Measuring the success of shoulder surgery - keeping it simple

 The American Shoulder and Elbow Surgeons score highly correlates with the Simple Shoulder Test

The most important reason for a shoulder surgeon to document his or or patients' shoulder comfort and function before and sequentially after therapeutic interventions is so that the surgeon can know his or her personal effectiveness in managing patients with a specific diagnosis using a specific treatment. The consistent application of standardized patient-assessed measures of shoulder comfort and function will help the surgeon identify what is not working well for which patients so that the treatment algorithm can be modified.

The value of a scoring system depends primarily on its ability to capture results from the highest percentage of patients. 

Systematically documenting shoulder comfort and function in the context of a busy surgical practice can be time consuming and expensive. The ideal tool is (a) one that is simple for the patient to access and use whether the patient is in the office or at home (by mail, email, phone, internet) and (b) simple for the surgeon's office to score and record. 

This article examines two extensively validated measures of shoulder comfort and function: 

the ASES score

and the Simple Shoulder Test

These authors conducted a retrospective review of the senior author’s database of 1810 simultaneous measurements on patients undergoing rotator cuff repair and total shoulder arthroplasty.

The correlation was excellent for the ASES and SST for all patients (n =1810; r = 0.81; P < .0001). The correlation of preoperative scores was strong-moderate (n = 1191; r = 0.60; P < .0001), and the correlation of postoperative scores was excellent (n = 619; r = 0.78; P < .0001). 

Both scores were determined to be highly responsive (see this link), for both the standardized response mean (2.8 for the ASES and 2.1 for the SST) and the effect size (2.2 for the ASES and 1.8 for the SST).

Comment: It is evident that the total SST and the ASES scores yield similar information. Here is a side by side comparison from the article, One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers.

However, the Simple Shoulder Test has the advantage of yielding easy to understand data on the on ability of patients to perform individual functions before and after treatment. For example, as shown in this link, patient can easily understand the function-specific data shown below for two year outcomes of anatomic total shoulder. 

It is more difficult to extract such information from more complex scoring systems. 

What is important is for each shoulder surgeon to build a system for measuring patient comfort and function into their practice workflow so that they can learn the effectiveness of their treatment approaches.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Does PROMIS have promise?

Correlation of Patient Reported Outcome Measurement Information System (PROMIS) with American Shoulder and Elbow Surgeon (ASES), and Constant (CS) scores in Idiopathic Adhesive Capsulitis


These authors sought to correlate the Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score with preexisting validated outcomes scores, American Shoulder and Elbow Surgeons score (ASES), and Constant score (CS) in patients with idiopathic adhesive capsulitis (AC).

The final cohort included 100 patients with AC of which there were 72% female and 87% right hand dominant, with a mean age of 55 years.

The PROMIS UE required fewer question responses (5.02 ±1.84) compared to the fixed questions burden with ASES (12) and CS (9).

The PROMIS UE displayed excellent correlation with both the ASES (r = 0.80, 95% [CI:20 0.72, 0.86], p < 0.001) and CS (r = 0.76, 95% CI [0.67, 0.83], p < 0.001).

Neither ceiling nor floor effects were present.

The authors concluded that "the PROMIS UE displayed comparable efficacy to commonly used legacy outcome scores (ASES and CS) in adhesive capsulitis. A lower question burden with the PROMIS UE carries a potential for wider acceptibility with the researchers and patients with shoulder pathology"

Comment: Reports on the use of PROMIS need to examined in the light of "what question should we be asking?" The wonderful benefit of simple patient reported outcome measures (ASES, Simple Shoulder Test), is that they are inexpensive and easily accessible to patients in clinic and at their homes (mail, email, on line) so that long term followup of the maximal number of patients is facilitated.

The Constant score fails in these regards because clinical  measurements are required using a goniometer and dynamometer which mandate that the patient return to the office for examination.

The PROMIS system also fails in these regards because access to a computer and training in the use of the system is required, both of which factors may interfere with patient participation.

The observation that the PROMIS approach reduces the "question burden" from 12 to 5 does not offset its "access burden".

The key to clinical outcome research is facilitating the long term followup for the maximum number of patients. Evidence is lacking that the PROMIS approach is helpful in this regard.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Total Shoulder Arthroplasty - how valuable is it?

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty

These authors analyzed 92 patients with glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty performed by an individual surgeon using a a press-fit, short-stem anatomic humeral component and a hybrid, all-polyethylene, pegged glenoid implant and that had 1-year follow-up with respect to their health-related quality-of-life (HRQoL) scores and patient-reported outcome measures (PROMs): Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function.

There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure.

The changes in VAS QoL (very weak to moderate), EQ-5D (weak), and SF-6D (weak) were significantly correlated (p < 0.05) with the changes in PROMs, demonstrating comparably acceptable validity. 

 There were large effect sizes in the VAS QoL (1.843), EQ-5D (1.186), and SF-6D (1.084) and large standardized response mean values in the VAS QoL (1.622), EQ-5D (1.230), and SF-6D (1.083), demonstrating responsiveness. The effect sizes of all PROMs were larger than those of the HRQoL scores.

Comment: In this well-done study, the authors point out that shoulder patient reported outcome metrics cannot be used in an analysis of comparative value of shoulder arthroplasty relative to other orthopaedic and nonorthopaedic conditions. 

Measurement of quality-adjusted life-years (QALYs a summary measure of health outcome that combines the impact of a treatment on a patient’s length of life) and health-related quality of life (HRQoL) can be used to compare alternative treatments of a specific condition, as well as treatments of disparate conditions. QALYs can be used with costs (direct and indirect) to determine cost utility (monetary cost/QALY), which can be used to perform cost utility analysis to compare, say a total shoulder to a rhinoplasty. 

It is not surprising to see a lack of tight correlation between patient reported outcome metrics and measures of health-related quality of life measures: they do not measure the same thing. The PROMS are used to measure the change in patient-assessed shoulder comfort and function. In this study the SST changed from 3 preoperatively to 10 postoperatively. This is exactly the same change documented in many different case series by different surgeons using different makes of implants. It is very reassuring to see consistently large effect sizes for the PROMs.

On the other hand, one could expect the HRQoL to have a strong correlation with the SST only if the shoulder operated on was the only factor affecting the patients health-related quality of life. Consider the patient who has a SST 3=>10 after a shoulder arthroplasty, but who at one year comes in  saying "now my other shoulder (or my hip or my knee or my back)  is killing me" or "I fell and broke my wrist" or "I now have cancer or ....". This is why the effect sizes are smaller for the HRQoL than for the PROM.

As shoulder surgeons we are responsible for an important, but only one part of a patient's health equation. The measure of our success is the value of our treatment, that is the benefit the patient realizes from our intervention divided by the cost of our evaluation and treatment (i.e. change in SST decided by the sum of preoperative imaging, implants, hospital costs, professional fees, rehabilitation and complications). In that the numerator seems pretty standard, optimization of this quotient is most effected by the denominator.

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Total Shoulder and Reverse Total Shoulder - How effective are they in restoring comfort and function?

Correlation of multiple patient-reported outcome measures across follow-up in patients undergoing primary shoulder arthroplasty

These authors performed a retrospective review of a shoulder arthroplasty database that routinely collects three commonly used patient-reported outcome (PRO) measures in this population: the Simple Shoulder Test (SST), Shoulder Pain and Disability Index (SPADI), and the American Shoulder and Elbow Surgeons (ASES) Assessment Form preoperatively and at 3, 6, 12, and 24months postoperatively. The study was limited to 848 patients undergoing primary shoulder arthroplasty were identified.

Preoperative correlations among PROs were moderate to strong (range, 0.66-0.77). Postoperative correlations were strong for all PRO comparisons (range, 0.73-0.94). Postoperative PRO correlations continued to strengthen over longer follow-up, with all values exceeding 0.78 at 2 years postoperatively. 

Comment: These are valuable data because the allow us to determine the percent of maximal possible improvement (%MPI) for anatomic and reverse shoulder arthroplasties. The percent of maximal possible improvement using any outcome measure is calculated as

the improvement: the difference between the postoperative score and the preoperative score

divided by

the maximal possible improvement: the difference between a perfect score and the preoperative score

As can be seen from the graphs below, the %MPI for anatomic and reverse total shoulders is essentially the same, whether measured by the SST, the ASES or the SPADI. 

These graphs also show that while in this series of patients each of these procedures lead to significant improvement, neither procedure fully restores the shoulder to normal patient reported comfort and function.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Cost-effectiveness and health-care value analysis - the elephant in the room

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty

These authors evaluated Health-related quality-of-life (HRQoL) scores and patient-reported outcome measures (PROMs) in 93 patients at year after anatomic shoulder arthroplasty for advanced glenohumeral osteoarthritis to establish values of HRQoL scores that can be used for cost effectiveness and value analysis and to assess relationships between HRQoL scores and shoulder and upper-extremity PROMs. 

Preoperative and postoperative functional outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function. Health utility was assessed with the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), and VAS Quality of Life (VAS QoL). 

There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure. 

Each of the metrics showed a large effect size and standardized response mean

The changes in VAS QoL and EQ-5D were significantly correlated with the changes in most PROMs, but the correlation was only weak to moderate.

The authors concluded that PROMs and HRQoL scores are not interchangeable, and studies of the cost-effectiveness and value of shoulder arthroplasty should incorporate both shoulder and upper-extremity PROMs and HRQoL scores. 

Comment: The value of a treatment is defined as the benefit to the patient divided by the cost of rendering that treatment. This article demonstrates that we have robust tools for evaluating the benefit to the patient of shoulder arthroplasty, both with respect to the improvement in patient self-assessed comfort and function (PROMS) and in the quality of life (HRQoL).

For determining the cost-effectiveness and value of treatment, the challenge is the difficulty in measuring the cost of care, the denominator of the value equation.

One recent study demonstrated the complexity of this assessment: Preparing for the bundled-payment initiative: the cost and clinical outcomes of total shoulder arthroplasty for the surgical treatment of glenohumeral arthritis at an average 4-year follow-up

The pre-hospitalization, hospitalization, and posthospitalization periods accounted for 3.5%, 88.4%, and 8.1% of the 4-year total cost of TSA, respectively. Within the pre-hospitalization period, the shoulder computed tomography scan was the most expensive component of care (37% of pre-hospitalization cost). During the hospitalization period, as well as during the entire 4-year study period, the operating room was the most expensive area (81% of hospitalization cost and 71% of total cost). Within the operating room, the implants were the single most expensive component of care (43% of hospitalization cost and 38% of total cost). The surgeon’s fee was $1,470 and was responsible for 8% of total cost. In the post-hospitalization period, home health care was the most expensive component of care (70% of post-hospitalization cost).

What emerges from that study is that 38% of the total cost is the cost of the implants used.

In a recent article, An analysis of costs associated with shoulder arthroplasty, the authors pointed out that the implant brand was a major factor the the cost of shoulder arthroplasty, however, as they stated "Because actual implant costs were the result of confidential contractual negotiations, actual dollar amounts could not be published nor could the brand names be published adjacent to their relative costs."

The most modifiable variable in the value of shoulder arthroplasty is the cost of the implant, yet because of the confidentiality of contract negotiations, the actual cost data are not available for analysis. We are aware of a major medical center that requires that implant vendors offer implant charges that are at the 25th percentile of the charges across the country. This means that, all other things being equal, the value of shoulder arthroplasty at that medical center would be substantially higher than average because their costs are less.

We conclude that we have a good tool-set for measuring the effectiveness of shoulder arthroplasty, but as a specialty, we do not have a meaningful way of measuring the cost of providing this procedure, especially with respect to implant costs, the elephant in the room.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Is the PROMIS Computer Adaptive Test of Value?

PROMIS physical function underperforms psychometrically relative to American Shoulder and Elbow Surgeons score in patients undergoing anatomic total shoulder arthroplasty

These authors evaluated the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF-CAT) relative to the American Shoulder and Elbow Surgeons (ASES) score in patients with glenohumeral osteoarthritis undergoing primary anatomic total shoulder arthroplasty (TSA).

UE-CAT took less time to complete than the ASES (62.6 seconds vs. 160.6 seconds).Responses from 179 patients (184 shoulders) were included. PF-CAT had a moderate correlation to ASES (r . 0.487; P <.001), with no floor or ceiling effects; ASES had a 1.1% floor effect and no ceiling effect. Person-item maps showed ASES to be superior to PROMIS PF-CAT psychometrically, with sequential and improved coverage of the latent dimension of shoulder disability.

This paper did not present data on the cost of the PROMIS system, the need for patient instruction in its use, the availability of the equipment and the issue of access of patients to the system in comparison to standard patient reported outcome measures (PROs). Thus while some authors emphasize the importance of "saving" 100 seconds, the actual effort in completing the PROMIS in comparison to a standard PRO remains unreported.

This article should be viewed along with a prior report:
Correlation of PROMIS Physical Function Upper Extremity Computer Adaptive Test with American Shoulder and Elbow Surgeons shoulder assessment form and Simple Shoulder Test in patients with shoulder arthritis 

The purpose of this study was to evaluate the Patient-Reported Outcomes Measurement Informative System Physical Function Upper Extremity Computer Adaptive Test (PROMIS PFUE CAT) measurement tool against the already validated American Shoulder and Elbow Surgeons (ASES) shoulder assessment form and the Simple Shoulder Test (SST) in patients with shoulder arthritis.

Fifty-two patients with the primary diagnosis of shoulder arthritis were asked to fill out the ASES, SST, and PROMIS PFUE CAT.

The PROMIS PFUE CAT showed a strong-moderate correlation with the SST (r = 0.64; P < .001) and a moderate correlation with the ASES (r = 0.57; P < .001). The average times to complete the SST, ASES, and PROMIS PFUE CAT were determined to be 96.9 ± 25.1 seconds, 160.6 ± 51.5 seconds, and 62.6 ± 22.8 seconds, respectively.

Comment: These authors suggest that computerized adaptive technology be used to decrease the burden placed on patients by currently accepted patient-reported outcome measurement tools.

The burden of the PROMIS approach is that the patient needs to have access to and use a computer uploaded with the necessary software. The cost of implementing this system is not mentioned in this paper. In contrast, the SST can be completed anywhere and requires only a pencil or a pen.

The scatter plot from this article also brings up another issue with the PROMIS: four patients who indicated that they could perform none of the 12 functions of the SST, still had PROMIS scores in the same range as three patients what could perform eight of these functions. Thus, the PROMIS was unable to discriminate between a non-functioning shoulder and a reasonably functional one.

At this point the promise of PROMIS does not seem compelling. 

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Patient reported outcomes - does a proprietary computerized adaptive testing system (CAT) reduce the burden on the patient ?

A concise shoulder outcome measure: application of computerized adaptive testing to the American Shoulder and Elbow Surgeons Shoulder Assessment

These authors point out that patient-reported outcome measures enable quantitative and patient-centric assessment of orthopedic interventions, but they can also be a burden for patients and practices.

They examined the utility of a computerized adaptive testing (CAT) method to in an attempt to reduce the number of questions on the American Shoulder and Elbow Surgeons (ASES) questionnaire.

They applied a previously developed ASES CAT system to the responses of 2763 patients who underwent shoulder evaluation and treatment and had answered all questions on the full ASES instrument. 

They found that by tailoring questions according to prior responses, CAT might reduce the number of questions by 40%.

The mean difference between CAT and full ASES scores was 0.14, and the scores were within 5 points in 95% of cases (a 12-point difference is considered the threshold for clinical significance) and were clustered around zero. The correlation coefficients were 0.99, and the frequency distributions of the CAT and full ASES scores were nearly identical. 

Comment: 

This article uses a proprietary CAT system, OBERED (http://www.oberd.com). The cost/time burden of implementing this system is not mentioned. The first author of this paper is the Chief Scientific Officer of Universal Research Solutions–OBERD and two of the other authors disclosed a financial conflict of interest with OBERED (employee and shareholder).

This article concluded that "the ASES CAT system lessens respondent burden with a negligible effect on score integrity". Actually, they did not measure the "respondent burden"; their primary outcome variable was the number of questions answered.  The "respondent burden" includes need to find access to the OBERED system, gaining working familiarity with the system, and understanding the results of the test.  Theses aspects of the burden were not evaluated in this study.

This article reports that a new CAT method has been developed to lessen the burden of obtaining patient reported outcomes. It shows that application of the CAT to the ASES questionnaire has a negligible impact on the outcome score while reducing the number of questions the patient needs to answer from 11 to 7. The total difference in time to complete the ASES with the two methods (signing into a terminal vs. on paper) was not reported.

The goals of capturing validated patient reported outcome data are (1) to optimize the chances that the largest percent of patients being followed will continue to participate in the followup over time (minimizing loss to followup), (2) enabling surgeons to assess their outcomes in a cost-effective way, and (3) providing prospective patients with understandable diagnosis- and procedure-specific data on their likely outcomes with the treatments available in the hands of their surgeon. If the outcomes can be easily assessed by the great majority of patients from their home, these goals can be met.

We continue to find that the non-proprietary and extensively validated Simple Shoulder Test greatly facilitates longitudinal capture of patient-reported data and helps greatly in sharing the results with the patients in terms of abilities to perform 12 important shoulder functions rather than by a number that is difficult for most to interpret.


=====

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

How important is range of motion to shoulder function before and after reverse total shoulder?

Clinical measurements versus patient-reported outcomes: analysis of the American Shoulder and Elbow Surgeons physician assessment in patients undergoing reverse total shoulder arthroplasty

These authors evaluated the relationship of the ASES physician-assessment measurements with patient-reported shoulder and general health outcomes for 74 patients at two years after a reverse total shoulder arthroplasty.

Preoperative physician measurements and patient scores were not significantly correlated. At two years postoperatively, only improvements in active forward flexion had a modest correlation with improvements in ASES patient scores (R = 0.36, P < .01).

Comment: While it is traditional to use range of motion as an outcome measure for shoulder arthroplasty, there are a number of problems with this tradition:

(1) range of motion measurements are observer dependent and may be subject to observe bias and inter observer variability

(2) range of motion measurements require patients to return to the office, excluding from followup those patients who cannot return

(3) as shown in the graph above, some patients with 140 degrees of active flexion have poor self-assessed comfort and function (as measured by the patient reported ASES score) while other patients have good self-assessed function with only 80 or 100 degrees of active flexion.

In this study active range of motion accounted for less than 30% of the variance in patient-reported shoulder function. What is of great importance is the investigation of the factors that determine the other 70%.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

How much improvement in the SST, ASES, and VAS score is clinically significant?

Determining the minimal clinically important difference for the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog scale measuring pain after shoulder arthroplasty.

Primary anatomic total shoulder arthroplasty (TSA), primary reverse TSA, or hemiarthroplasty was performed in 326 patients. The SST score, ASES score, and VAS pain score were collected preoperatively and at a minimum of 2 years postoperatively (mean, 3.5 years).

The minimal clinically important differences (MCIDs) were calculated for the ASES score, SST score, and VAS pain score using a 4-item anchor question evaluating improvement after treatment. Patients were asked the following: “Since your shoulder replacement surgery, please rate your response to treatment: A, none—no good at all, ineffective treatment; B, poor—some effect but unsatisfactory; C, good—satisfactory effect with occasional episodes of pain or stiffness; D, excellent—ideal response, virtually pain free.” Patients were classified by the anchor question as having “no change” (A group [none] and B group [poor] combined) or “change” (C group [good]). The D group (excellent) was not included in the analysis because this was considered beyond minimal change.

The MCIDs for the ASES score, SST score, and VAS pain score were 20.9 (P < .001), 2.4 (P < .0001), and 1.4 (P = .0158), respectively. 

Duration of follow-up and type of arthroplasty (anatomic TSA vs reverse TSA) did not have a significant effect on the MCIDs (P > .1) except shorter follow-up correlated with a larger MCID for the ASES score (P = .0081). 

Younger age correlated with larger MCIDs for all scores (P < .024). Female sex correlated with larger MCIDs for the VAS pain score (P = .123) and ASES score (P = .05).

Patients treated with a shoulder arthroplasty require a 1.4-point improvement in the VAS pain score, a 2.4-point improvement in the SST score, and a 21-point improvement in the ASES score to achieve a minimal clinical importance difference from the procedure.

Comment: MCID is one way of looking at the amount of improvement, but it has a problem. Consider two patient having a shoulder arthroplasty, each with an improvement of 3 in the SST score (both exceeding the 2.4 MCID improvement).

Their outcomes are not the same. For that reason we use both the preoperative to postoperative change in the SST as well as the percent of maximal possible improvement to characterize the result:

Here we can see that Smith only improved by 27% of the maximal possible improvement, whereas Jones improved by 75% of the maximal possible improvement (even though the improvement in both cases exceeded the MCID).

We've found that the concept of %MPI is easier to explain to patients than MCID.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Is there sufficient PROMIS to re-invent the wheel?

Psychometric evaluation of the PROMIS Physical Function Computerized Adaptive Test in comparison to the American Shoulder and Elbow Surgeons score and Simple Shoulder Test in patients with rotator cuff disease

The National Institutes of Health has recently developed the Patient-Reported Outcomes Measurement System (PROMIS) Computer Adaptive Test (CAT) that applies technology of computerized adaptive testing used in examinations like the Graduate Records Examinations.
With CAT, questions are sequentially administered from a large item ‘‘bank’’ until predetermined reliability criteria are met. Each question response produces a probability curve of the respondent’s estimated ability. For example, a patient who can throw a ball with ease has a high probability of having upper-end physical function. Subsequent questions can then be chosen by the CAT ‘‘engine’’ that will further discriminate the respondent’s estimated ability while uninformative and repetitive questions are omitted.

These authors studied 187 patients with clinical diagnosis of rotator cuff disease completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), and PF CAT.

Responses from 187 patients were analyzed. The PF CAT required fewer questions than the ASES or SST (PF CAT, 4.3; ASES, 11; SST, 12). Correlation between all instruments was moderately high. Item reliability was excellent for all instruments, but person reliability of the PF CAT was superior (0.93, excellent) to the SST (0.71, moderate) and ASES (0.48, fair). Ceiling effects were similar among all instruments (PF CAT, 0.53%; SST, 6.1%; ASES, 2.3%). Floor effects were found in 21% of respondents to the SST but in only 3.2% of PF CAT and 2.3% of ASES respondents.

Comment: Unfortunately the CAT requires the patient to be at a computer or tablet that carries the program. It cannot be completed on paper and thus is not amenable to follow-up mailings. The authors did not measure the time to complete the PROMIS nor its relative convenience or user-friendliness. They did not study the ability of the PROMIS responses to be translated into terms that patients can easily grasp. It is 'the new kid on the block' so that its results cannot be compared to data collected in the past.

By contrast the user-friendly Simple Shoulder Test can be completed on paper anywhere in the world in under two minutes and requires nothing other than a pencil. The SST has been utilized in over 650 publications according to a recent PubMed search. As early as ten years ago, it was recognized that this simple 12 item questionnaire had the ability to characterize (1) the function of normal shoulders, (2)  the functional deficits for many different diagnoses, and (3) the different responses of male and female patients. Here are some figures from that article that was based on 2674 patients.

The characteristics of the Simple Shoulder Test have been well defined

Reliability, validity, and responsiveness of the simple shoulder test: Psychometric properties by age and injury type

Minimal Clinically Important Differences in ASES and Simple Shoulder Test Scores After Nonoperative Treatment of Rotator Cuff Disease

The Simple Shoulder Test is more responsive than the DASH, measures of motion and strength in assessing change following shoulder arthroplasty.

The utility of this instrument in documenting comfort and function of the shoulder before and after treatment has been extensively documented, for example

Can the ream and run procedure improve glenohumeral relationships and function for shoulders with the arthritic triad?

The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases.

Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less.

The simple shoulder test is responsive in assessing change following shoulder arthroplasty.

Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming.

Shoulder scoring scales for the evaluation of rotator cuff repair.

It can be easily used to track patients' recovery over time.

As well as its use in multiple languages, for example

Validation of the Simple Shoulder Test in a Portuguese-Brazilian Population. Is the Latent Variable Structure and Validation of the Simple Shoulder Test Stable across Cultures?

Validation of the Dutch version of the Simple Shoulder Test

Validation and reliability of a Spanish version of Simple Shoulder Test (SST-Sp)

Finally, and perhaps most importantly, while the PROMIS score is a number without particular meaning to a patient, the results of the SST can be easily communicated:

We are not sure that the PROMIS is progress.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Reverse total shoulder - what outcome score to use?

Assessment of the optimal shoulder outcome score for reverse shoulder arthroplasty

These authors used a database of 148 patients having reverse total shoulders to compare preoperative and postoperative Constant-Murley Scores, American Shoulder and Elbow Surgeons Scores, and Subjective Shoulder Values.

They found no significant differences in the mean improvement between the scores.  Multivariate regression analysis the 3 outcome measures was able to predict 38.9% of the variation in improvement in forward elevation.

The authors concluded that the 3 shoulder outcome scores, regardless of whether they were patient reported or physician based, appear to appropriately reflect improvements after RSA with equal validity.

Comment:  This study demonstrates that various outcome instruments can show the benefit of reverse total shoulder arthroplasty. So what is there to choose among them?

It seems to us that the goals of outcome scores are (1) to enable each surgeon to track his/her results so that those patients failing to improve can be identified and the reasons for those failures investigations and (2) to enable different surgeons to compare and contrast results with different surgical approaches for different pathologies.

Keeping in mind that there is a cost with administering and analyzing each score in each patient, we have sought to optimize the benefit / cost ratio for outcome assessment. This consistently leads to the Simple Shoulder Test, a test that is patient-derived, sensitive, validated, short (12 questions), easy to administer and covers the range of complaints of individuals with shoulder disorders. For fun, compare the effort needed to administer the Constant Score or the ASES score and decide if there is enough incremental value (if any) of these instruments to justify the increased cost of administration and analysis.

The use of the Simple Shoulder Test in evaluating reverse total shoulders is illustrated in the articles below:

What is a Successful Outcome Following Reverse Total Shoulder Arthroplasty?

Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years.

The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture

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Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'



See from which cities our patients come.



See the countries from which our readers come on this post.