a standardized method for the assessment of shoulder function
TRANSCRIPT
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8/9/2019 A Standardized Method for the Assessment of Shoulder Function
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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
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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 -
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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-
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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
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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-
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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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