Measuring Shoulder Function – which indices to use?

We’re delighted to welcome a contribution this month from Damien Nolan who is a physiotherapist and Clinical Educator at the School of Health and Rehabilitation Sciences at UQ in Brisbane, sharing his research into shoulder outcome measures with us:

This post aims to present the best functional/disability indices to use in clinical practice; providing the reader with a greater understanding of the most applicable tools available for the management of shoulder patients. When we consider the different ways in which we can assess effectiveness of intervention in shoulder pathologies, naturally outcomes such as pain, range of motion (ROM) and strength come to mind. However, adapting a broader approach, incorporating overall physical, emotional and social functioning into assessment is recommended, as per the World Health Organization model of Functioning, Disability, and Health [1]. More than 30 shoulder assessment tools / questionnaires have been described in the literature. Thus, indices included in this discussion those most frequently cited in the literature and those most commonly used in practice. Consequently, the seven indices I will discuss are:

1.       The Disabilities of the Arm, Shoulder, and Hand (DASH) and QuickDASHdownload

2.       The Shoulder Pain and Disability Index (SPADI)

 3.       The Western Ontario Shoulder Instability Index (WOSI)

 4.       The Oxford Shoulder Score (OSS)

 5.       The Simple Shoulder Test (SST)

 6.       The Constant Score (CS)

 7.       The Shoulder Disability Questionnaire (SDQ)

Which measure is best?

There is no gold standard or one-size-fits-all tool for assessing shoulder function [2]. Nonetheless, different questionnaires have been researched more than others, and have been shown to be more applicable to certain conditions and populations. The choice of the measure used should depend on the purpose (information you are aiming to get from the client) and practical considerations (is it user-friendly, does it have low measurement error etc.)  To determine which the optimal measure to use is, let’s investigate three issues: availability, client / therapist burden, and psychometric properties.

Availability

English versions of all of the tools are available online free of charge (click the links above). The DASH is available in 35 languages, and is thus the most readily accessible index for international clinicians [2,3,4].

Burden

The table below summarises the practical burden of using each tool. Naturally, the durations involved may vary depending on the client, so the table purely provides guideline times. As shown in the right hand column, the first three measures have greater variability in the guideline times for the clinician. This may be explained by the fact that there is a greater body of literature examining these tools, and perhaps certain researchers utilise more conservative methods of administering than others. Overall, client timeframes are similar for each of the indices.

Measure

Guideline time for client (mins)

Guideline time for clinician to administer / score (mins)

DASH

<5

5 – 10

QuickDASH

2

5 – 8

SPADI

2 – 5

3 – 10

OSS

2

5

SDQ

2

5

WOSI

No published data; estimated 3 minutes.

No published data; estimated 6 minutes.

SST

2 – 3

5

Constant Score

5 – 7

No published data

         [2,3,4].

Psychometric properties

First; a quick review of the four main psychometric properties:

Validity is the extent to which a measure assesses what it is intended to measure. A responsive tool is one that can accurately measure clinically important change over time. Reliability investigates whether the tool performs consistently on repeated applications. Internal consistency is similar to validity; dealing with the extent to which items in a subscale are correlated (for example, the subscales of pain and disability in the SPADI).

A review of the evidence has shown that the DASH instrument, exhibits the best psychometric properties of all the shoulder indices [2,5]. The SPADI has the second strongest. Both measures are reliable and valid, and compare well with each other across various shoulder conditions. The SPADI has been shown to be the most responsive measure across several different settings and populations [2,5]. The DASH & QuickDASH are not shoulder-joint specific, and hence their responsiveness is lower than shoulder-specific tools such as the SPADI. Psychometric properties of the Quick DASH are similar to those of the DASH, however these findings are based on far fewer studies [2,3,5].

So which one should I use?

To answer this question, let’s go through a clinical reasoning process:

“My patient is presenting with a shoulder complaint. Which measure should I initially be thinking of using?”

Findings from systematic reviews show that the SPADI, DASH or Quick DASH are the most recommended functional assessment tools. They have the strongest psychometric properties, are user-friendly, and have been widely tested in many different shoulder disorders [2,3,5].

“Is there a guide as to when I might choose one over the other?”

The DASH is most suitable for conditions which affect function of different joints of the upper limb (e.g. Rheumatoid Arthritis and Multiple Sclerosis) . It is also the most comprehensive of the three tools, and will therefore provide the most in-depth assessment of the client’s limitations. Additionally, it incorporates psychosocial functioning into the assessment, measuring the three areas of the WHO ICF model (body impairments, activity restrictions, and limitations in social participation). Finally, despite its design as a measure for the entire upper limb, its suitability for use has still been shown in regional disorders of the shoulder; for example, rotator cuff repairs and proximal humeral fractures [6,7]. The QuickDASH will not give as comprehensive an assessment as the DASH, instead providing a summary of symptoms and function. It can be used instead of the DASH with similar precision, although it should be noted that it is not as widely tested. Furthermore, the studies that have examined it have primarily consisted of surgical populations. [10,11] Evidence supports the use of the SPADI following shoulder arthroplasty and in adhesive capsulitis [8,9]. It is more responsive than the DASH in shoulder pain, tendinopathy, and impingement, but either can be used [3].

 “What information from the patient history would suggest I should consider a different questionnaire?”

The WOSI should be used with shoulder instability or following stabilisation surgery. It has greater responsiveness than the previous measures in this population, and exhibits higher reliability and validity. [12,13]

“Why am I not favouring the other measures mentioned previously?”

The remaining tools (numbers 4 – 7 in the initial list) each have some shortfalls in terms of their psychometric properties; from doubts about their validity and responsiveness, to a lack of information on their minimal clinically important difference. Additionally, even when one of these tools is somewhat strong in a particular population, the DASH are SPADI are equally supported [2,3,4,5].

Limitations of functional indices of the shoulder

Although these indices are beneficial to use in clinical practice, they are not without limitations. A frequently-cited deficit of shoulder questionnaires relates to clients presenting with a complaint in the non-dominant side. However, this is not a limitation. An injury to the non-dominant shoulder will result in less functional limitations for the individual, and the questionnaire will reflect that. In the case of the DASH, if no difficulty was experienced turning a key in the preceding week, then this is documented as so (even if the symptomatic side is never used to perform that task). The index is assessing overall function, not hand dominance. Perhaps the most noteworthy limitation relates to altered movement. We must be aware that clients may report that they can carry out a particular task with no difficulty, thereby giving them a good baseline score. However, on observation, we discover that compensatory maladaptive movement patterns are allowing them to do this. Finally, the scope of the indices may not always specifically target the client’s primary functional deficits (e.g. elite athlete still functioning at a high level). Consequently, a patient-specific functional scale is worthwhile as an additional tool, and one which can be re-assessed at more frequent intervals.

Author:  Damien Nolan (d.nolan2@uq.edu.au)

For more reading see the  Shoulder Outcome Measures section on our website here

 References:

 1.       World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization.

2.       Angst, F., Schwyzer, H. K., Aeschlimann, A., Simmen, B. R., & Goldhahn, J. (2011). Measures of adult shoulder function: Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and its short version (QuickDASH), Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) society standardized shoulder assessment form, Constant (Murley) Score (CS), Simple Shoulder Test (SST), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ), and Western Ontario Shoulder Instability Index (WOSI). Arthritis Care Res (Hoboken), 63 Suppl 11, S174-188.

3.       Roy, J. S., MacDermid, J. C., & Woodhouse, L. J. (2009). Measuring shoulder function: a systematic review of four questionnaires. [Review]. Arthritis Rheum, 61(5), 623-632.

4.       Roy, J. S., MacDermid, J. C., & Woodhouse, L. J. (2010). A systematic review of the psychometric properties of the Constant-Murley score. [Review]. J Shoulder Elbow Surg, 19(1), 157-164.

5.       Bot, S. D., Terwee, C. B., van der Windt, D. A., Bouter, L. M., Dekker, J., & de Vet, H. C. (2004). Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. [Review]. Ann Rheum Dis, 63(4), 335-341.

6.       Slobogean, G. P., Noonan, V. K., & O’Brien, P. J. (2010). The reliability and validity of the Disabilities of Arm, Shoulder, and Hand, EuroQol-5D, Health Utilities Index, and Short Form-6D outcome instruments in patients with proximal humeral fractures. J Shoulder Elbow Surg, 19(3), 342-348.

7.   MacDermid, J. C., Drosdowech, D., & Faber, K. (2006). Responsiveness of self-report scales in patients recovering from rotator cuff surgery. J Shoulder Elbow Surg, 15(4), 407-414.

8.   Angst, F., Goldhahn, J., Drerup, S., Aeschlimann, A., Schwyzer, H. K., & Simmen, B. R. (2008). Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis Rheum, 59(3), 391-398.

9.   Staples, M. P., Forbes, A., Green, S., & Buchbinder, R. (2010). Shoulder-specific disability measures showed acceptable construct validity and responsiveness. J Clin Epidemiol, 63(2), 163-170.

10.   Gummesson, C., Ward, M. M., & Atroshi, I. (2006). The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord, 7, 44.

11.   Angst, F., Goldhahn, J., Drerup, S., Flury, M., Schwyzer, H. K., & Simmen, B. R. (2009). How sharp is the short QuickDASH? A refined content and validity analysis of the short form of the disabilities of the shoulder, arm and hand questionnaire in the strata of symptoms and function and specific joint conditions. Qual Life Res, 18(8), 1043-1051

12.   Kirkley, A., Griffin, S., McLintock, H., & Ng, L. (1998). The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med, 26(6), 764-772.

13.   Rouleau, D. M., Faber, K., & MacDermid, J. C. (2010). Systematic review of patient-administered shoulder functional scores on instability. [Review]. J Shoulder Elbow Surg, 19(8), 1121-1128

 

 

 

 

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