Shoulder Outcome Scores

We undertook a review of the development of shoulder scoring systems that are used commonly to assess shoulder function in the general and athletic populations in advance of the development of our outcome scores for contact and overhead athletes.

Constant Score:
The Constant Score [1] was developed by Constant and Murley in 1987 and was one of the first outcome measures developed to assess shoulder function. Although it was created before the introduction of modern outcome tool development methodology, it is easy to administer with clear instructions and is therefore extensively used. It comprises both clinician-assessed physical examination findings and subjective patient-reported assessments. The original publication justified neither the inclusion of specific items, nor the relative weighting of points to items. The Constant Score is not effective in the evaluation of shoulder instability and has not been validated for assessing improvements in shoulder function after treatments [2]. The Contant score is available free for use by clinicians and researchers.

Oxford Shoulder Score:
The Oxford Shoulder Score [3] and Oxford Shoulder Instability Score [4] are widely used shoulder scores in the UK that were developed as patient-reported outcome measures for patients undergoing shoulder operations other than stabilisation, and for patients undergoing surgery for shoulder stabilisation, respectively. These were both developed by interviewing 20 patients referred to an outpatient shoulder clinic. As the demographics of these patients were not described, it is uncertain whether or not these patients represented the general population for whom the score is designed, or a reasonable range of shoulder conditions and treatments. The provisional scoring systems were tested on 2 further groups in an undisclosed manner and a final 12-item scoring system was developed for both shoulder scores. The rationale for the selection of the final set of items was not reported. The shoulder scores were tested for reliability by patients repeating the test after 48 hours. This is a very short recall period that is unlikely to exclude the possibility of patients remembering their first responses. The Oxford Shoulder Score and Shoulder Instability Score were analysed for responsiveness or sensitivity to change after shoulder surgery by comparison with the Constant Shoulder Score and non-specific scores that included the HAQ, Rowe and SF-36. questionnaires. The Oxford Shoulder Score and Shoulder Instability Score were more sensitive than the generic questionnaires. These shoulder scores have therefore been tested to provide reliable, valid and sensitive assessments of shoulder symptoms and function in the general population. The Oxford Outcome Scores require a license from ISIS to use - this may incur a fee.

DASH Score:
The Disabilities of the Arm, Shoulder and Hand (DASH) [5] scoring system was developed to assess the level of disability for any patient with any condition affecting the upper limb by covering domains including symptoms, physical function, social function and psychological function. As the developers of the DASH questionnaire intentionally excluded disease or joint-specific questions, the DASH cannot specifically assess the shoulder. The DASH was developed without consultation with patients with the conditions of interest and may therefore not address the issues of most important to the patients. The DASH has been demonstrated to be less sensitive than specific shoulder questionnaires in the evaluation of shoulder function [6,7]. The DASH and QuickDASH scoring systems are available free for use by clinicians for treatment and research. 

Several specific shoulder scores have been developed that are used less frequently.

  1. The Rating Sheet for Bankart Repair [8] evaluates patients undergoing anterior shoulder stabilisation and assesses 3 domains including stability (50 points), range of motion (20 points), and function (30 points). The weighting of scores for the domains was not justified, patients were not consulted during the item selection process, and several questions are included that prompt patients to consider 2 or more factors in responding to one question. 
  2. The UCLA Shoulder Score [13-6] also did not justify the attribution of weighted scores to items, and patients opinions were not surveyed during the development stages. 
  3. The Shoulder Pain and Disability Index (SPADI) [9] had no patient input in item selection, and has poor reliability. 
  4. The American Shoulder and Elbow Surgeons Evaluation Form (ASES) [10] did not report the method used to select questions for the form, and the patient-reported part of the form has a limited range of responses leading to poor sensitivity to change in condition status and no rationale was provided for the formulas required to determine the final overall score. 
  5. The Shoulder Rating Questionnaire [11] did not explain the item selection process or the weighting of scores, and was not compared with existing shoulder scoring systems for sensitivity. 
  6. The Simple Shoulder Test [12] was devised to assess improvement in shoulder function after treatment interventions for all shoulder conditions and comprises 12 questions with yes or no responses to objective and subjective items. The selection process for the 12 final items was not described and no formal tests were performed to validate it for its purpose.
  7. The Western Ontario Shoulder Indices are 3 questionnaires for patients with shoulder instability (WOSI) [6], rotator cuff pathology (WORC) [7], and osteoarthritis of the shoulder (WOOS) [16]. They were developed for use as a primary outcome measure in clinical trials evaluating treatments, and were comprehensively tested during development. Items were generated by review of the relevant literature, interviewing clinicians, and interviewing patients. The final set of questions for each index was selected by determining the most important factors from a patients perspective. These outcome measures were validated for their purpose by ensuring reliability of results, comparison with existing shoulder scoring systems, and by confirming sensitivity to change in patients condition after treatment interventions. Finally, the Rotator Cuff
  8. Quality of Life (RC-QoL) [17] assessment was created for use as an outcome tool in patients with the full spectrum of rotator cuff disease. Reliability of results was assessed by the average difference in scores rather than utilising more robust statistical tests. Further validation demonstrated that the RC-QoL was no better at disciminating between large and massive rotator cuff tears than previously developed scores such as the ASES or Functional Shoulder Elevation Test.

Three shoulder outcome scores have been previously developed for the athletes shoulder. Tibone and Bradley developed the first athletes shoulder outcome score [18]. This scoring system was intended to evaluate shoulder function in all types of athlete. Both objective and subjective components were included, but the subjective components (pain, power, endurance, stability, intensity) were arbitrarily awarded considerably more points.

A modification of the athletes shoulder scoring system developed by Tibone and Bradley, was performed by Kuhn and Hawkins in an attempt to change the focus of assessment to shoulder instability and the athletes ability to perform their usual sport [19]. The weighting of subjective functional performance was arbitrarily increased further and relatively fewer points allocated to objective items. There is no published data available for the validation of the original or modified athletes shoulder scoring systems.

The third scoring system designed to evaluate shoulder function in athletes is the Kerlan-Jobe Orthopaedic Clinic Score [20]. This was developed as a self-assessed patient- reported outcome measure utilising only subjective items. The selection of items for the scoring system has not been described and the allocation of different score weightings to different items was done arbitrarily by the authors and not justified. The scoring system is intended to evaluate shoulder and elbow function together before and after treatment, and therefore any change in total score cannot be definitely attributed either joint. The scoring system was validated for reliability and sensitivity, but no direct comparison was made with similar existing shoulder scores, such as the Constant, DASH, or Oxford Scores.

A common problem with scoring systems that incorporate clinician-assessed, objective items is that expert clinicians do not consistently assign similar outcome instrument items to a specific joint or disease [21], and outcome instruments designed to be specific for a single joint often detect disability in other joints also [22]. In addition, assessment tools completed by clinicians are prone to bias and error [2], and may not reflect patients perspectives. For outcome instruments to accurately reflect patients response and progress after treatment it is fundamental that patients are involved in the development and validation of such instruments. The most important measure of outcome in athletes recovering from an injury is a return to the same pre-injury level of sporting performance. [23].

To use many of these scoring systems online we recommend

  1. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clinical Orthopaedics. 1987; 214: 160-164.
  2. Conboy VB, Morris RW, Kiss J, et al. An evaluation of the Constant-Murley shoulder assessment. Journal of Bone and Joint Surgery [Br]. 1996; 78-B: 229-232.
  3. Dawson J, Fitzpatrick R, Carr A. Questionnaire on the perception of patients about shoulder surgery. Journal of Bone and Joint Surgery. 1996; 78: 593-600.
  4. Dawson J, Fitzpatrick R, Carr A. The assessment of shoulder instability: The development and validation of a questionnaire. Journal of Bone and Joint Surgery [Br]. 1999; 81-B: 420-426.
  5. Hudak PL, Amadio PC, Bombardier C, et al. Development of an upper extremity outcome measure: The DASH (Disabilities of the Arm, Shoulder, and Head). American Journal of Industrial Medicine. 1996; 29: 602-608.
  6. Kirkley A, Griffin S, McLintock H, et al. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability: The Western Ontario Shoulder Instability Index (WOSI). American Journal of Sports Medicine. 1998; 26: 764-772.
  7. Kirkley A, Griffin S, Alvarez C. The development and evaluation of a disease-specific quality of life measurement tool for rotator cuff disease: The Western Ontario Rotator Cuff Index (WORC). Clinical Journal of Sport Medicine. 2003; 13: 84-92.
  8. Rowe CR, Patel D, Southmard WW. The Bankart procedure A study of late results. Journal of Bone and Joint Surgery [Am]. 1977; 59: 122.
  9. Amstutz HC, Sew Hoy AL, Clarke IC. UCLA anatomic total shoulder arthroplasty. Clinical Orthopaedics. 1981; 155: 7-20.
  10. Roach KE, Budiman-Mak E, Songsiridej M, et al. Development of a shoulder pain and disability index. Arthritis Care & Research. 1991; 4: 143-149.
  11. Richards RR, An K-N, Bigliani LU, et al. A standardized method for the assessment of shoulder function. Journal of Shoulder and Elbow Surgery. 1994; 3(6): 347-352.
  12. LInsalata JC, Warren RF, Cohen SB, et al. A self-administered questionnaire for assessment of symptoms and function of the shoulder. Journal of Bone and Joint Surgery [Am]. 1997; 79: 738-748.
  13. Kirkley A, Griffin S, Dainty K. Scoring systems for the functional assessment of the shoulder. Arthroscopy: Journal of Arthroscopic and Related Surgery. 2003; 19(10): 1109-1120.
  14. Lo IKY, Griffin S, Kirkley A. The development of a disease-specific quality of life measurement tool for osteoarthritis of the shoulder: The Western Ontario Osteoarthritis of the Shoulder (WOOS) index. Osteoarthritis and Cartilage. 2001; 9: 771-778.
  15. Hollinshead RM, Mohtadi NG, Vande Guchte RA, et al. Two 6-year follow-up studies of large and massive rotator cuff tears: Comparison of outcome measures. Journal of Shoulder and Elbow Surgery. 2000; 9: 373-381.
  16. Kuhn JE. The assessment of outcomes for the treatment of the overhead athlete. In: Warren RF, ed. The shoulder and the overhead athlete. Philadelphia: Lippincott-Williams & Wilkins, 2004; Appendix 5-5.
  17. Kuhn JE. The assessment of outcomes for the treatment of the overhead athlete. In: Warren RF, ed. The shoulder and the overhead athlete. Philadelphia: Lippincott-Williams & Wilkins, 2004; Appendix 5-6.
  18. Alberta FG, ElAttrache NS, Bissell S, et al. The development and validation of a functional assessment tool for the upper extremity in the overhead athlete. The American Journal of Sports Medicine. 2010; 38(5): 903-911.
  19. Davis AM, Beaton DE, Hudak PL, et al. Measuring disability of the upper extremity: a rationale supporting the use of a regional outcome measure. Journal of Hand Therapy. 1999; 12: 269-274.
  20. Beaton DE, Katz JN, Fossel AH, et al. Measuring the whole or the parts? Validity, reliability, and responsiveness of the disabilities of the arm, shoulder and hand outcome measure in different regions of the upper extremity. Journal of Hand Therapy. 2001; 14: 128-146
  21. Fayad F, Mace Y, Lefevre-Colau S, et al. Measurement of shoulder disability in the athlete: a systematic review. Annales de readaptation et de medicine physique. 2004; 47: 389-395

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