Shoulder motion, function and satisfaction after arthroplasty

A recent article, Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty, pointed out that satisfaction after shoulder arthroplasty - can be associated with scores on patient-reported outcome measures (PROMs). (See Patient satisfaction after shoulder arthroplasty - anticipation and informing). In turn, PROMs are dependent upon restoring lost shoulder range of motion (ROM). The authors questioned whether there was a threshold in postoperative active ROM beyond which additional improvement in motion was not associated with additional improvement in the PROMs that primarily measured function (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES] score, and the Shoulder Pain and Disability Index [SPADI]). (Of note, other outcome measures, such as the Shoulder Arthroplasty Smart Score, primarily measure motion (70% of the total score) attributing only 10% of the points to function).

They included 4,459 TSAs (1,802 aTSAs, 2,657 rTSAs) with minimum 2-year follow-up. Indeed they found thresholds in postoperative ROM that were associated with no further improvement in the standard PROMs.

The "S" shapes of these curves are interesting. See for example the figures below plotting the patient's Simple Shoulder Test (SST) responses against active flexion and active external rotation. 

At the left side of these curves, improvement in motion has little effect on the number of SST functions the shoulder could perform. In the middle, there is a steep improvement in function with increasing range. At the right hand of the "S", the curve flattens out so that further improvements in range are not strongly associated with increased function. For the SST the inflection points (thresholds) were 153 degrees for active flexion, 50 degrees of active external rotation, and active internal rotation to L2. Similar thresholds were found for other function-based outcome measures, including the ASES score and the SPADI.

Subjective satisfaction was assessed by asking patients to rate their shoulder as being  “worse”, “unchanged”, “better”, or “much better” compared to before surgery. Among shoulders that achieved all ROM thresholds, 93% of patients rated their shoulder as “much better” compared to before surgery.

It is interesting to view these results in the light of data presented in Practical Evaluation and Management of the Shoulder. The authors of that book characterized elevation in terms of the angle of elevation

and the plane of elevation.

They learned that - rather than being confined to "abduction" and "flexion" - different functions were performed in different planes and with different angles of elevation.

It can be seen that the average maximum angle of elevation for eight normal subjects was 148 degrees, and that this range was not necessary for most of the activities of daily living.

Of course the ability to perform functions does not only depend on elevation angle and plane, but also on the rotation of the arm as shown below.

Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty is an important article in that it can help guide motion goals for arthroplasty surgery and postoperative rehabilitation. It suggests that a shoulder that has active elevation to 180, external rotation to 90 and internal rotation to T7 may not be more functional or satisfactory than one has 153 degrees of active flexion, 50 degrees of active external rotation, and active internal rotation to L2. 

Comment to 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). 

How much should it cost to evaluate the shoulder?

Characterizing the comfort, function, and range of motion of the shoulder before and sequentially after treatment are the cornerstones clinical shoulder practice. As is the case for most types of measurement, greater accuracy, precision, and detail can be purchased with more money. The amount of accuracy, precision, and detail needed depends on questions that need to be answered.

For example, the authors of Test-retest reliability of isometric shoulder muscle strength during abduction and rotation tasks measured using the Biodex dynamometer found that shoulder muscle strength in abduction and rotation measured with the pricey Biodex dynamometer (see this link) are reproducible and correlate with the strength assessment of the Constant Score; under what circumstances is the increased cost worth it?  Furthermore, the Constant Score itself requires the costs of travel and a clinic visit (see this Constant–Murley Score: systematic review and standardized evaluation in different shoulder pathologies).

By contrast, validated mail-in questionnaires assessing shoulder comfort and function avoid the costs of equipment, travel and an office visit and provide information on the patient's ability to perform individual shoulder functions before and sequentially after treatment (see Shoulder joint replacement arthroplasty - what outcomes do patients care about?). 

As another example, the ranges of shoulder motion can be measured using an expensive artificial intelligence-based image recognition detectable sensor (see Comparative accuracy of a shoulder range motion measurement sensor and Vicon 3D motion capture for shoulder abduction in frozen shoulder); in what circumstances is the information gained worth the cost?

 Even the use of a simple goniometer by clinical staff requires travel and an office visit. 

Travel and visit costs for clinical followup can be avoided by the use of telehealth, as emphasized by the authors of Validation of an on-screen application-based measurement of shoulder range of motion (ROM) over telehealth medium who sought to investigate the accuracy and reliability shoulder range of motion measurement through telehealth in 24 healthy volunteers and 16 symptomatic patients with shoulder range of motion (ROM) deficits. The shoulder ROM was first examined physically using the goniometer in the clinic and then over Zoom. Comparison of the two methods showed only minor mean differences for the healthy volunteers and the patients. They concluded that the telehealth method of measuring shoulder ROM was accurate and reliable when compared to the clinical goniometer method.

Even simpler and more accessible than telemedicine is asking the patient, family, or friend to email photos of the arm in selected positions to follow ranges of motion in the treatment of conditions such as frozen shoulder and during joint replacement rehabilitation. 

Patients can be sent the figures below, asking them to position the arm as far in the indicated direction as possible. By keeping the photos on file the surgeon can monitor patient progress. The advantage of this system is that the patient need not be connected in real-time via telehealth, but can send in the photos at whatever time works for them.

Here are a few examples:

 

This approach can demonstrate active range 

assisted range

and the relative contributions of glenohumeral to scapulothoracic motion.

While this approach to following shoulder motion during treatment may not be as accurate as direct in-person measurements, it provides a cost effective method for monitoring the progress of shoulder range of motion achieved by physical therapy and surgery. Again, because photographs can be sent at a time convenient to the patient and viewed at a time convenient for the surgeon, this simple approach is easily accessible at both ends of the communication. If problems are identified, an in-person evaluation can be arranged. 

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

Follow on twitter: https://twitter.com/RickMatsen or 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).

Rotator cuff tears - what determines the patient's comfort and function?

The symptoms experienced by patients with rotator cuff pathology vary widely, ranging from asymptomatic to disabling (see Asymptomatic Rotator Cuff Tears). In A prospective multipractice investigation of patients with full-thickness rotator cuff tears: the importance of comorbidities, practice, and other covariables on self-assessed shoulder function and health status the authors found that shoulder function of patients with cuff tears was correlated with medical and social comorbidities. 

In a study of 191 patients with full thickness cuff tears, the authors of A prospective, multipractice study of shoulder function and health status in patients with documented rotator cuff tears  found that shoulder function was significantly correlated with  patient sex, involvement of the infraspinatus tendon and workers’ compensation claims. 

The authors of Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity found that the extent of the cuff tear was poorly associated with the shoulder's comfort or function. 

A systematic review, Are Psychosocial Factors Associated With Patient-reported Outcome Measures in Patients With Rotator Cuff Tears? found that lower emotional and mental health function was associated with greater pain, disability and lower physical function in patients with cuff tears.

The authors of Psychological distress negatively affects self-assessment of shoulder function in patients with rotator cuff tears found that higher levels of psychological distress are associated with inferior patient self-assessment of shoulder pain and function using the VAS, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score.

Depression may drive patients to have evaluation and treatment for cuff disorders as suggested by the authors of Depression increases the risk of rotator cuff tear and rotator cuff repair surgery: a nationwide population-based study. who found that a diagnosis of cuff tear and the incidence of rotator cuff repair surgery was greater in patients with depression. Depressed patients also had a significantly increased risk of subsequent rotator cuff repair surgery.

Recently, the authors of Rotator cuff tendinopathy: magnitude of incapability is associated with greater symptoms of depression rather than pathology severity again pointed out that while rotator cuff tendinopathy develops in most persons during their lifetimes, it is often accommodated, and that there is limited correspondence between symptom intensity and pathology severity. 

They studied the relative association of functional capability with symptoms of anxiety or depression and with quantifications of rotator cuff pathology such as defect size, degree of retraction, and muscle atrophy among 71 adults seeking specialty care for symptoms of rotator cuff tendinopathy who had a recent shoulder MRI and completed the following questionnaires: 

1.Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health questionnaire (a measure of symptom intensity and magnitude of

capability, consisting of mental and physical health subscores), 

2. Generalized Anxiety Disorder (GAD) questionnaire (measuring symptoms of anxiety), and 

3. Patient Health Questionnaire (PHQ) (measuring symptoms of depression). 

Muscle atrophy was assessed based on oblique-sagittal plane MRI images medial to

the coracoid process according to the system of Warner et al with conversion to a 4-point numeric scale. Grade 0 (no atrophy) was assigned when the muscle completely filled its fossa and there was a convex extension out of the fossa; grade 1 (mild atrophy), when the muscle filled the fossa and the outer contour was flat with respect to the fossa; grade 2 (moderate atrophy), when the muscle was concave with respect to the fossa; and grade 3 (severe atrophy), when the muscle was barely apparent in the fossa.

They found the magnitude of incapability among patients seeking care for rotator cuff pathology was associated with symptoms of depression but not with the severity of the rotator cuff pathology.

Comment: Taken together these studies suggest that the symptoms and degree of disability experienced by patients with rotator cuff tears is strongly influenced by factors other than the magnitude of the cuff pathology. Such factors may include coverage by workers' compensation insurance, patient sex, social well being and mental health. These same factors may influence the tipping point for rotator cuff repair surgery and may have negative effects on the outcome of this procedure as well.

To add this blog to your reading list in Google Chrome, click on the reading list icon

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).

Does the size of the cuff tear matter?

Patient self-assessed shoulder comfort and function and active motion are not closely related to surgically documented rotator cuff tear integrity.

The rationale for rotator cuff repair surgery is that better integrity of the cuff should be associated with better comfort and function. However, in patients with cuff disease, there is not good evidence that the degree of rotator cuff integrity is closely associated with the shoulder's comfort, function, or active motion. The goal of this study was to explored these relationships in shoulders with surgically documented cuff disease.

In 55 shoulders having surgery for cuff-related symptoms, the authors correlated the preoperative Simple Shoulder Test score with the objectively measured preoperative active shoulder motion and with the integrity of the cuff observed at surgery.

The 16 shoulders with tendinosis or partial-thickness tears had an average Simple Shoulder Test score of 3.7 ± 3.3, active abduction of 111° ± 38°, and active flexion of 115° ± 36°. The corresponding values were 3.6 ± 2.8, 94° ± 47°, and 94° ± 52° for the 22 full-thickness supraspinatus tears and 3.9 ± 2.7, 89° ± 39°, and 100° ± 39° for the 17 supraspinatus and infraspinatus tears.

In the plots below, one can see the wide variations in the SST scores, the active flexion, and the active abduction in the shoulders with (a) 'intact' cuffs with tendinosis or partial tears, (b) full-thickness supraspinatus tears, and (c) supraspinatus and infraspinatus tears. In this group of shoulders with surgically-documented pathology, the size of the cuff tear did not have an effect on patient self-assessed comfort and function (as measured by the Simple Shoulder Test) or on active flexion or abduction (as objectively measured by the Kinect motion capture system).

Comment: In this study, surgically observed cuff integrity was not strongly associated with the shoulder's comfort or function. The management of patients with rotator cuff disorders needs to be informed by a better understanding of the factors other than cuff integrity that influence the comfort and functioning of shoulders with cuff disease.



=====
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 do rotator cuff tears influence shoulder motion?

Scapulohumeral rhythm relative to active range of motion in patients with symptomatic rotator cuff tears

These authors studied 14 patients with rotator cuff tears and 14 healthy individuals with 35 reflective markers on the trunk and upper limb tracked by an optoelectronic system to measure the scapulohumeral rhythm (the ratio of glenohumeral to scapulothoracic motion in arm elevation) while the subjects carried out 5 comfortable scapular plane maximal arm elevations. They found a value of 3.9 for healthy controls.

Patients were separated by maximal arm elevation of 85° (category A) and 40° (category B). 

The mean scapulohumeral rhythm ratio during arm elevation was 2.8 for patients in category A; these patients  had a relatively consistent pattern as shown below with much lower values than controls (that is relatively less glenohumeral movement and relatively more scapulothoracic motion).  

The patients with only 40 degrees of active motion (Group B) had widely varying patterns of motion as shown below

The authors concluded that patients who reached at least 85° compensated for the loss of glenohumeral motion by increased scapulothoracic contribution.  In contrast, patients who had less active range of motion had less contribution from scapulothoracic motion.

Comment: This study demonstrates that some patients with cuff deficiency can compensate by increasing the scapulothoracic contribution to active motion. There were only seven patients in each group and we are not presented with the cuff tear sizes in the two groups.

In our management of individuals with chronic cuff tears we encourage them to try a simple exercise program that encourages use of both the glenohumeral and scapulothoracic musculature (shown below)

It is interesting that some patients sent to us for consideration of reverse total shoulders because of apparent pseudoparalysis are able to regain substantial function with this simple exercise.

===

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.

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