a standardized method for the assessment of shoulder function

8/9/2019 A Standardized Method for the Assessment of Shoulder Function

1/6

ORI IN L RTI LES

st n r ize

metho

for the

assessment of

shoul er

function

Research Committee, American Shoulder and Elbow Surgeons

Robin

Richards,

MD,

FRCS C , Chairman, Kai-Nan An, PhD,

Louis U. Bigliani,

MD,

Richard

J.

Friedman,

MD,

FRCS C ,

Gary M. Gartsman,

MD,

Anthony G. Gristina, MD,

Joseph P. Iannotti,

MD,

PhD, Van

C. Mow,

PhD, John A. Sidles, PhD, and

Joseph D. Zuckerman,

MD,

Rosemont,

.

The American Shoulder

n

Elbow Surgeons have

opte

a

standardized form

for assessment

of

the shoulder. The form has a patient self-evaluation section

n a

physician assessment section. The patient self-evaluation section

of

the

form contains visual analog scales for pain

n

instability

n

an activities

of

daily living questionnaire. The activities

of

daily living questionnaire is

m rke

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 n assesses range of

motion, specific physical signs, strength,

n

stability. A shoulder score can be

derived from the visual analogue scale score for pain 50 )

n

the cumulative

activities of daily living score 50 ). It is hope that adoption of this instrument

to measure shoulder function will facilitate communication between investigators,

stimulate multicenter studies,

n

encourage validity testing

of

this

n

other

available instruments to measure shoulder function

n

outcome.

J

SHOULDER EL OW SURG

7994;3:347 52

h American Shoulder and Elbow Surgeons

adopted a standardized form fo r the assess

ment of shoulder function at their annual closed

meeting held

October

31 to

November

2, 1993,

in Williamsburg, Virginia. This

form

was de

veloped by the Research Committee

of

the

American Shoulder and Elbow Surgeons

ASES ,

which recommended its use to the Ex

ecutive Committee. The Executive Committee

agreed with the concept and content

of

the form,

and the

form

was adopted by the membership.

From the Research Committee, Americon Shoulder and El

bow Surgeons, Rosemont, III.

Reprint requests: American Shoulder and E

lbow

Surgeons,

6300 North River Rd., Suite 727, Rosemont, IL60018-4226.

Copyright 1994 by Journal of Shoulder and Elbow Surgery

Board of Trustees.

1058-2746/94/ 3.00

+

0

32 59628

Most

clinicians agree that a standardized

method of assessing musculoskeletal function

facil itates communication between investiga

tors, permits and encourages multicenter trials

to be performed, and allows the communication

of

useful and relevant outcome

data

to physi

cians, healthcare administrators, and the gen

eral

public. 11

The

ASES

Standardized Shoulder

Assessment Form was developed during a 3

year

t ime period. The concept of the form was

discussed at the ASES closed meeting held in

Chicago in 1990. It was bel ieved that any pro

posed form should be reviewed by the mem

bership before adoption. The key attributes of

any proposed form identi fied by the member

ship as being desirab le were 1 ease of use;

2 a method of assessing activities of

daily

liv

ing ADLs ; and 3 inclusion

of

a patient self

evaluation section.

7


2/6

348 Richards et al.

J. Shoulder lbow Surg

November ecember 7994

SHOULDER ASSESSMENT FORM

MERI N

SHOUlDERANDElBOW SURGEONS

Name:

Date

Age:

I

Hand dominance:

R L Ambi

Sex: M F

Diagnosis:

Initial Assess? Y

N

Procedure/Date:

Followup:

M

Y

Figure 1

Demographic information.

All

forms that existed at that time

were

re

viewed by the Research Committee.13 4 7 9 12 A

draft

form was presented to the membership at

the closed meeting held in Seattle, Washington,

in September 1991. The membership was en

couraged to use the

form

and to

offer

construc

tive criticism.

More

than 70 suggestions

fo r

change and

improvement

were made

after

dis

tribution

of

the first

draft

. The suggested

changes were reviewed by a subcommittee

of

the Research Committee in the summer

of

1992.

The form was revised and redistributed

after

the

SES closed meeting held in Vai l ,

Colorado

in

September 1992.

Another 15 suggestions were made, and most

were

incorporated

into the form that was

adopted by the membersh ip. It is the

belief

of

the Research Committee and the American

Shoulder and Elbow Surgeons that the shoulder

assessment

form

represents a state-of-the-art

assessment tool fo r patients with shoulder dis

orders. The

form

consists of a physician as

sessment section and a patient self-evaluation

section. The patient self-evaluation section can

be completed in

approximately

3 minutes. The

presence of a physician

or paramedical worker

is not required fo r the completion of the patient

self-evaluation

portion

of

the form. Forms

are

available from

the ASES office in

Chicago and

are also available

on diskette (WordPerfect 5.1

WordPerfect

Corp. Orem

Utoh), because it is

recognized that

individual

investigators may

wish to customize the form

fo r their

use. The

addition of

other questions

or

specific maneu

vers on physical examination is

encouraged

ac

cording to the distinctive needs of individuals

and groups working with specific subsets

of

pa

tients. The SES standardized shoulder assess

ment form is offered as a basel ine measure of

shoulder function

applicable

to

al l

patients re

gardless of diagnosis.

DEMOGRAPHIC

IN ORM TION

The pat ient s name, age, hand dominance,

sex, diagnosis, and procedure

are

noted (Fig

ure 1). Spaces

are available

to note the date

of

the assessment and the date of procedure, if an

operative

procedure

has been

performed

. An

annotation is

also

present to indicate whether

the patient is being seen

fo r

the f irst t ime

and

if not, what the length of

follow-up

is. It is an

ticipated that many clinicians

will

wish to cus

tomize this portion

of

the form according to

their needs and the format

of

patient demo

graphic information at their parent institution.

PATIENT SELF EVALUATION

The patient self-evaluation

form

is

divided

into three sections.

Pain

The first section concerns pain (Fig

ure 2). The patients are asked to identify

whether they are having pain in the shoulder

and are asked to record the location of their

pain on the pain dioqrom. Patients are asked

whether they have pain at night and whether

they take

pain

medication. The next question

identi fies the use of a nonnarcotic analgesic.

Another question identifies the use of narcotic

medication. The patient is asked to record the

number

of

pills required each

day

. The severity

of

pain

is

graded

on a 10 cm visual

analog

scale

that ranges

from

0 (no pa in at

al l

) to 10 (pa in

as bad as it can be .

13,

Instability

The pat ient is asked to ident ify

whether he or she experiences symptoms of in

stabili ty (Figure 3). The sensation of instability

experienced by the patient is assessed quanti

tatively according to a visual

analog

scale. A

higher score is given, if the shoulder feels very

unstable.

Activities of daily living Ten activities

of

daily

living

are

assessed on a

four-point ordinal

scale (Figure 4 2 The patients

are

asked to cir -


3/6

No pain at al l

J. Shoulder Elbow Surg

Volume 3 Number

P TIENTSEU EV LU TION

Are you havlng

pain In

your ahouldfJI7

(circle

oomIct

Mark where your pain is

00

you

have pain

Inyour shoulder at nlgh ?

you take pain medication (aspirin, dvII Tylenol tc.)?

you take narootlc

pain

medication

oodelne

Of atronger)?

How many

plUs

do

you take

e h

day average ?

How

bad

Is

your pain today

m rk line)?

0 1 I I I

Richards et al. 349

No

Yes No

Yes No

Yes No

pills

I

10

Pain

as

bad

as It can be

Figure Patient self-evaluation: pain questionnaire. (Advil, Whitehall

Robins lnc., Madison, N.J.; Tylenol,

McNe

il Consumer, Pleasantville, N .J.)

Does

your shoulder

feel uns1able (as It Is

going to dislocate?)

Very

stable

I

Yes I No

Figure 3 Patient self-eval uation: instability questionnaire.

cle 0, if they

are

unable to

do

the act ivity, 1, if

they find it very

difficult

to

do

the activ ity, 2, if

they find it somewhat difficult to

do

the activity,

and 3, if they find no difficulty in

performing

the

activity. Each shoulder is assessed separateJy.

Because 10 questions

are

asked the maximum

score is 30. The 10 questions include activit ies

that are heavily dependant on a range of shoul

der

mot ion that is free

from

pain. The patients

are also asked to identify their normal work and

sporting activities. The cumulative activities of

daily

living score is derived by totaling the

scores

awarded fo r

each of the individual ac

tivities.

PHYSICI N SSESSMENT

The physician assessment portion of the form

consists

of

the

following

sections.

Range of motion

Total (combined gle

nohumeral and scapulothoracic) shoulder mo

tion is measured, because the

ability

to

differ-

entiate glenohumeral from scapulothoracic

rno-

t ion is not consistent (Figure 5). Both active and

passive motion

fo r

both shoulders is recorded.

The use of a

goniometer

is preferred. Forward

elevation is measured as the maximum

arm-

trunk angle

viewed

from

any direction. External

rotat ion is measured with the

arm comfortably

at the side and .c lso with the

arm

at 90of

ab-

duction. Internal rotation is measured by noting

the highest segment

of

spinal anatomy reached

with the thumb. Cross-body adduction is mea

sured by measuring the distance

of

the ante

cubital fossa from the opposite acromion.

Signs

Signs are

graded

0 if not present, 1

if

mild 2

if

moderate, and 3

if

severe (Fig

ure 6). Signs that are assessed include supra

spinatus

or

greater tuberosity tenderness, ac

romioclav icular jo int tenderness, and biceps

tendon tenderness or biceps tendon rupture. If

tendon tenderness is present in other locations,

the examiner is asked to note the location. Im

pingement is assessed in three ways: (1) passive

forward

elevation of the shoulder in slight in-


4/6

350 Richards et 1

1 Shoulder Elbow Surg

November December 1994

Cirde

the number in the box that indicates your ability to do the following aetMties:

o

Unable

to do ; 1 VfKY dil li


5/6

J. Shoulder Elbow Surg

Volume 3, Number

Richards et al . 35

STRENGTH

record MAC grade)

o - nooonlrllClion; 1

llid

2

an translation or over rim of glenoid)

Anterior translation

o

1

2 3 o 1 2 3

Posterior translation

o 1 2 3 o 1 2 3

Inferlot Iransletion ouicus sign)

o 1 2 3 o 1

23

Antetlor

apprehension

o

1

2 3

o 1 2 3

Reptoduces symptOtnS?

Y

N

Y

N

Voluntary Inslability?

Y

N

Y

N

Relocetlon test positMI?

Y

N

Y

N

Generalizedligamentous

laxity?

Y

N

Other physical findings:

Examner s name:

Date

Figure

8

Physician assessment : instab ility.

has been f ou nd acceptable to the membership

of

the

Amer

ican Shoulder and Elbow Surgeons.

It is the membership s hope that adoption of this

form will encourage its use and its comparison

with other measures of outcome. The Research

Committee also recognizes that communication

between specialty groups i s i mp o rt a nt. Use of

a sta nd ardi ze d e va lu at io n instrument such as

the SF 3 6 as a g en eral he al th o ut come measure

is encouraged at this tim e, bec ause it is a m ea

sure of general heol th status t ha t most healt h

care

workers

and administrators

will

know.

Testing of the vario us o ut co me measures that

are available

is to be enc ouraged, and it is the

Research Committee s

hope

that this

will

occur

and will

allow

further evolution and refine out-


6/6

352

Richards

et

01

outcome measurement instruments

fo r

the

shoulder.

The authors acknowledge the support encour-

agement and counsel of American Society of Shoul

de r

an d Elbow Surgeons past presidents Frederick

A. Matsen III MD, Richard J. Hawkins, MD, FRCS C ,

Robert J. Neviaser, MD, Russell F. Warren MD,

and

president Harvard Ellman, MD.

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a standardized method for the assessment of shoulder function

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