Surgeons Recommend Broad Patient Assessment After Surgery for Shoulder

Before and after measurements of pain, motion, strength, and function are a good way to track which patients improve with surgery and rate the level of success or failure for each procedure. But there are over 30 different tests that can be done. All are not equal or reliable. So, to help surgeons decide which test to use and when to use it, this article reviews many of the commonly used before and after outcomes measures.

You may even recognize the names of some of these tests: the American Shoulder and Elbow Surgeons (ASES) shoulder outcome score, the Constant Shoulder Score, Disabilities of the Arm, Shoulder, and Hand (DASH), the Western Ontario Osteoarthritis of the Shoulder Index (WOOS).

The American Shoulder and Elbow Surgeons (ASES) test has been around for the last 15 years. It was developed by a committee with the hope of using it for research. The ASES can be used with all patients no matter what's wrong with the shoulder. And it can be used for patients treated conservatively (nonoperatively) as well as for those who end up having surgery for their shoulder problem.

The ASES assesses pain, instability, and function (activities of daily living or ADLs). The one major disadvantage of this test is the level of difficulty in calculating the score. It is widely used in the U.S. and Europe and can be used for research and for a general idea of how the shoulder is doing.

The Constant score is used to measure before and after results from surgery, but it can be used with nonsurgical cases as well. It does measure pain, activities of daily living (ADLs), shoulder motion, and strength.

But the Constant score test has not been validated for all different kinds of shoulder problems. And there are problems with examiner bias when it comes to measuring strength and motion. So, for now, the authors of this article who reviewed all the tests don't recommend using it until some of these issues have been ironed out.

Everyone agrees that the Disabilities of the Arm, Shoulder, and Hand (DASH) is a good measure of disability for the arm that can stand alone (i.e., other tests aren't needed along with it). It's a questionnaire patients take answering questions about symptoms and physical function.

It can be completed quickly, scored with moderate ease, and used with many different shoulder problems (e.g., arthritis, tendinitis, psoariatic arthritis, rotator cuff problems and repair, shoulder joint replacement). For general assessment and worker's compensation claims, the DASH can't be beat.

And finally, the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) is rated the best for assessing results of total shoulder replacement and treatment for arthritis of the shoulder. The patient answers 19 questions about symptoms (including pain), sport, recreation, work, lifestyle, and emotional function.

This test can be given in a variety of languages including English, Spanish, French, and German. The WOOS can even be used to measure before and after results following arthroscopic debridement (cleaning out) of the joint.

Other tests are available to test more specific results. For example, there is the Rotator Cuff Quality of Life and Western Ontario Rotator Cuff Index. For patients who have had surgery for rotator cuff disease, there are a few additional tests such as the Rowe Rating Sheet for Bankart Repair, the Western Ontario Rotator Cuff index (WORC), and the Wolfgang criteria.

And that's just the short list. There are tests for disability, pain, instability, sports injuries, and even for patients who are on Worker's Compensation. Some tests (e.g., ASES, UCLA, SANE) are quick and easy to complete. Tests that are user-friendly (or patient-friendly) are popular. The Disabilities of the Arm, Shoulder, and Hand (DASH) falls into this category.

Finding and using the best tool to assess results (called outcomes) can be a bit of a challenge. The user (surgeon, physical therapist, sports specialist, researcher) decides which one to use based on several factors such as type of shoulder-specific problem, intended use of the data collected (clinical versus research), and ease of use and scoring (quick and simple are preferred). Other influencing factors can include whether or not the patient is a Worker's Compensation claim, whether surgery has been done to treat the problem, and how much information detail is desired.

After looking each test over and evaluating their validity and reliability, the authors make one final conclusion. And that is: to obtain the highest level of outcome assessment, a test of general health outcome should be done. Along with that, the clinician or researcher should also measure activity and administer a disease- or condition-specific questionnaire. Combined together these outcome measures will give a broad assessment of each patient.

Reference: 

Rick W. Wright, MD, and Keith M. Baumgarten, MD. Shoulder Outcomes Measures. In Journal of the American Academy of Orthopaedic Surgeons. July 2010. Vol. 18. No. 7. Pp. 436-444.

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