Why the Simple Shoulder Test is my preferred patient reported outcome measure.

Many different shoulder outcome measures have been proposed. 

Some ask the patient: "How would you rate your shoulder function as a percentage of normal, with 0% being completely nonfunctional and 100% being completely normal?" or "How would you rate your shoulder today as a percentage of normal, where 0% represents no function and 100% represents normal function?". 

Some ask the patient to make a mark on a visual analogue scale 

 

Some ask for a measurement of range of motion that is included in an overall score

Some use computer adaptive testing to derive a single number representing pain and function.

And still others generate a single number based on "hands-on" evaluation of strength and motion by a trained observer combined with patient answers to questions about pain and function.

While each of these may have advantages, my preferred outcome measure is simple, easily accessible to almost all patients, and reflects what the patient believes they can do with their shoulder. 

It is the Simple Shoulder Test, a set of twelve "yes" or "no" shoulder function questions:

1. Is your shoulder comfortable with your arm at rest by your side?
2. Does your shoulder allow you to sleep comfortably?
3. Can you reach the small of your back to tuck in your shirt with your hand?
4. Can you place your hand behind your head with the elbow straight out to the side?
5. Can you place a coin on a shelf at the level of your shoulder without bending your elbow?
6. Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow?
7. Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow?
8. Can you carry 20 pounds at your side with the affected extremity?
9. Do you think you can toss a softball underhand 10 yards with the affected extremity?
10. Do you think you can throw a softball overhand 20 yards with the affected extremity?
11. Can you perform your usual work? 
12. Can you perform your usual sport? 

 Completion of the SST requires only a pencil and a stamped envelope. 

As a result use of the SST avoids the risk of selection bias that can result from excluding those who cannot use a computer or who cannot travel for in a person examination. It also avoid the problems of observer bias and inter-observer variability; the consistent observe this the most important one: the patient.

The easy accessibility of the SST enables long term studies with low percentages of "lost to followup".

Since its introduction by Doug Harman and Steve Lippitt in 1993 it has been used in 1,637 publications in peer reviewed journals at the time of this post and has been translated to and validated in multiple languages, including Spanish, French, German, Italian, Chinese, Japanese, Korean, Portuguese, Dutch, Swedish, Turkish, Russian, Arabic, Hindi, Thai, and Bulgarian, enabling cross-cultural studies. 

Instead of yielding a single numerical score (which may have limited meaning to our patients), the SST gathers easily understandable information about the individual's ability to perform 12 separate function. This enables surgeons and patients to understand the ability of a procedure to address the functional deficits of particular importance to the individual.

Some have criticized the Simple Shoulder Test having a "ceiling effect", meaning that some patients can perform all 12 of the functions. However, the "ceiling" is pretty high: a shoulder that can throw 20 yards, lift a full gallon container to the level of the shoulder with the arm held straight, and allow comfortable sleep is an excellent shoulder by any measure.

The SST is a low cost and practical method for surgeons to measure their own effectiveness in treating a wide range of shoulder conditions and to collaborate broadly in clinical research.

Development of the SST

1. Identifying Common Shoulder Activities:

   • The questions were selected after methodologically cataloguing the presenting complaints of patients with a broad range of shoulder conditions.
   • The 12 commonest complaints were converted in to simple "yes" "no" questions. 
   • As a result, the SST focuses on basic, everyday activities that are commonly affected by shoulder dysfunction. These include actions like reaching, lifting, carrying, and activities of daily living such as grooming or dressing.
   • The development team aimed for questions that would resonate universally across patients with varying shoulder conditions.
   • The questions were administered to a population of individuals with normally function of their shoulders and without sonographic evidence of cuff pathology. These individuals consistently had the ability to perform at least 10 of the twelve questions.

2. Simplicity for Self-Administration:

   • The questions were crafted to be easy for patients to understand and answer without requiring significant medical interpretation. This ensures that the SST is accessible and practical in busy clinical settings.

3. Binary Response Format:

   • Each question requires a simple "yes" or "no" response, reflecting whether the patient can or cannot perform the activity. This format was chosen to streamline data collection and interpretation.

4. Validation Process:

   • The SST was subjected to a rigorous validation process to ensure reliability and consistency in measuring shoulder function. The questions were refined based on patient feedback and expert reviews to ensure relevance and clarity.
   • It was tested across various patient groups with different shoulder pathologies, confirming its utility in diverse clinical scenarios.

5. Focus on Outcomes:

   • The SST emphasizes patient-reported outcomes rather than objective clinical measurements alone. This aligns with a growing emphasis on understanding how conditions affect patients’ lives and activities.

By centering the questions on common functional tasks, the SST allows healthcare providers to gauge the practical impact of shoulder problems and the effectiveness of interventions over time.

By focusing on functional activities that matter to patients, the SST provides a practical, patient-centered measure of shoulder function.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Assessing arthroplasty outcomes - how do we know if we're doing better for our patients?

In this era where many new innovations in shoulder arthroplasty are being brought forward, the incremental clinical value of each of these innovations can only be measured by assessing whether they improve patient self-assessed comfort and function to a greater degree than the methods in current use.

To document patient self-assessed comfort and function after different approaches to shoulder arthroplasty, we continue to use the Simple Shoulder Test (SST) introduced by Douglas Harryman and Steve Lippitt in 1993 because

(1) The "low tech, low cost" nature of the SST optimizes longitudinal participation by a high percentage of patients by avoiding barriers (such as the need to travel for an in-person examination or the need for a computer interface). In this way, the risk of selection bias can be minimized.

(2) The SST documents the patient's ability to perform important individual functions before and sequentially after any type of shoulder arthroplasty, providing granularity not available from single numerical scores.

(3) The SST eliminates concerns regarding inter-observer variability, observer bias, and industrial influence, thereby enabling meaningful comparisons among procedures and centers

(4) Consenting patients are prospectively enrolled by the research staff. After enrollment, the followup is managed by the research staff, completely independent of potential interference from the surgical team. The result is a high level of continued participation over time following the arthroplasty.

We are celebrating our 2000th patient prospectively enrolled in the Shoulder Research database. We are continuing to learn more about what improves the comfort and function of our patients.

Comment: Comparing the incremental value to the patient of new innovations over current methods requires tools, such as the SST, that facilitate the unbiased longitudinal assessment of a high percentage of patients treated with the different methods.

Comments welcome at shoulderarthritis@uw.edu

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link


Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/


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). 

Patient satisfaction after shoulder arthroplasty - anticipation and informing

Surgeons want their patients to be satisfied with the outcome of their shoulder arthroplasty. Two recent studies have correlated patient satisfaction with patient reported outcomes.

In the first, Reaching MCID, SCB, and PASS for ASES, SANE, SST, and VAS following Shoulder Arthroplasty Does Not Correlate with Patient Satisfaction, the authors attempted to correlate patient satisfaction with previously defined values for minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for ASES, SANE, SST, and VAS at 2 years following shoulder arthroplasty for 352 patients.

They point out that historically the thresholds for MCID, SCB and PASS were established based on anchoring questions that did not account for patient satisfaction

In their study, satisfaction was assessed by a questionnaire asking: 1) on a scale of 1 to 10, what is your overall satisfaction with your surgical outcome? 2) if you could go back in time, would you undergo this operation again? (yes/no) 3) for the same condition, would you recommend this operation to a friend or family member? (yes/no).

ASES scores improved from 42 to 88, SANE improved from 36 to 87, SST improved from 5 to 10, and VAS improved from 5 to 1.

Mean patient satisfaction was 9.0. 94% of the patients would undergo surgery again
94% of the patients would recommend surgery.

12% of the patients reported satisfaction scores below 8 out of 10. This subset of patients had a mean ASES of 75, SANE of 71, SST of 8, and VAS of 2.

8 patients did not reach MCID for any of the outcome metrics, but 5 of these reported satisfaction scores of 8 or higher.

42 patients did not reach SCB in any of the four outcome metrics, but 28 of these reported satisfaction scores of 8 or higher.

24 patients did not reach PASS in any of the four outcome metrics, but 14 of these reported satisfaction scores of 8 or greater.

Spearman correlation coefficients were weak or very weak for reaching MCID, SCB, and PASS in ASES, SANE, SST, and VAS and all three study outcome metrics.


A second study, Anatomic Total Shoulder: Predictors of Excellent Outcomes at Five Years after Arthroplasty, reported minimum 5-year outcomes in patients undergoing TSA and sought to determine characteristics predictive of patients achieving an excellent functional outcome.

Preoperative demographic variables and Simple Shoulder Test (SST) scores were obtained pre-operatively and at a minimum of five years after surgery for 188 patients. A final SST ≥ 10 and percentage of maximal possible improvement (% MPI) of ≥ 66.7% were determined to be the thresholds for excellent outcomes. 

Mean SST scores improved from 3 to 10. 62% and 71% of these patients achieved an excellent outcome as defined by five-year SST ≥ 10 and %MPI ≥ 66.7%, respectively.

Male sex and commercial insurance coverage were predictors of both SST ≥ 10 and %MPI ≥ 66.7. Workers' Compensation insurance was predictive of not obtaining SST ≥ 10 or %MPI ≥ 66.7).









The threshold for MCID was passed by the vast majority (95%) of patients undergoing TSA but did not necessarily indicate an excellent, satisfactory outcome.

The authors remind us that while the type of insurance is associated with patient outcome,  the type of insurance coverage is a surrogate indicator for the patients’ social determinants of health. For example, patients having commercial insurance may be more likely to have higher levels of primary care, education, income, social support, as well as overall physical and mental health than patients covered by an alternative type of insurance. Each of those patient characteristics may be important factors affecting the outcome.

Comment: These studies point out that satisfaction is not strongly related to the absolute value of the amount of improvement. This makes sense: a patient improving from a preoperative SST sore from 2 to 6 will have exceeded the MCID, but still only can perform 6 of the 12 SST questions. Alternatively, an SST improvement from 9 to 11 would not exceed the MCID, but would indicate a shoulder that could perform 11 of the 12 SST functions.

A strong component of postoperative patient satisfaction is that the procedure met the patient's expectations of it. The observation that satisfaction is strongly correlated with an SST ≥ 10 and %MPI ≥ 66.7% indicate that the patient's expectation is that they will have a highly functional shoulder after arthroplasty (SST ≥ 10) and that most of their preoperative functional deficit will be mitigated by the procedure ( %MPI ≥ 66.7%).

This is valuable information for the arthroplasty surgeon. In patients who are unlikely to achieve SST ≥ 10 and %MPI ≥ 66.7%, it would seem prudent to inform them of this preoperatively - to set realistic expectations. Charles Neer understood this clearly; patients who were unlikely to achieve high levels of function were placed in a "limited goals" category and he carefully explained this reality to them before surgery.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Contact: shoulderarthritis@uw.edu

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). 

The challenge of measuring shoulder arthroplasty outcomes: bias, ceiling effects, and practicality.

Each surgeon has the opportunity - indeed the responsibility - to keep track of her or his surgical outcomes for the purpose of knowing what is and what is not working in the practice. This point is discussed in detail in this link. In that many failures of arthroplasty occur more than five years after surgery, long-term followup is critical.




Three of the key elements of an effective/informative/practical outcome system are (1) capturing the highest possible percentage of patients treated, (2) being able to present the results to patients in terms that patients and surgeons understand, and (3) having a system that is validated and universally applicable so that data can be compared among centers.

#1 requires minimizing exclusion bias. Many scales, such as the Constant Score, the UCLA score, and the Shoulder Arthroplasty Smart score require the patient to return to the office for the measurement of ranges of motion (and, in some cases, strength). In addition to risking observer bias and inter-observer variability, the requirement of returning to the office risks selectively excluding those patients living at a distance from their provider, those unwilling or unable to return, and those of limited economic means. Computer-based scoring systems, such as the PROMIS and Computer Adaptive Testing, risk selectively excluding patients without access to computers, those who are not computer literate and those not proficient in English. The ideal system makes it easy for all patients to be included in long-term followup: inexpensive, quick to complete, accessible independent of the location of the patient and independent of the patient's computer literacy and access.

#2 requires that the outcome data are presented in a way that is meaningful to the patient and surgeon. Most patients will have difficulty understanding the significance of a "score of 72" on PROMIS, Constant, UCLA or SAS, but many would understand the significance of the improvement in specific shoulder functions achieved by their surgeon for a specific condition presented as shown below (showing results obtained using the Simple Shoulder Test results for extended head hemiarthroplasty in the treatment of patients having cuff tear arthropathy with retained active elevation).





#3 Most of the commonly used outcome measures have been carefully validated, for example see Is the Simple Shoulder Test a valid outcome instrument for shoulder arthroplasty? which shows, in spite of the fact that 15% percent of the patients achieved the maximal SST score, there was a near-perfect correlation between satisfaction and the final SST score, suggesting that the "ceiling effect" is likely to have little clinical significance.





What this means is that a shoulder that can perform each of the 12 SST functions (below) is an excellent and highly satisfactory shoulder.





If the ceiling effect was a concern, one could add a thirteenth question: "Can you throw a football 100 yards with the affected arm?". Very few shoulders, normal or post-arthroplasty, would hit the ceiling of 13/13 "yes" responses.


In the same vein, the authors of Validation of a machine learning–derived clinicalmetric to quantify outcomes after total shoulderarthroplasty and Exactech Equinoxe anatomic versus reverse total shoulder arthroplasty for primary osteoarthritis: case controlled comparisons using the machine learning–derived Shoulder Arthroplasty Smart score correctly point out that the Shoulder Arthroplasty Smart score (you can experiment with it on this link) does not have a ceiling effect. In order to achieve the ceiling of the SAS score, the shoulder needs to be measured as having 180 degrees of active forward elevation, internal rotation to T7, and 90 degrees of active external rotation with the arm at the side.


These values will be difficult to attain because they are substantially greater than those found in the general population (see Shoulder range of movement in the general population: age and gender stratified normative data using a community-based cohort): average active shoulder flexion was 160° and average active external rotation was 59°.

Another approach for those concerned about the "ceiling effect" is put forth by the authors of Quantifying success after anatomic total shoulder arthroplasty: the minimal clinically important percentage of maximal possible improvement. They expressed the amount of improvement as the percentage of maximum possible improvement (%MPI) (based on a prior study: The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases). The %MPI is calculated as (postoperative score - preoperative score)/(perfect score - preoperative score). The "ceiling" in the %MPI would only be reached if the score improved from the worst possible score to the best possible score - a rare event.
Then they determined the minimal clinically important difference (MCID) for the %MPI using the anchor method. Interestingly their calculated MCID-%MPI values are similar for many of the commonly used scores: 33% for the SST, 32% for the ASES score, 38% for the UCLA score, 30% for the Shoulder Pain and Disability Index score, and 33% for the Shoulder Arthroplasty Smart score.


Comment: A surgeon's choice of the optimal patient followup system needs to be made in consideration of the above factors as well as the required staff time and cost of implementation. The goal is to capture long-term data on the highest percentage of patients treated using a method that is affordable and practical for the office.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Shoulder arthroplasty outcomes - it's not academic, it's personal

Many articles written about measuring surgical outcomes fail to emphasize the greatest value of collecting followup data - the opportunity for self-improvement. As the inscription on the Temple of Apollo states: "physician, know thyself".

The phrase "the surgeon is the method" means that each surgeon's indications, technique and outcomes are particular to her or him. While it is of interest to know how patients fare at some famous center, it is more important for each of us to know the characteristics of the patients we treat and how they do with the treatments we provide for them. In order for us to "own our outcomes" we need to collect our results in a systematic way that minimizes selection bias. We need to follow each of our patients long enough to know if our treatment was successful and to ask "if not, why not" (Codman: A Study of Hospital Efficiency).

Yet it is surprising how few surgeons (whether in community or academic practice) have implemented a meaningful followup system that will help improve their practice. The best time to implement such a self-improvement system is now - for surgeons new to practice, start on day one before things get "too busy". It's a gift that will keep on giving.

To attain this goal, a practical method of following patient comfort and function is needed - one that is accessible for all patients treated (including those who cannot use computers or tablets, those who cannot return to the office for periodic followup, and those who have a limited command of the language). An inexpensive, validated method approach is provided by the Simple Shoulder Test, the SST: 12 simple "yes" or "no" questions that can answered with nothing more than a pencil and then mailed in to the surgeon's office. The SST is now being used in multiple languages, including Arabic, Argentinian, Chinese, Dutch, Italian, Japanese, Lithuanian, Persian, Polish, Portuguese, Spanish, and Turkish.

Patients can be encouraged to participate in long term followup with periodic completion of the SST by explaining, "I care about how my patients do over time after their treatment. When patients fill out this simple followup form, it lets me learn how well things are working out and what adjustments I may need to make in my approach to get the best possible results in the future. What I know today is based on past patients helping me in this effort".

The value of systematic followup is shown in the figure below that presents the results of 176 patients having the ream and run procedure for glenohumeral arthritis. The SST score is on the vertical axis and the years after surgery are shown on the horizontal axis. The solid line shows excellent average long-term outcomes (the dotted lines represent the standard deviations). End of story? No! The opportunities for practice improvement lie in the red box. The surgeon can learn by studying each of these cases: wrong indication? wrong patient? wrong implant? wrong technique? wrong rehabilitation? or subtle complication (e.g. delayed Cutibacterium infection)?

An important additional value of the SST is provided by its granularity, which presents data on the ability to perform specific functions before and after surgery in a form that is meaningful to surgeons and patients alike. This is in contrast to presenting the data as single number ASES, Codman, SAS, SANE, or PROMIS score or as the percent of patients that exceeded the minimal clinically important difference (MCID) - neither of which are likely to be as helpful to surgeons and to their patients as information on the improvement in the ability to perform specific shoulder functions.

The figure below shows the preoperative and minimum two year post-operative functions performable by patients with cuff tear arthropathy with retained active elevation having a CTA hemiathroplasty. These are the personal results from an individual surgeon presented in a form easily understood by the surgeon and patients alike.

An additional way of presenting a surgeon's outcome data is discussed by the authors of Quantifying Success After Anatomic Total Shoulder Arthroplasty: the Minimal Clinically Important Percentage of Maximal Possible Improvement. They point to the value of the percent maximal possible improvement (%MPI) as a way of communicating the improvement after shoulder arthroplasty. This concept was introduced in The Prognosis for Improvement in Comfort andFunction After the Ream-and-Run Arthroplastyfor Glenohumeral Arthritis and is defined as the amount of improvement divided by the maximum possible improvement:

%MPI = 100% X (post operative score - preoperative score/(maximum possible score - preoperative score).

For the SST the maximum possible score is 12.

Thus a patient with a preoperative SST score of 2 and a postoperative score of 10 would have achieved 100% X (10-2)/(12-2) or 80% maximum possible improvement.

They conducted a retrospective review of 1,593 primary anatomic total shoulders having a minimum of 2 year followup.

They found that the SST, ASES, UCLA had higher rates of patients achieving a %MPI > 30%, but lower rates of achieving the minimum clinically important difference (MCID). Conversely, the Constant and SAS scores had higher rates of patients achieving the MCID, but a lower rate of achieving %MPI > 30%.

They concluded that the %MPI offers a simple method to quickly assess improvements across patient outcome scores.

If a surgeon knows her or his average %MPI after anatomic shoulder arthroplasty (say 45%) is easy for the patient to understand this information: "in my experience patients with your findings before surgery regain about 45% of their normal comfort and function".

That is easier to understand than the more abstract concept of the MCID:"You have an X% chance of an improvement exceeding a calculated minimal clinically important difference (which may vary according to which procedure is performed as pointed out by the authors of The minimal clinically important differences of the Simple Shoulder Test are different for different arthroplasty types).

An issue with applying the MCID as a threshold for success is that it does not differentiate between different situations in which the improvement exceeded the MCID. For example an improvement after aTSA from 2 to 4 (a modest result) and an improvement from 9 to 11 (an excellent outcome) are not at all the same, even though both had an improvement in excess of the MCID of 1.6 for aTSA. It seems of greater value to use %MPI which is (4-2)/(12-2) or 20% for the first case and (11-9)/(12-9) or 67%.

Comment: Following patients to determine their outcome is the responsibility of each surgeon. As illustrated above, systematic followup can be both simple and powerful. The keys are (1) starting now, (2) using a outcome measure that is both practical and that does not systematically exclude patients because of inability to return to the office or inability to use computers or tablets, (3) analyzing and learning from the causes of failure to achieve the desired result, and (4) sharing the data with patients in a manner they can easily understand.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

The value of shoulder outcome scores - what does the patient care about?

Authors often evaluate outcome scores in terms of what statisticians care about, but rarely in terms of what is of interest to the patient. For example, some scores give a substantial weight to range of motion, yet as is shown in this link and by the authors of Relationship Between Patient-Reported Assessment of Shoulder Function and Objective Range-of-Motion Measurements, range of motion is only loosely associated with patient comfort and function. It would seem that patients are most interested in what the shoulder does or does not allow them to do.

Two recent articles by the same author prompted reflection on how one might make an outcome score meaningful to the patient.

In the first, The American Shoulder and Elbow Surgeons score highly correlates with the Simple Shoulder Test the author found that in 1810 simultaneous measurements (both rotator cuff repair and total shoulder arthroplasty) the correlation of the scores 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). 

In Can the Single Assessment Numeric Evaluation (SANE) be used as a stand-alone outcome instrument in patients undergoing total shoulder arthroplasty? the author found that  correlation was excellent for the SANE score and the ASES score (n . 1447, r . 0.82, P <.0001), WOOS score (n . 1514, r . 0.83, P <.0001), and SST score (n . 1095, r . 0.81, P <.0001). The correlation of preoperative scores was moderate and that of postoperative scores was strong-moderate when the SANE score was compared with all 3 other scores. All scores were highly responsive. Interestingly, 39% of the patients did not answer all of the ASES questions.

While the author concluded that " The SANE score may provide the same information as the WOOS, ASES, and SST score regarding outcomes with a significant reduction in responder burden, " this is not actually the case. The SANE, the WOOS, the ASES, the PROMIS, the UCLA, and the Constant score each reduce the patient's comfort and function to a single number using a formula that weights the different components without regard to the priorities of the individual patient.  The question is whether such a single number is of value to the patient, e.g. "after your surgery your "score" is likely to improve from 37 to 63".  

By contrast, the Simple Shoulder Test is a highly patient-accessible measure that takes but a minute to compete by patients whether they are at home or in the office, is free from observer bias, requires no scoring or computer, and yields data on 12 individual functions without attaching a weight to them:

Thus it is easy for prospective patients to see which functions are likely to be improved after surgery as shown below for the reverse total shoulder and which allows the prospective patient to decide which functions are of highest priority (e.g. sleeping comfortably may be of prime importance to one patient, while the ability to lift a pound to shoulder level may be of highest priority to another).

Such data are likely to be surgeon-dependent; thus surgeons who collect their own data can use them to inform prospective patients that "in my personal experience only two out of ten patients with a condition similar to yours are able to sleep comfortably before a reverse total shoulder while after surgery seven out of ten regain this ability; only one in ten are able to lift a pound to shoulder level before surgery while seven out of ten can do this after surgery". 

This type of presentation informs the patient that (1) the surgeon cares about their personal outcomes enough to collect and analyze their own data and (2) while surgery helps most individuals, there are patients who do not regain full functionality. Surgeon-specific data of this type can be an important part of the preoperative discussion and informed consent. 

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Return to comfortable sleep after rotator cuff repair - evaluation using the Simple Shoulder Test

 Majority of patients find sleep patterns return to normal 6 months following rotator cuff repair

These authors observe that "Because sleep disturbances from pain are a primary driver for patients with rotator cuff tears to see a physician, one of the main goals of rotator cuff repair (RCR) surgery is to eliminate night-time pain and restore normal sleep patterns in these patients."  They sought to determine the percentage of patients undergoing arthroscopic rotator cuff repair (RCR) who reported preoperative sleep disturbances and how their sleep disturbance resolved over time after repair surgery. 

In their evaluation, they used question 2 of the Shoulder test (SST): "does your shoulder allow you to sleep comfortably?" 

291 patients (89%) reported preoperative sleep disturbances. Patients with workers’ compensation cases were significantly more likely to report sleep disturbances; all 34 patients who had workers’ compensation cases reported preoperative sleep disturbances compared with 88% of patients without workers’ compensation cases. Additionally, the pretreatment mean VAS pain score was significantly higher in the group that reported sleep disturbances. No other significant differences were detected between groups. Notably, their study showed no statistically significant relationship between rotator cuff tear size or patient demographics. In addition, this study showed that postoperatively, there was no statistically significant relationship between rotator cuff tear size and the resolution of sleep disturbances,

Of those with preoperative sleep disturbance, 19% failed to resolve their sleep disturbance. Within the cohort of patients who reported resolution of sleep disturbances, 46% reported resolution by 3 months postoperatively; an additional 31%, by 6 months; a further 14%, by 12 months; and the final 8%, by 24 months. 

Of those 35 patients without preoperative sleep disturbance, 12 had sleep disturbance at 3 months, 2 at 6 months and 1 at 24 months.

Comment: This study demonstrates the utility of analyzing the 12 specific functions assessed by the Simple Shoulder Test.

Most shoulder evaluation systems in common use (Constant, ASES, SAS, PROMIS, SANE, etc) present the result as a single numerical score which may carry little meaning to the average patient.  By contrast, the Simple Shoulder Test presents data on the postoperative improvement in individual shoulder functions in a way that is easily understood as shown in the example below showing the patient reported outcomes for scapulothoracic fusion. Patients come to surgery desiring to improve their lost comfort and function, not to get a higher "score" on some outcome measure.

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   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).