Scoring systems for the functional assessment of the shoulder

doi:10.1016/j.arthro.2003.10.030

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 19, Issue 10, December 2003, Pages 1109-1120

https://doi.org/10.1016/j.arthro.2003.10.030 Get rights and content

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).

Section snippets

The rating sheet for Bankart repair

In 1978, Carter Rowe published a classic article evaluating the long-term results of the Bankart repair.1 It was in this article that he introduced a new rating system for the postoperative assessment of patients undergoing anterior stabilization. This system scores patients based on 3 separate areas—stability, motion, and function—with 1 item for each of these areas. The weighting is such that stability accounts for 50 points, motion for 20 points and function for 30 points, giving a total

The UCLA shoulder score

The University of California at Los Angeles Shoulder Rating scale was first published in 1981 in a paper by H. C. Amstutz et al.2 The instrument was intended to be used in studies of patients undergoing total shoulder arthroplasty for arthritis of the shoulder. Since then, however, it has been used for patients with other shoulder conditions including rotator cuff disease3 and shoulder instability.4

This instrument assigns a score to patients based on 5 separate domains: pain, function, active

The shoulder pain and disability index (SPADI)

In 1991, Roach et al. published the development and evaluation of the SPADI.5 The authors state that “the SPADI was developed to provide a self-administered instrument that would reflect the disability and pain associated with the clinical syndrome of painful shoulder.” It was designed as both a discriminative and evaluative instrument. The majority of the item generation and reduction was carried out by a panel of 3 rheumatologists and a physical therapist without direct patient input. Further

The American shoulder and elbow surgeons evaluation form (ASES)

In 1993, the Society of the American Shoulder and Elbow Surgeons developed a standardized form for the assessment of shoulder function.6 The purpose was to facilitate communication between investigators and to permit and encourage multicenter trials. The members felt that the required attributes of any new tool were ease of use, a method of assessing activities of daily living and inclusion of a patient self-evaluation section. The research committee of the ASES reviewed all published forms

The constant score

The Constant Score7 has become the most widely used shoulder evaluation instrument in Europe. This scoring system combines physical examination tests with subjective evaluations by the patients. The subjective assessment consists of 35 points and the remaining 65 points are assigned for the physical examination assessment.

The subjective assessment includes a single item for pain (15 points) and 4 items for activities of daily living (work 4, sport 4, sleep 2, and positioning the hand in space

The disabilities of the arm, shoulder and hand (DASH)

Recently, the American Academy of Orthopaedics Surgeons (AAOS) along with the Institute for Work & Health (Toronto, Ontario, Canada) developed an outcome tool to be used for patients with any condition of any joint of the upper extremity. This instrument called the Disabilities of the Arm, Shoulder and Hand Measurement tool or DASH is made available by the AAOS. A brief description of the methodology for the item generation and the initial item reduction phases has been published.9 In 1999, the

The shoulder rating questionnaire

In 1997, L’Insalata et al. published the Shoulder Rating Questionnaire “a self-administered questionnaire for the assessment of symptoms and function of the shoulder.”18 It is unknown how the items on the instrument were generated or selected. It is simply stated that “A preliminary questionnaire was developed.” The preliminary questionnaire was administered to 30 patients and a subset of those patients were interviewed to identify clinical relevance, relative importance, and ease of completion

The simple shoulder test (SST)

In 1992 Lippitt, Harryman, and Matsen reported on the development and testing of the Simple Shoulder Test (SST).19 The purpose of the instrument is stated to be a means of documenting the functional improvement resulting from a specified procedure performed by a specific surgeon in response to a given diagnosis and to characterize the severity of the condition.

The SST consists of 12 questions with “yes or no” response options. The instrument combines subjective items and items that actually

The western Ontario shoulder tools

In 1998, Kirkley et al. published the first in a series of disease-specific quality of life measure tools for the shoulder, The Western Ontario Shoulder Instability Index (WOSI).14 This instrument was developed and evaluated using the methodology as described by Kirschner and Guyatt.22 The stated purpose of the instrument was for use as the primary outcome measure in clinical trials evaluating treatments for patients with shoulder instability.

In 2001, the second in the series of

The western Ontario shoulder instability index (WOSI)

The reliability of the WOSI has been evaluated in 51 stable patients at 2 weeks and 3 months in conjunction with a global rating of change score. The patient population tested was only briefly described as patients with shoulder instability who were stable and it is not clear how diverse a population this was. The ICCs at 2 weeks and 3 months for the total score (.95 and .91) and individual domain scores (range .72 to .94) are reported.

The instrument was administered to 47 patients undergoing

The western Ontario osteoarthritis of the shoulder index (WOOS)

The reliability of the WOOS instrument has been evaluated in 58 stable patients at 3 months in conjunction with a global rating of change score. The patient population tested was described as meeting the inclusion criteria of primary osteoarthritis of the shoulder. The ICC was calculated based on the 22 subjects who remained stable over the 3 months. The ICC for the total score was .96 and for each of the domains ranged from .87 to .95. This number may be falsely decreased by the long

The western Ontario rotator cuff index (WORC)

The reliability and validity of the WORC was assessed in patients who were being treated for rotator cuff tendinosis with no or a small full-thickness cuff tear. Patients completed the WORC and other measures of health as well as a global rating of change score. Those that indicated they had not changed at 2 weeks were used for the analysis of reliability. The ICC was calculated based on the 50 subjects who remained stable over the 2 weeks. The ICC for the total score was .96 and for each of

The rotator cuff quality-of-life measure (RC-QOL)

In October 2000, Hollinshead et al. published a paper reporting on the 6-year follow-up of large and massive rotator cuff tears.27 In the article, they introduced a new disease-specific quality of life instrument for patients with rotator cuff disease. The instrument was developed and tested using similar methodology to that described by Guyatt et al.28 This instrument is indicated for use as an outcome tool in patients with the “full spectrum of rotator cuff disease.”

Item generation was

Oxford shoulder scores (OSS)

Similar to Kirkley et al., Dawson, Fitzpatrick and Carr29 have published 2 questionnaires that deal with the perceptions of patients about shoulder surgery. The first, the Oxford Shoulder Score (OSS) was published in 1996 and is for patients having shoulder operations other than stabilization. The second questionnaire was published in 1999 and is meant for the group of patients who had been excluded from the original questionnaire, those presenting with shoulder instability.30 Both are 12-item

Conclusion

In summary, older instruments designed for evaluating shoulder conditions were developed at a time when little information was available or little attention was paid to the appropriate methodology for such endeavors. However, there now exist a number of instruments that are excellent for specific conditions of the shoulder. Much work remains to be done to evaluate these instruments in specific patient populations, to determine values for the minimally clinically important difference for each of

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The subcoracoid distance is correlated with pain and internal rotation after reverse shoulder arthroplasty
2024, JSES International
A proposed etiology of anterior shoulder pain and limited internal rotation after reverse shoulder arthroplasty (RSA) is impingement of the humeral component on the coracoid or conjoint tendon. The primary goal of this study was to investigate radiographic surrogates for potential coracoid or conjoint tendon impingement and their relationship to postoperative pain and internal rotation after RSA.
A retrospective review of a clinical registry was performed to identify patients with (1) primary RSA, (2) minimum 2-year clinical follow-up, and (3) satisfactory postoperative axillary lateral radiographs. The primary radiographic measurement of interest was the subcoracoid distance (SCD), defined as the distance between the posterior aspect of the coracoid and the anterior glenosphere. Additional measurements were as follows: anterior glenosphere overhang, posterior glenosphere overhang, native glenoid width, lateralization of glenosphere relative to the coracoid tip, lateralization shoulder angle, and distalization shoulder angle. The primary clinical outcome of interest was the 2-year postoperative Visual Analog Scale score. Secondary outcomes were (1) internal rotation (IR) defined by spinal level (IRspine), (2) IR at 90 degrees of abduction, (3) American Shoulder and Elbow Surgeons score, (4) forward flexion, and (5) external rotation at 0 degrees of abduction. Linear regression analyses were used to evaluate the relationship of the various radiographic measures on the clinical outcomes of interest.
Two hundred seventeen patients were included. There was a statistically significant relationship between the SCD and Visual Analog Scale scores: B = −0.497, P = .047. There was a statistically significant relationship between the SCD and IRspine: B = −1.667, P < .001. Metallic lateralization was also positively associated with improving IRspine; increasing body mass index was negatively associated. There was a statistically significant relationship between the SCD and IR at 90 degrees of abduction: B = 5.844, P = .034.
For RSA with a 135° neck shaft angle and lateralized glenoid, the postoperative SCD has a significant association with pain and IR. Decreasing SCD was associated with increased pain and decreased IR, indicating that coracoid or conjoint tendon impingement may be an important and potentially under-recognized etiology of pain and decreased IR following RSA. Further investigations aimed toward identifying a critical SCD to improve pain and IR may allow surgeons to preoperatively plan component position to improve clinical outcomes after RSA.
Rotator cuff isometric exercises in combination with scapular muscle strengthening and stretching in individuals with rotator cuff tendinopathy: A multiple-subject case report
2024, Journal of Bodywork and Movement Therapies
To assess the effects of a rehabilitation protocol of rotator cuff (RC) isometrics coupled with traditional shoulder exercises on patient-rated outcomes, muscle strength, and electromyographic activity in individuals with RC tendinopathy. Methods: Eleven individuals (8 women and 3 men, 37.9 ± 5.6 years) with RC tendinopathy performed isometric RC exercises in combination with scapular muscle stretching and strengthening for 6 weeks. Treatment effects were assessed with patient-rated pain and shoulder function, isometric muscle strength, electromyographic activity during arm elevation and internal and external shoulder rotation, and pain during arm elevation before and at the end of the first session, and after 6 weeks of intervention. Results: There were improvements in pain and shoulder function, increased isometric muscle strength for arm elevation and internal rotation, increased muscle activity of the infraspinatus and serratus anterior, and reduced pain during arm elevation after 6 weeks of intervention. Discussion: This case report showed improvements on pain and function, increases on isometric strength of the shoulder and on electromyographic activity of the serratus anterior and infraspinatus muscles, as well as decreases on pain during arm elevation, after a 6-week intervention of RC isometric exercises associated with scapular muscle stretching and strengthening in patients with RC tendinopathy.
Validity and reliability of the Thai functional internal rotation scale for shoulder arthroplasty
2023, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology
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.
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.
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).
The Thai Functional Internal Rotation Scale has good validity and excellent reliability in assessing internal rotation function in Thai shoulder arthroplasty patients.
Evaluation of muscle strength recovery following superior capsular reconstruction using a tensor fascia lata graft: a comparison with the unaffected side
2023, Journal of Shoulder and Elbow Surgery
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.
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 motionand acromiohumeral distance were also evaluated.
The postoperative range of motions and acromiohumeral distance (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).
Abduction strength was not sufficiently restored after SCR when compared to that on the unaffected side.
Osteoporosis does not affect bone mineral density change in the proximal humerus or the functional outcome after open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up
2023, Journal of Shoulder and Elbow Surgery
The aim of this prospective study was to investigate bone mineral density (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.
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 for osteoporosis status was employed. Postoperative and 6-week, 3-, 6-, and 12-month shoulder radiographs and dual-energy x-ray absorptiometry of the shoulder with BMD measures in 4 templated regions of interest (ROIs) were performed. Functional outcomes, Western Ontario Osteoarthritis of the Shoulder index, Constant score, visual analog scale pain (VAS), and 36-Item Short Form Survey, were collected.
A total of 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 nonosteoporosis groups. The BMD values gradually declined from baseline to 3-month follow-up in all 4 ROIs of the operated shoulders. All 4 ROIs in the operated shoulder presented with a reduction in BMD at 3, 6, and 12 months compared with baseline, whereas no significant BMD changes were seen in the healthy shoulder during the study period. The functional outcomes displayed an increase in Constant score from 3 to 12 months, but a decrease in domains of the 36-Item Short Form Survey from preinjury to 12 months (physical functioning, general health, and bodily pain). Preinjury and 12-month Western Ontario Osteoarthritis of the Shoulder index, VAS pain at rest, and VAS pain at activity were comparable.
BMD changes appeared swiftly in the proximal humerus, after the treatment of displaced 3- or 4-part 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 the treatment of displaced 3- or 4-part fractures with ORIF.
Platelet-Rich Plasma Injection Can Be a Viable Alternative to Corticosteroid Injection for Conservative Treatment of Rotator Cuff Disease: A Meta-analysis of Randomized Controlled Trials
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
To explore whether platelet-rich plasma (PRP) injection can be a viable alternative to corticosteroid (CS) injection for conservative treatment of rotator cuff disease.
This 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 from January 1, 1990, to March 20, 2022, for English-language randomized controlled trials that compared PRP and CS injections for patients with rotator cuff disease. Two evaluators independently screened the literature, extracted data, and assessed the level of evidence and methodologic quality of the enrolled studies. The meta-analysis was conducted using RevMan software (version 5.3.3).
Thirteen nonsurgical randomized controlled trials with 725 patients were included. Compared with CS, PRP provided statistically worse short-term (<2 months) changes in American Shoulder and Elbow Surgeons (ASES) assessment scores, Simple Shoulder Test scores, and Disabilities of the Arm, Shoulder and Hand questionnaire scores but provided better medium-term (2-6 months) changes in Disabilities of the Arm, Shoulder and Hand scores, as well as long-term (≥6 months) changes in Constant-Murley scores, ASES scores, and Simple Shoulder Test scores. No statistically significant differences regarding pain reduction were found between the 2 groups. PRP injections led to worse short-term changes in forward flexion and internal rotation but better medium-term changes in forward flexion and external rotation. PRP showed significantly lower rates of post-injection failure (requests for subsequent injections or surgical intervention prior to 12 months) than CS. No outcome reached the minimal clinically important difference. After sensitivity analyses excluding studies with substantial clinical and/or methodologic heterogeneity, PRP showed better medium-term changes in ASES scores and visual analog scale scores and long-term changes in visual analog scale scores that reached the minimal clinically important difference.
Without the drawbacks of CS injection, PRP injection is not worse than CS injection in terms of pain relief and function recovery at any time point during follow-up. PRP injection may reduce rates of subsequent injection or surgery, and it might provide better improvements 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.
Meta-analysis of Level I and II studies.

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ISAKOS scientific committee reportScoring systems for the functional assessment of the shoulder

Abstract

Section snippets

The rating sheet for Bankart repair

The UCLA shoulder score

The shoulder pain and disability index (SPADI)

The American shoulder and elbow surgeons evaluation form (ASES)

The constant score

The disabilities of the arm, shoulder and hand (DASH)

The shoulder rating questionnaire

The simple shoulder test (SST)

The western Ontario shoulder tools

The western Ontario shoulder instability index (WOSI)

The western Ontario osteoarthritis of the shoulder index (WOOS)

The western Ontario rotator cuff index (WORC)

The rotator cuff quality-of-life measure (RC-QOL)

Oxford shoulder scores (OSS)

Conclusion

J Shoulder Elbow Surg

Soc Sci Med

Arthritis Cartilage

J Chronic Dis

The Bankart procedure—A study of late results

J Bone Joint Surg Am

UCLA anatomic total shoulder arthroplasty

Clin Orthop

Repair of rotator cuff. Factors influencing reconstruction

J Bone Joint Surg Am

Scoring systems for shoulder conditions

Am J Sports Med

Development of a shoulder pain and disability index

Arthritis Care Res

A clinical method of functional assessment of the shoulder