Monday, October 26, 2020

Rotator cuff injury - how to measure shoulder function and functional improvement.

The Western Ontario Rotator Cuff Index Normative Values for Age and Gender

These authors sought to determine determine normative values for the Western Ontario Rotator Cuff Index (WORC) values and assess whether the WORC needs an adjusted score for age- and gender. 

The WORC questionnaire consists of 21 items divided in 5 domains. The 5 domains are physical symptoms (1), sports and recreation (2), work (3), social function (4), and emotional disability (5). Each item is scored on a 100-mm scale, ranging from 0 (best) to 100 (worst). Of note is that this inverted scale can create confusion because the worst values are "100". Thus they had to use a formula to convert the total and domain scores into percentages, with 0% as the lowest functional status level and 100% the highest, to allow easy clinical applicability.

The mean total  WORC score was 94 (±9) and the mean total WORC score in every age and gender category was > 90%. Of all participants, 85% scored between 91%-100%, 63 participants (15%) scored 100%.

They found no statistically significant differences between genders in the overall score, domain scores and within the age categories.

Comment: Patient-reported measures (PRM's) are the essential element of assessing the status of the shoulder before and sequentially after treatment. While some surgeons use the "adjusted" Constant score, age and sex adjustments are not necessary as long as patients are appropriately stratified according to the question being asked, e.g. "are women with supraspinatus tears less functional than men?" or "are patients <50 yrs with supraspinatus tears less functional than patients> 50?"

For measuring functional improvement for each patient, a very simple metric can be used with any PRM: the percent of maximum possible improvement (%MPI). The math is easy:

(postoperative PRM minus preoperative PRM)/(perfect PRM minus preoperative PRM). 

The %MPI avoids the issues of determining different "MCIDs" (minimal clinically important differences) for different patient populations, different diagnoses and different procedures.

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