneity, PRP showed better medium-term Δ ASES, Δ VAS, and long-term Δ VAS which reached the MCID.
Conclusions
Without the drawbacks of CS injection, PRP injection is not worse than CS injection in pain relief and function recovery at any time point of the follow-up. PRP injection may reduce rates of subsequent injection or surgery, and might provide better improvement in pain and function in the medium- to long-term. PRP injection can be a viable alternative to CS injection for conservative treatment of rotator cuff disease.
Level of Evidence
Systematic review of Level I and II studies.
Introduction:
Although surgical techniques have advanced to avoid a postoperative re-tear after rotator cuff surgery, it remains unclear how to directly evaluate the risk of a re-tear.
Objective:
To describe how muscle elasticity with real-time tissue elastography could be used to avoid re-tear in individual cases after rotator cuff repair.
Case description:
This case series included four patients, two per tear size (small and large/massive), with contrasting changes in muscle elasticity of the supraspinatus muscle. All patients underwent primary arthroscopic or open rotator cuff repair. The elasticity of the supraspinatus muscle was evaluated at relaxed and elongated positions of 0° and 60° shoulder abduction angles, respectively. The change in muscle elasticity at 1 month after surgery was characteristically different, and we predicted that a greater elasticity in the elongated position indicated a higher risk of re-tear. The cases with high risk underwent careful rehabilitation to avoid re-tear, and no re-tears were recorded in this report.
Conclusion:
Our findings suggested that evaluation of muscle elasticity using real-time tissue elastography, which provides an indication of the risk of re-tear, in the clinical setting might be useful for therapists, who could adjust the intensity of rehabilitation, and for patients.
Nghiên cứu nhằm đánh giá kết quả phẫu thuật khâu chóp xoay khớp vai bằng kỹ thuật hai hàng qua nội soi. 31 người bệnh rách chóp xoay khớp vai được phẫu thuật khâu chóp xoay rách qua nội soi khớp vai bằng kĩ thuật hai hàng, theo dõi, đánh giá chức năng khớp vai theo thang điểm UCLA với thời gian theo dõi trung bình 9,9 tháng (ngắn nhất 8 tháng, dài nhất 12 tháng). Điểm UCLA trung bình sau mổ cải thiện rõ rệt từ 12,4 lên 30,3. Chức năng khớp vai sau mổ: 32,3% rất tốt, 54,8 % tốt, 12,9% trung bình. Chức năng khớp vai sau mổ không bị ảnh hưởng bởi mức độ co rút gân, kích thước rách, hình thái rách chóp xoay, không tìm thấy sự khác biệt có ý nghĩa thống kê giữa nhóm thoái hóa mỡ độ III và nhóm thoái hóa mỡ độ 0, I, II. Phẫu thuật khâu chóp xoay bằng kĩ thuật hai hàng qua nội soi là phương pháp điều trị hiệu quả, áp dụng được cho các hình thái, kích thước rách và mức độ co rút gân chóp xoay khác nhau.
Background
Clinical failure associated with non-operative treatment of rotator cuff tears may be due to inadequate characterization of the individual’s functional impairments. Clinically, restricted passive range of motion (ROM, restrictions imply capsular tightness), limitations in muscle strength, and larger rotator cuff tears are hypothesized to be related to altered glenohumeral kinematics. Understanding these relationships, as well as the relationship between glenohumeral kinematics and patient reported outcomes (PROs) prior to exercise therapy, may help characterize functional impairments in individuals with rotator cuff tears. The objectives of the study were to describe the baseline presentation of individuals with an isolated supraspinatus tear, including passive ROM, rotator cuff muscle strength, tear size, PROs, and glenohumeral kinematics, and to determine associations among these variables.
Methods
One-hundred one individuals with symptomatic isolated supraspinatus tears were recruited for the study and underwent assessments of passive glenohumeral ROM, isometric muscle strength, and ultrasonography to assess anterior-posterior tear size. Glenohumeral kinematics during scapular plane abduction were measured using biplane radiography. Furthermore, PROs including the American Shoulder and Elbow Surgeons score (ASES) and the Western Ontario Rotator Cuff Index (WORC) were also collected.
Results
Individuals presented with decreased ROM, external rotation weakness compared to the non-involved side, and pain/ disability as measured by the ASES and WORC. These findings were not associated with glenohumeral kinematics, with the exception of a weak positive association between glenohumeral contact path lengths and WORC scores (ρ = 0.25, P = 0.03). Tear size was 11.7 ± 5.7mm and maximum anterior and superior translations and contact path lengths were 3.0 ± 3.8% glenoid width, 3.5 ± 3.8% glenoid height, and 38.2 ± 20.7% glenoid size, respectively.
Conclusion
Individuals with a symptomatic isolated supraspinatus tear presented with decreased ROM, external rotation weakness, and pain/disability as measured by the ASES and WORC. However, no abnormal kinematics associated with these limitations were observed. Thus, given the tear is isolated to the supraspinatus tendon and no capsular restrictions are present, normal function of the glenohumeral joint may be possible during scapular plane abduction.
Aims
Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.
Methods
Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively.
Results
A total of 138 patients underwent ADROM; 111 patients were available for long-term follow-up at a mean of 10.9 years (range 1 to 20). Mean age was 50.8 years (18 to 75);79 (57.2%) were female. Mean time from primary ORPF to ADROM was 11.9 months (6 to 19). Five patients developed superficial wound infection; ten developed symptomatic osteonecrosis/post-traumatic arthrosis (ON/PTA); four underwent revision arthrolysis. Median OSS improved from 17 (interquartile range (IQR) 12.0 to 22.0) preoperatively to 40.0 (IQR 31.5 to 48.0) postoperatively, and 39.0 (IQR 31.5 to 46.5) at long-term follow-up (p < 0.001). Median EQ-5D-3L improved from 0.079 (IQR -0.057 to 0.215) to 0.691 (IQR 0.441 to 0.941) postoperatively, and 0.701 (IQR 0.570 to 0.832) at long-term follow-up (p < 0.001). We found that aROM improved in all planes (p < 0.001). Among the variables assessed on multivariable analysis, a manual occupation, worsening Charlson Comorbidity Index and increasing socioeconomic deprivation were most consistently predictive of worse patient-reported outcome scores. Patients who subsequently developed ON/PTA reported significantly worse one-year and late OSS.
Conclusion
ADROM in patients with persistent symptomatic stiffness following ORPF can achieve excellent short- and long-term outcomes. More deprived patients, those in a manual occupation, and those with worsening comorbidities have worse outcomes following ADROM. Cite this article: Bone Joint J 2022;104-B(1):157–167.
Background
Patients with Subacromial Pain Syndrome show reduced co-contraction of the teres major during abduction. Consequent insufficient humeral depressor function may contribute to painful irritation of subacromial tissues and offers a potential target for therapy. A crucial gap in knowledge is whether the degree of teres major co-contraction in these patients is influenced by pain itself. To gain insight into this matter, we assessed whether relief of subacromial pain with local analgesics leads to increased adductor co-contraction in 34 patients with subacromial pain.
Methods
In a single-arm interventional study with 34 patients, electromyographic activity of the latissimus dorsi, pectoralis major, teres major and deltoid was assessed during isometric force tasks in 24 directions before and after subacromial Lidocaine injection. Co-contraction was quantified using the activation ratio; range [−1 (sole antagonistic activation, i.e. co-contraction) to 1 (sole agonistic activation)].
Findings
There were no changes in activation ratio of the teres major after the intervention (Z-score: −0.6, p = 0.569). The activation ratio of the latissimus dorsi increased to 0.38 (quartiles: 0.13–0.76), indicating decreased co-contraction (Z-score: −2.0, p = 0.045).
Interpretation
Subacromial analgesics led to a decrease in co-contraction of the latissimus dorsi, whereas no change in the degree of teres major co-contraction was observed. This study shows that decreased teres major co-contraction in patients with subacromial pain, likely is not the consequence of pain itself, opening a window for physical therapy with training of teres major co-contraction to reduce subacromial irritation and pain.
Level of evidence
Level II treatment study.
Background
Anterior shoulder instability frequently occurs in young, physically active individuals, and may be treated with surgical stabilization. Previous studies have shown that males more often require surgical management for anterior shoulder instability and may have a higher frequency of recurrent instability episodes following surgical management, but females have been found to have increased incidence of apprehension after surgical stabilization. The purpose of this study is to review the literature and assess anterior shoulder surgical stabilization postoperative outcomes between males and females to identify and describe sex-based differences.
Methods
A systematic search of electronic databases was conducted to identify level I-IV clinical studies on anterior shoulder instability published between 1960 and August 2020. We included studies that evaluated sex-specific outcomes in patients who underwent anterior shoulder instability procedures. A meta-analysis of the data was performed to analyze sex-specific outcomes.
Results
Thirty studies (2.1%) met inclusion criteria, representing 9,829 patients. Of the studies that reported the number of male and female patients, 74% were male and 26% were female. Twenty-six studies utilized Bankart repair alone, two utilized open Latarjet procedure alone, and two had a Bankart repair group and Latarjet procedure group. Instability recurrence, return to sport (RTS), and apprehension were included in the meta-analysis. Our meta-analysis demonstrated a significantly higher rate of instability recurrence for males than females who underwent arthroscopic Bankart repair (RR = 1.25; 95% CI = [1.03, 1.52]; p = 0.0239). We did not identify a significant difference between males and females in rates of apprehension (RR = 0.68; 95% CI = [0.37, 1.27]; p = 0.2300) or RTS (RR = 0.98; 95% CI = [0.81, 1.18]; I² = 0%; p = 0.8110) for arthroscopic Bankart repair or open Latarjet procedure.
Conclusion
For patients who underwent arthroscopic Bankart repair for anterior shoulder stabilization, recurrent rates of instability were significantly higher for males than females. When open Bankart and Latarjet procedures were included, there was no difference. No difference was seen between males and females after arthroscopic Bankart repair or open Latarjet procedures with regards to return to sport or apprehension.
Background
A number of patient-reported outcome measure (PROMs) instruments are used to assess shoulder pain, function, and postoperative satisfaction. Computer adaptive tests (CAT) have been developed in an effort to tailor question delivery, decrease time to completion and floor/ceiling effects, and increase compliance. Previous investigations have demonstrated excellent correlation between Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity CAT (UE-CAT) and American Shoulder and Elbow Surgeons (ASES) instruments, indicating that the PROMIS UE-CAT may be an acceptable alternative to the ASES. Prior to widespread adoption, however, rigorous psychometric validation must be performed. Thus, the purpose of this study was to evaluate the psychometric properties of PROMIS UE-CAT relative to the ASES score in patients undergoing primary rotator cuff repair (RCR).
Methods
A retrospective study of an institutional RCR registry was performed from July 2018 through March 2019. Preoperative PROMIS UE-CAT and ASES scores were collected. Floor and ceiling effects were determined, and convergent validity was established through Pearson correlations. Rasch partial credit modeling was used for psychometric analysis of the validity of PROMIS UE-CAT and ASES question items, a previously established methodology for assessing shoulder PROMs. Person-item maps were generated to characterize the distribution of question responses along the latent dimension of shoulder disability.
Results
Responses from 107 patients (107 shoulders) were included. PROMIS UE-CAT had a strong correlation to ASES (r=0.684; P <.001), with a 3.7% floor effect and no ceiling effect; ASES had no floor or ceiling effects. PROMIS UE-CAT person-item maps revealed excellent test item coverage between floor and ceiling effects; however, all PROMIS UE-CAT items except “Difficulty putting on a jacket” demonstrated non-sequentially ordered responses indicating poor reliability of item responses corresponding to shoulder function. While PROMIS UE-CAT initially demonstrated superior instrument efficiency with fewer test items for overall equivalent coverage of shoulder function assessment, final models after recursive item elimination revealed the ASES instrument to have more well-fitting items over a broader range of shoulder function.
Conclusion
Despite its overall strong correlation with ASES and equivalent coverage between floor and ceiling effects, the psychometric properties of PROMIS UE-CAT indicate a need for optimization of individual test items to correspond to shoulder function. Until further refinements in the PROMIS UE-CAT instrument are made, it should not replace the ASES instrument in patients undergoing primary RCR.
Rotator cuff tear is the most common shoulder pathology and primary repairs are being done more frequently. Failed rotator cuff tears are a real challenge for shoulder surgeons, especially when tears are massive and irreparable. Multiple surgical techniques have been developed to overcome this challenging pathology. The decision-making process should always start with full assessment of patient general health and function, in order to reach the most appropriate surgical treatment. Graft interpositions, also known as bridging reconstruction, are introduced as a joint-preserving surgery, trying to avoid the tendon morbidity associated with other procedures. The theory behind this technique is to restore the anatomy and bridge the defect by attaching the graft to the lateral aspect of the tendon and connecting it back to the greater tuberosity, with the goal of reconnecting the rotator cuff to the humerus and restoring normal shoulder function. The clinical and radiological data for bridging reconstruction are not abundant, but recent published studies are showing promising results. The aim of this chapter is to provide an overview of the bridging grafts, patient evaluation, surgical technique, and postoperative rehabilitation protocol and also to discuss recent clinical and radiological results of this technique.
A floating shoulder is the result of two or more disruptions to the bony-ligamentous complex that provides structural support to and enables function of the shoulder girdle. Patients presenting with a floating shoulder injury are often polytraumatized. Heterogeneity of the injury pattern and concomitant injuries to the patient mean that certain patients will benefit from surgery while others benefit from nonoperative treatment. In general, more severe injuries, as defined by mechanism of injury, fracture displacement, and concomitant injury burden receive operative treatment, while less severe injuries are treated nonoperatively. Clinical outcomes for patients who sustain a floating shoulder injury appear to be correlated to the glenopolar angle, meaning the goal of either surgical or nonsurgical treatment should be restoration of normal anatomic relationships throughout the shoulder.
W e carried out a prospective study of 93 patients undergoing surgery for conditions of the rotator cuff during 1994 and 1995. They were assessed before operation and after six months, and four years, using the patient-based Oxford Shoulder Score (OSS), the SF-36 questionnaire and the Constant shoulder score. The response rates were higher for the OSS and SF-36. The correlation coefficients were high (r > 0.5) between all scores at each stage of the study. While all scores improved substantially at six months, the Constant score was reduced significantly at four years. This did not correlate with the patients' judgement of the change in symptoms or of the success of the operation. Our study suggests that patient-based measures of pain and function can reliably assess outcomes in the medium term after surgery to the shoulder.
We have developed a 12-item questionnaire for completion by patients presenting with shoulder instability. A prospective study of 92 patients was undertaken involving two assessments, approximately six months apart, performed in an outpatient department. Each patient completed the new questionnaire and the SF36 form. An orthopaedic surgeon completed the Constant shoulder score and the Rowe assessment. The new questionnaire and the Rowe clinical score each achieved a large standardised effect size (≥ 0.8) and compared favourably with relevant items on the SF36. By contrast, the Constant score barely registered any effect, confirming that it may be relatively insensitive to changes in clinical status for this particular condition. The questionnaire provides a measurement of outcome for shoulder instability which is short, practical, reliable, valid and sensitive to changes of clinical importance.
This paper describes the development of an evaluative outcome measure for patients with upper extremity musculoskeletal conditions. The goal is to produce a brief, self-administered measure of symptoms and functional status, with a focus on physical function, to be used by clinicians in daily practice and as a research tool. This is a joint initiative of the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies (COMSS), and the Institute for Work and Health (Toronto, Ontario).Our approach is consistent with previously described strategies for scale development. In Stage 1, Item Generation, a group of methodologists and clinical experts reviewed 13 outcome measurement scales currently in use and generated a list of 821 items. In Stage 2a, Initial Item Reduction, these 821 items were reduced to 78 items using various strategies including removal of items which were generic, repetitive, not reflective of disability, or not relevant to the upper extremity or to one of the targeted concepts of symptoms and functional status. Items not highly endorsed in a survey of content experts were also eliminated. Stage 2b, Further Item Reduction, will be based on results of field testing in which patients complete the 78-item questionnaire. This field testing, which is currently underway in 20 centers in the United States, Canada, and Australia, will generate the final format and content of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Future work includes plants for validity and reliability testing. © 1996 Wiley-Liss, Inc.
Several methods have been devised to estimate shoulder function, none of which is entirely satisfactory. The method described in this article is applicable irrespective of the details of the diagnostic or radiologic abnormalities caused by disease or injury. The method records individual parameters and provides an overall clinical functional assessment. It is accurately reproducible by different observers and is sufficiently sensitive to reveal even small changes in function. The method is easy to perform and requires a minimal amount of time for evaluation of large population groups.
We have analysed the Constant-Murley (1987) assessment for 25 patients with shoulder pathology. We found the score easy to use, with low inter- and intraobserver errors, but sufficiently imprecise in repeated measurements to give concern in its use for clinical follow-up of patients.
We have calculated 95% confidence limits for a single assessment to be within 16 to 20 points in most cases. In addition, we found that all our subjects with instability as their main problem scored within five points of the maximum; this suggests that the scoring method may need to be revised for use on these patients.
We developed a 12-item questionnaire for completion by patients having shoulder operations other than stabilisation. A prospective study of 111 patients was undertaken before operation and at follow-up six months later. Each patient completed the new questionnaire and the SF36 form. Some filled in the Stanford Health Assessment Questionnaire (HAQ). An orthopaedic surgeon assessed the Constant shoulder score.
The single score derived from the questionnaire had a high internal consistency. Reproducibility, examined by test-retest reliability, was found to be satisfactory. The validity of the questionnaire was established by obtaining significant correlations in the expected direction with the Constant score and the relevant scales of the SF36 and the HAQ. Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at follow-up. Changes in scores were compared with the patients’ responses to postoperative questions about their condition. The standardised effect size for the new questionnaire compared favourably with that for the SF36 and the HAQ. The new questionnaire was the most efficient in distinguishing patients who said that their shoulder was much better from all other patients.
The shoulder questionnaire provides a measure of outcome for shoulder operations which is short, practical, reliable, valid and sensitive to clinically important changes.
The purpose of this study was to develop a valid, reliable, and responsive disease-specific quality of life measurement tool for patients with shoulder instability. Development included 1) identification of a specific patient population; 2) generation of issues specific to the "disease" ("items") from reviewing the literature, interviewing health caregivers, and interviewing patients representing all demographics, disease type and severity, and treatments; 3) item reduction using patient-generated frequency-importance products and correlation matrices; and 4) pretesting the prototype instrument on 2 groups of 10 patients. The final instrument, the Western Ontario Shoulder Instability Index, has 21 items representing 4 domains. The instrument attributes (validity, reliability, and responsiveness) were evaluated. Construct validation demonstrated that this index correlated predictably with other measures. Reliability was very high at 2 weeks and 3 months, and the index was more responsive (sensitive to change) than five other shoulder measurement tools (the Disabilities of the Arm, Shoulder and Hand scale; The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; the UCLA Shoulder Rating Scale; the Constant Score; and the Rowe Rating Scale), a global health instrument (the SF12), and range of motion. Since the patient's perception of changes in health status is the most important indicator of the success of a treatment, we suggest that this measurement tool be used as the primary outcome measure to evaluate treatments in this patient population, although it can also be used for monitoring patients' progress in clinical practice.
We carried out a prospective study of 93 patients undergoing surgery for conditions of the rotator cuff during 1994 and 1995. They were assessed before operation and after six months, and four years, using the patient-based Oxford Shoulder Score (OSS), the SF-36 questionnaire and the Constant shoulder score. The response rates were higher for the OSS and SF-36. The correlation coefficients were high (r > 0.5) between all scores at each stage of the study. While all scores improved substantially at six months, the Constant score was reduced significantly at four years. This did not correlate with the patients' judgement of the change in symptoms or of the success of the operation. Our study suggests that patient-based measures of pain and function can reliably assess outcomes in the medium term after surgery to the shoulder.
A shoulder pain and disability index (SPADI) was developed to measure the pain and disability associated with shoulder pathology. The SPADI is a self-administered index consisting of 13 items divided into two subscales: pain and disability. Thirty-seven male patients with shoulder pain were used in a study to examine the measurement characteristics of the SPADI. Test-retest reliability of the SPADI total and subscale scores ranged from 0.6377 to 0.6552. Internal consistency ranged from 0.8604 to 0.9507. SPADI total and subscale scores were highly negatively correlated with shoulder range of motion (ROM) supporting the criterion validity of the index. Principal components factor analysis with and without varimax rotation supported the construct validity of the total SPADI and its subscales. High negative correlations between changes in SPADI scores and changes in shoulder ROM indicated the SPADI detected changes in clinical status over short time intervals. The SPADI should prove useful for both clinical and research purposes.
The American Shoulder and Elbow Surgeons have adopted a standardized form for assessment of the shoulder. The form has a patient self-evaluation section and a physician assessment section. The patient self-evaluation section of the form contains visual analog scales for pain and instability and an activities of daily living questionnaire. The activities of daily living questionnaire is marked on a four-point ordinal scale that can be converted to a cumulative activities of daily living index. The patient can complete the self-evaluation portion of the questionnaire in the absence of a physician. The physician assessment section includes an area to collect demographic information and assesses range of motion, specific physical signs, strength, and stability. A shoulder score can be derived from the visual analogue scale score for pain (50%) and the cumulative activities of daily living score (50%). It is hoped that adoption of this instrument to measure shoulder function will facilitate communication between investigators, stimulate multicenter studies, and encourage validity testing of this and other available instruments to measure shoulder function and outcome.
A shoulder pain and disability index (SPADI) was developed to measure the pain and disability associated with shoulder pathology. The SPADI is a self-administered index consisting of 13 items divided into two subscales: pain and disability. Thirty-seven male patients with shoulder pain were used in a study to examine the measurement characteristics of the SPADI. Test-retest reliability of the SPADI total and subscale scores ranged from 0.6377 to 0.6552. Internal consistency ranged from 0.8604 to 0.9507. SPADI total and subscale scores were highly negatively correlated with shoulder range of motion (ROM) supporting the criterion validity of the index. Principal components factor analysis with and without varimax rotation supported the construct validity of the total SPADI and its subscales. High negative correlations between changes in SPADI scores and changes in shoulder ROM indicated the SPADI delected changes in clinical status over short time intervals. The SPADI should prove useful for both clinical and research purposes.
A prospective study was done of fifty total shoulder replacements in forty-four patients who were followed for an average of 3.5 years (range, 2.0 to 7.5 years). The preoperative diagnosis was osteoarthritis in thirty-three shoulders, rheumatoid arthritis in eleven, and a previous fracture of the humeral head in six shoulders. Nine of the shoulders had a tear of the rotator cuff. The Neer-II system of total shoulder replacement with a non-metal-backed component was used in all fifty shoulders. At follow-up, forty-four shoulders (88 per cent) had no significant pain. Of the six painful shoulders, four had loosening of the glenoid component and one had malposition of both components. Three of the six shoulders had no significant pain after revision. The average range of active forward elevation in all of the shoulders improved from 71 to 100 degrees, and both external and internal rotation improved as well. Five specific activities of daily living were evaluated, and the patients' ability to perform them improved from 14 to 78 per cent. Thirty-five shoulders (68 per cent) were rated by the patients as much better; thirteen shoulders (26 per cent), as better; and three (6 per cent), as no better. An incomplete lucent line was noted around five (10 per cent) of the cemented humeral stems and around thirty-seven (74 per cent) of the glenoid prostheses. Four arthroplasties (8 per cent) required revision: three for loosening of the glenoid component and one for malposition of both components.(ABSTRACT TRUNCATED AT 250 WORDS)
Many controlled trials rely on subjective measures of symptoms or quality of life as primary outcomes. The relative merits of different response options for these measures is an important, but largely unexplored, issue. Therefore, we compared the responsiveness of seven-point Likert vs visual analogue scales (VAS) in a questionnaire measuring quality of life in chronic lung disease. The VAS and seven-point scale versions of the questionnaire were administered to 28 patients before and after completing an inpatient respiratory rehabilitation program of known benefit. For all four dimensions of the questionnaire (dyspnea, fatigue, emotional function, and mastery) the VAS showed a larger improvement than the seven-point scale when both were standardized on a scale of 0-10. However, in each case the variability of the improvement was greater using the VAS. The difference in improvement between the two scales was not statistically significant. We conclude that the two methods of presenting response options show comparable responsiveness. The ease of administration and interpretation of the seven-point scale recommend its use in clinical trials.
In fifty patients who had fifty tears of the rotator cuff that had been repaired, we correlated the preoperative findings by history, physical examination, and radiography with the operative findings, the difficulty of the repair, and the results after an average follow-up of 3.5 years. The results, which were rated on the basis of pain, function, range of motion, strength, and satisfaction of the patient, were satisfactory in 84 per cent and unsatisfactory in 16 per cent. The correlations of the preoperative findings with the results showed that pain and functional impairment, the primary indications for repair, were significantly relieved. The longer the duration of pain was preoperatively, the larger the cuff tear and the more difficult the repair were. The strength of abduction and of external rotation before repair was of prognostic value: the greater the weakness, the poorer the result. The poorest results were in patients with strength ratings of grade 3 or less. Limitation of active motion preoperatively was also of prognostic value: in patients who were unable to abduct the shoulder beyond 100 degrees preoperatively, there was an increased risk of a poor result. An acromiohumeral distance of seven millimeters or less (measured on the anteroposterior radiograph) suggested a larger tear and the likelihood that after repair there would be less strength in flexion, less active motion, and lower scores. Single or double-contrast arthrography was not consistently accurate in estimating the size of the tear. After so-called watertight repair and anterior acromioplasty, successful results can be anticipated in a high percentage of patients.
Tests or measures in clinical medicine or the social sciences can be used for three purposes: discriminating between subjects, predicting either prognosis or the results of some other test, and evaluating change over time. The choices made at each stage of constructing a quality of life index will differ depending on the purpose of the instrument. We explore the implications of index purpose for each stage of instrument development: selection of the item pool, item scaling, item reduction, determination of reliability, of validity, and of responsiveness. At many of these stages, not only are the requirements for discriminative, predictive, and evaluative instruments not complementary, they are actually competing. Attention to instrument purpose will clarify the choices both for those developing quality of life measures and for those selecting an appropriate instrument for clinical studies.
The UCLA total shoulder arthroplasty was designed to mobilize the shoulder joint in order to permit normal anthropometric range of motion and durable long-term fixation of the components. The prosthesis is fundamentally nonconstrained for the usual arthritic conditions, currently with four sizes of femoral and glenoid components. For patients with deficient and irreparable rotator cuffs, additional restraint may be effected by using a superior glenoid subacromial rim. The first 11 patients have been followed for 1 1/2 to 3 1/2-years; relief of pain has been complete in all but two patients. The function and range of motion results were related to the status of the rotator cuff; five patients achieved excellent results, including two with osteoarthritis who had near normal function. Patients with deficient rotator cuffs achieved functional use of the extremity but without full range of motion. Functionally, in addition to the five patients who were rated excellent, two were rated as being good, three fair, and one poor. In addition to five with excellent range of motion, there were three good and four fair ratings. Two patients, one with grossly deficient musculature caused by a gunshot wound and a second who was posttrauma required revision surgery with a subacromial glenoid prosthesis. This prosthesis is now frequently utilized if muscles and rotator cuff are deficient at the primary surgery, in order to provide additional restraint. Determination of the efficacy of hooded components will require further follow-up. The additional size ranges and components together with improved instrumentation have greatly facilitated recent surgery.
The preoperative function, expectations of pain relief and expectations of improvement in activities of daily living were compared with the results nine months after total hip replacement in 145 patients with osteoarthrosis or rheumatoid arthritis. patients improved functionally and their expectations generally were met. They were most satisfied with improvements in pain relief and mobility but 28% still expressed disappointment because specific expectations were not fulfilled. The expectations of doctors were higher than those of occupational therapists.
Building on prior conceptual schemes, this article presents a sociomedical model of disability, called The Disablement Process, that is especially useful for epidemiological and clinical research. The Disablement Process: (1) describes how chronic and acute conditions affect functioning in specific body systems, generic physical and mental actions, and activities of daily life, and (2) describes the personal and environmental factors that speed or slow disablement, namely, risk factors, interventions, and exacerbators. A main pathway that links Pathology, Impairments, Functional Limitations, and Disability is explicated. Disability is defined as difficulty doing activities in any domain of life (from hygiene to hobbies, errands to sleep) due to a health or physical problem. Feedback effects are included in the model to cover dysfunction spirals (pernicious loops of dysfunction) and secondary conditions (new pathology launched by a given disablement process). We distinguish intrinsic disability (without personal or equipment assistance) and actual disability (with such assistance), noting the scientific and political importance of measuring both. Disability is not a personal characteristic, but is instead a gap between personal capability and environmental demand. Survey researchers and clinicians tend to focus on personal capability, overlooking the efforts people commonly make to reduce demand by activity accommodations, environmental modifications, psychological coping, and external supports. We compare the disablement experiences of people who acquire chronic conditions early in life (lifelong disability) and those who acquire them in mid or late life (late-life disability). The Disablement Process can help inform research (the epidemiology of disability) and public health (prevention of disability) activities.
The purpose of this study was to compare patients' and physicians' evaluations of the results of 147 total hip arthroplasties. The patients and physicians independently evaluated pain and over-all satisfaction with the outcome of the procedure using a 10.0-centimeter visual-analog scale. They also answered a questionnaire with which they assessed general health, functional ability, and pain. The mean (and standard deviation) analog rating for pain (with 0.0 centimeters indicating no pain and 10.0 centimeters, severe pain) was 1.7 +/- 2.6 centimeters as assessed by the patients and 1.1 +/- 1.8 centimeters as assessed by the physicians (p < 0.001, paired t test). The mean analog rating for over-all satisfaction (with 0.0 centimeters indicating poor and 10.0 centimeters, excellent) was 8.6 +/- 2.1 centimeters as assessed by the patients and 8.8 +/- 1.7 centimeters as assessed by the physicians (p = 0.07, paired t test). There was a marked disparity between the patients' and the physicians' scores when the patients assigned a low score to a particular area. For the thirty patients who rated the pain as more than 4.0 centimeters, the mean analog rating was 6.8 +/- 2.1 centimeters according to the patients, while it was 3.6 +/- 2.7 centimeters according to the physicians (p < 0.001, linear regression). The mean analog rating for over-all satisfaction according to the nineteen patients who rated this parameter as less than 7.0 centimeters was 3.8 +/- 2.0 centimeters, while the mean rating according to the physicians 6.5 +/- 2.8 centimeters (p < 0.001, linear regression). The patients' and physicians' evaluations were similar regarding the results of the total hip arthroplasty when the patients had little or no pain and were satisfied with the result. However, the disparity increased as the patients' ratings for pain increased and their ratings for over-all satisfaction decreased. This study highlights a discrepancy between patients' and physicians' evaluations of the results of total hip arthroplasty. This discrepancy increased when the patient was not satisfied with the outcome. The use of patients' self-administered questionnaires as well as traditional physician-generated assessments may provide a more complete evaluation of the results of total hip arthroplasty.
We evaluated the comparability of four commonly used shoulder scoring systems in the United States. Fifty-two patients had 53 shoulder stabilization procedures. Surgical procedures included 34 open Bankart-type repairs, 15 capsular shifts, and 4 arthroscopic stabilizations. Results were assessed using the following scales: 1) Rowe, 2) modified-Rowe, 3) University of California at Los Angeles, and 4) the pre-1994 American Shoulder and Elbow Surgeons scale. No consensus has been reached on the relative value of these systems. We observed significant variations using these systems. A majority of our patients (85%) had excellent results when the University of California at Los Angeles scoring system was used. However, only 38% of the patients had excellent results when the modified-Rowe scale was used. Overall, good or excellent results were observed in 89% to 95% of the patients using these four scoring systems. The University of California at Los Angeles score correlated poorly with the other systems. Interrater reliability between the four systems was poor. Generalized results of an investigation can be biased based on the selection of a scoring system. The lack of a widely accepted scoring system for the shoulder limits comparison of management for shoulder conditions. Thus, a widely accepted shoulder scoring system is needed.
A self-administered questionnaire was designed to assess the severity of symptoms related to and the functional status of the shoulder. It includes domains of global assessment, pain, daily activities, recreational and athletic activities, work, satisfaction, and areas for improvement. Each domain is graded separately and is weighted to arrive at the total score. The over-all scale and each domain were prospectively tested for validity, reliability, and responsiveness to clinical change. One hundred patients who were seen for evaluation of the shoulder were enrolled in the study. The validity of the scale was demonstrated by moderate-to-high correlation of the domains and individual questions of the Shoulder Rating Questionnaire with those of the Arthritis Impact Measurement Scales 2. Validity was supported further by significant correlation of the scores in each domain with the level of satisfaction in that domain and by significantly lower scores in domains that patients selected as areas important for improvement. The over-all scale and each domain were internally consistent (Cronbach alpha, 0.71 to 0.90). Reproducibility was evaluated by repeated administration of the questionnaire after a mean of three days to forty patients whose condition was clinically stable. Reproducibility of the over-all questionnaire and individual domains was excellent (Spearman-Brown index, 0.94 to 0.98). Individual questions were reproducible, with a weighted kappa value of more than 0.7 for each. Responsiveness was evaluated by comparison of the preoperative and postoperative scores of thirty patients who had a satisfactory result one year after an operation on the shoulder. The over-all Shoulder Rating Questionnaire and each domain were responsive to clinical change as demonstrated by favorable standardized response means (range, 1.1 to 1.9) and indices of responsiveness (range, 1.1 to 2.0). Similar analysis performed for individual diagnostic groups supported the validity, reliability, and responsiveness of the questionnaire in each group. The self-administered shoulder questionnaire was found to be valid, reliable, and responsive to clinical change. These qualities should make it a useful instrument for the prospective assessment of the outcome of treatment of disorders related to the shoulder.
Our purpose was to compare the effectiveness of traditional treatment with immediate arthroscopic stabilization in young patients who have sustained a first traumatic anterior dislocation of the shoulder. Forty skeletally mature patients younger than 30 years of age were randomly allocated to immobilization for 3 weeks followed by rehabilitation (group T) or arthroscopic stabilization (within 4 weeks of injury) followed by an identical immobilization and rehabilitation protocol (group S). A blinded research assistant performed all follow-up evaluations. The dominant arm was involved in 35% of subjects. The injury occurred in a sporting event in 70% of subjects. At 24 months, there was a statistically significant difference in the rate of redislocation (T = 47%, S = 15.9%, P = .03). An intention-to-treat analysis comparing disease-specific quality of life using the validated Western Ontario Shoulder Instability (WOSI) index showed statistically significantly better results in the surgically treated group at the 33 months (T = 633.93 v S = 287.1, P = .03) and no significant difference in range of motion. At an average 32 months follow-up, a significant reduction in redislocation and improvement in disease-specific quality of life is afforded by early arthroscopic stabilization in patients less than 30 year of age with a first, traumatic, anterior dislocation of the shoulder.
The purposes of this report are (1) to describe the development of a quality-of-life outcome measure for rotator cuff disease (RC-QOL) and a new simple test of rotator cuff function, the Functional Shoulder Elevation Test (FSET), and (2) to compare these with the SF-36 and the American Shoulder and Elbow Surgeons Assessment (ASESA) in a cohort of 86 patients with surgically treated large and massive rotator cuff tears. The RC-QOL is a 34-item self-administered questionnaire that has demonstrated excellent reliability, face validity, and ability to discriminate between large and massive cuff tears; it has also confirmed the construct of higher correlations with the other shoulder outcome measures than with the SF-36. The FSET is a simple test of rotator cuff function that uses 5% body weight and measurement of pain and discomfort on a 100-point visual analog scale. It was highly correlated with the RC-QOL and ASESA and discriminated between large and massive cuff tears. The study achieved an 82% follow-up at an average of 3.5 years. Large cuff tears had statistically significantly improved outcome scores in comparison with massive cuff tears on these 3 outcome measures. The SF-36, however, was not able to discriminate between tear sizes. The RC-QOL and the FSET are recommended outcome measures for rotator cuff disease.
The purpose of this study was to develop and validate a disease-specific quality of life measurement tool for osteoarthritis (OA) of the shoulder.
An instrument which could be used as the primary outcome measure in clinical trials involving patients with OA of the shoulder was developed using a specific methodological protocol: (1) identification of a specific patient population; (2) item generation; (3) item reduction; (4) pre-testing of the prototype questionnaire and (5) determining the validity, reliability and responsiveness of the final questionnaire.
The final instrument contains 19 items, each with a visual analog response option for the four domains (six questions for pain and physical symptoms, five questions for sport, recreation and work, five questions for lifestyle function and three questions for emotional function). Ten of the 19 questions had not been identified previously on other shoulder measurement tools. The instrument proved to be valid by demonstrating predicted correlations with previously published shoulder measures, global health status measure and range of motion. The new instrument was also more responsive than other shoulder measurement tools, a global health status measure and range of motion.
Since the patient's own perception of changes in health status is the most important indicator of the success of treatment we suggest that this measurement tool be used as the primary outcome in clinical evaluation of various treatments for OA of the shoulder and monitoring patients over time.
The purpose of this study was to develop a valid and reliable disease-specific quality-of-life measurement tool for patients with rotator cuff disease.
Health-related quality-of-life measurement tool development.
Methodology for the development and evaluation of the tool included the following: 1) identification of a specific patient population, 2) generation of potential items, 3) item reduction, 4) pretesting the prototype instrument, 5) determination of reliability, and 6) validation.
The final instrument, the Western Ontario Rotator Cuff Index, double dagger has 21 items representing five domains, each with a Visual Analog Scale-type response option. Construct validation demonstrated that this instrument correlated predictably with other measurement tools (Disabilities of the Arm, Shoulder, and Hand outcome measure; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; University of California Los Angeles Shoulder Rating Scale; Constant Score; Rowe; Sickness Impact Profile; Short Form 36; and range of motion; 21 of 21 correlations within 0.19). Reliability was very high at 2 weeks, with an intraclass correlation coefficient of 0.96 and was more responsive (sensitive to change) than the other five shoulder measurement tools, global health instruments, and range of motion.
This measurement tool can be used as the primary outcome in clinical trials evaluating treatments in this patient population, although its features are equally attractive for monitoring patients' progress in clinical practice.
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