Functional outcomes assessment in shoulder surgery

Table 1 General shoulder measures

Measure	Description	Validity	Reliability	Responsiveness	MCID
The constant score[36,39,74,75]	10 items: Physical Examination (4 motion, 1 strength) Subjective evaluation (1 pain, 4 ADL) Score: 0-100 (Higher = better) 65 points for physical examination 35 points for subjective evaluation	Criterion validity with WORC, Penn, SST, Oxford, and others. Weaker correlation with DASH, ASES, SF-36 Content validity - concern over methods for strength testing Construct validity high except for shoulder instability; scores and strength decrease with age for both sexes	Very good ICC for shoulder dysfunction 0.8-0.87 SEM 8.9	Excellent except for Shoulder instability Effect size: Arthroplasty: 2.23- 3.02 Rotator cuff repair: 1.92 Shoulder instability: 0.20	10.4
UCLA shoulder score[27,65,76-78]	5 items Likert pain scale (1) Function (1) Active forward elevation (1) Forward elevation strength (1) Patient satisfaction (yes/no) Score 0-35 10 pts for pain/function, 5 pts each for active foreward elevation, strength, and satisfaction Can be converted to 0-100 pts for comparison	Criterion validity: Correlated sternly with Constant, ASES, and SF-36; fair to good correlation with SST; fair correlation with constant score; very good correlation with WOSI Construct validity: Demonstrated improvement after subacromial decompression; UCLA score had poor and fair correlation to forward motion and the abduction ratio respectively	Not evaluated	Limited Evaluation Effect size: Subacromial decompression 2.73 at 6 mo Proximal humerus fractures- moderate responsiveness	Not established
DASH[75,79]	30 items Physical activities in arm, shoulder, hand (21) symptoms of pain, tingling, weakness (5) Impact on social activities (4) Score: 0-100 (Lower = Better) Must answer 27 questions to be scored 4 optional sport/music/work items	Criterion validity: Correlated with other scores over different regions of the upper extremity and general outcome measures including the SF-36 Construct validity Difference between: working/not able to work; disease and health state; ability to do what they want versus not able	Excellent ICC: 0.77-0.98 SEM: 2.8-5.2	Excellent Effect size (all studies): 0.4-1.4	10 for shoulder complaints 17 for elbow, wrist and hand
SST[49,68,75]	12 yes/no items	Criterion validity: Strong correlation with ASES, moderately correlated with physical function portion of SF-12 Content validity Differences between: Age groups; shoulder instability versus rotator cuff injury; workers compensation status	Excellent ICC: 0.97-0.99 SEM: N/E	Limited Evaluation Effect size 0.8 in shoulder instability and rotator cuff injuries	2 for rotator cuff disease
ASES evaluation form[55,56,75,80]	11 items Pain VAS (1) Function (10) Score: 0-100 (Higher is better) 50 pts pain/50 pts function Physician assessment is not scored	Criterion validity: Strong correlation with constant-Murley, UCLA, and SST; strong correlation with multiple rotator cuff specific scores; and highly correlated with the SF-12 functional domains, but not the emotional, mental health, and social portions. Content validity Differences found between: Gotten much better and slightly better; minimally, moderately, and maximally functionally limited	Excellent ICC: 0.84-0.96 SEM: 6.7	Excellent Effect size (all studies) 0.9-3.5	6.4 for various shoulder pathologies 12-17 for rotator cuff disease
PENN shoulder score[56,58,81-83]	24 items Pain VAS scales with rest, ADLs, strenuous activities (3) Patient satisfaction VAS (1) Functional assessment section (20) Score 0-100 (Higher = Better) Pain 30 pts Satisfaction 10 pts Function 60 pts	Criterion validity: Excellent correlation with constant; excellent to very good correlation with ASES; Content validity: PSS is negatively affected by chest related, but not other medical comorbidities; pain subscale was not responsive to surgical and nonsurgical treatments	Excellent ICC: 0.94 SEM: 8.5	Not rigorously evaluated Effect size of pain subscale 1.84 for all comers	11.4 for patients with shoulder problems undergoing physical therapy 21 for patients with impingement

UCLA: University of California Los Angeles; ASES: American shoulder and elbow surgeons; DASH: Disabilities of the arm, shoulder and hand; SST: Simple shoulder test; PENN: Pennsylvania; MCID: Minimum clinically important difference: SF-36: Short Form 36; SEM: Standard error of measurement; ICC: Intraclass correlation coefficient; VAS: Visual analog scale; ADL: Activity of daily living.

Table 2 Condition specific shoulder measures

Instability	Description	Validity	Reliability	Responsiveness	MCID
WOSI[62,65,84]	21 items: Physical symptoms (10) Sport/recreation/work function (4) Lifestyle function (4) Emotional function (3) Score: 0-2100 (Lower = Better) (can be converted into 0%-100% scale)	Content validity: Items established by experts and patients Criterion validity: Excellent Correlate: VAS Function and DASH, good with CMS and Rowe	Excellent ICC: 0.87-0.98	Excellent Effect size: 1.67 for stabilization	220/2100
OSIS[28,62]	12 Items: Score: 12-60 (Lower = Better)	Criterion validity: Correlated with rowe and constant scores	Excellent PCC: 0.97	Very good Effect size: 0.8	Not reported
MIIS[62,66]	22 items: Pain (4) Instability (5) Function (8) Occupation and sports (5) Score: 0-100 (lower = better)	Criterion validity: Low to moderate correlation with shoulder rating questionnaire. Otherwise untested	Excellent ICC: 0.98	Not reported	Not reported
Rowe score[63,64]	3 items: Stability (50 points) Motion (20 points) Function (30 points) Score: 0-100 (both subjective and examination dependant)	Content Validity: poorly described development and methodology Criterion Validity: Correlated with WOSI and CMS	Fair ICC 0.7	Very good Effect size 1.2	Not reported
Rotator cuff
WORC[69]	21 items: Physical symptoms (10 items) Sport/recreation/work function (4 items) Lifestyle function (4 items) Emotional function (3 items) Score: 0-2100 (Lower = Better) (can be converted into 0%-100% scale)	Content validity: Items established by experts and patients Criterion validity: Correlated with ASES, DASH and UCLA	Excellent ICC: 0.96	Excellent Effect size: 0.96	245/2100
RCQoL[85]	34 items: Symptoms and physical complaints (16 items) Sport/recreation (4 items) Work related concerns (4 items) Lifestyle issues (5 items) -Social and Emotional Issues (5 items) Score: 0-3400 (Lower = Worse) (can be converted into 0-100 scale)	Content validity: Items established by experts and patients Criterion validity: Correlated with ASES. Construct validity: able to differentiate large and massive tears	Poor ICC: Not reported Reported as average difference of final score = 5%	Excellent Effect size: Not reported SRM: 1.43	Not reported

WOSI: The Western Ontario Shoulder Instability Index; OSIS: The Oxford Shoulder Instability Score; MIIS: The Melbourne Instability Shoulder Scale; WORC: The Western Ontario rotator cuff index; RCQoL: Rotator cuff quality-of-life measure; MCID: Minimum clinically important difference; ICC: Intraclass correlation coefficient; VAS: Visual analog scale; SRM: Standardized response mean.