Jean-Sébastien Roy

Measuring shoulder function: A systematic review of four questionnaires

OBJECTIVE To conduct a systematic review of the quality and content of the psychometric evidence relating to 4 shoulder disability scales: the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Shoulder Pain and Disability Index (SPADI), the American Shoulder and Elbow Surgeons (ASES) score, and the Simple Shoulder Test (SST). METHODS We conducted a structured search using 3 databases (Medline, CINAHL, EMBase). In total, 71 published primary studies were analyzed. A pair of raters conducted data extraction and critical appraisal using structured tools. A descriptive synthesis was performed. RESULTS Quality ratings of 55% of the studies reviewed reached a level of > or =75%. Most studies suggest that all 4 questionnaires have excellent reliability (intraclass correlation coefficient > or =0.90). The 4 questionnaires are strongly correlated (r >0.70) with each other and with a number of similar indices, and the questionnaires were able to differentiate between different populations and disability levels. The minimal detectable change (MDC) is approximately 9.4 for the ASES, 10.5 for the DASH, and 18 for the SPADI; the minimal clinically important difference (MCID) is approximately 6.4 for the ASES and 10.2 for the DASH, and ranges between 8 and 13 for the SPADI. MDC and MCID have not been defined for the SST. CONCLUSION The psychometric properties of the ASES, DASH, and SPADI have been shown to be acceptable for clinical use. Conversely, some properties of the SST still need be evaluated, particularly the absolute errors of measurement. Overall, validation studies have focused on less clinically relevant properties (construct validity or group reliability) than estimates of MDC and MCID.

A systematic review of the psychometric properties of the Constant-Murley score

HYPOTHESIS The purpose of this study was to conduct a systematic review of the psychometric evidence relating to Constant-Murley score. MATERIALS AND METHODS A search of 3 databases (Medline, CINAHL, and EMBASE) and a manual search yielded 35 relevant publications. Pairs of raters used structured tools to analyze these articles, through critical appraisal and data extraction. A descriptive synthesis of the psychometric evidence was then performed. RESULTS Quality ratings of 23% of the studies reviewed reached a level of 75% or higher. Studies evaluating the content validity of the Constant-Murley score suggest that the description in the original publication is insufficient to accomplish standardization between centers and evaluators. Despite this limitation, the Constant-Murley score correlates strongly (>or= 0.70) with shoulder-specific questionnaires, reaches acceptable benchmarks (rho > 0.80) for its reliability coefficients, and is responsive (effect sizes and standardized response mean > 0.80) for detecting improvement after intervention in a variety of shoulder pathologies. DISCUSSION This systematic review provides evidence to support the use of the Constant-Murley score for specific clinical and research applications but underscores the need for greater standardization and precaution when interpreting scores. Methods to improve standardization and measurement precision are needed. Responsiveness has been shown to be excellent, but some properties still need be evaluated, particularly those related to the absolute errors of measurement and minimal clinically important difference. CONCLUSION Given the widespread acceptance for usage of the Constant-Murley score in clinical studies and early indications that the measure is responsive, studies defining more rigid standardization of the tools/procedures are needed. LEVEL OF EVIDENCE Level 1.

Advanced practice physiotherapy in patients with musculoskeletal disorders: a systematic review

BackgroundThe convergence of rising health care costs and physician shortages have made health care transformation a priority in many countries resulting in the emergence of new models of care that often involve the extension of the scope of practice for allied health professionals. Physiotherapists in advanced practice/extended scope roles have emerged as key providers in such new models, especially in settings providing services to patients with musculoskeletal disorders. However, evidence of the systematic evaluation of advance physiotherapy practice (APP) models of care is scarce. A systematic review was done to update the evaluation of physiotherapists in APP roles in the management of patients with musculoskeletal disorders.MethodsStructured literature search was conducted in 3 databases (Medline, Cinahl and Embase) for articles published between 1980 and 2011. Included studies needed to present original quantitative data that addressed the impact or the effect of APP care. A total of 16 studies met all inclusion criteria and were included. Pairs of raters used four structured quality appraisal methodological tools depending on design of studies to analyse included studies.ResultsIncluded studies varied in designs and objectives and could be categorized in four areas: diagnostic agreement or accuracy compared to medical providers, treatment effectiveness, economic efficiency or patient satisfaction. There was a wide range in the quality of studies (from 25% to 93%), with only 43% of papers reaching or exceeding a score of 70% on the methodological quality rating scales. Their findings are however consistent and suggest that APP care may be as (or more) beneficial than usual care by physicians for patients with musculoskeletal disorders, in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction.ConclusionsThe emerging evidence suggests that physiotherapists in APP roles provide equal or better usual care in comparison to physicians in terms of diagnostic accuracy, treatment effectiveness, use of healthcare resources, economic costs and patient satisfaction. There is a need for more methodologically sound studies to evaluate the effectiveness APP care.

Effect of motor control and strengthening exercises on shoulder function in persons with impingement syndrome: a single-subject study design.

The aim of the study was to evaluate the effect of an intervention including shoulder control and strengthening exercises on function in persons with shoulder impingement. Eight subjects with shoulder impingement were evaluated weekly during the nine weeks of this single-subject design study. The study was divided into three phases (A(1)-B-A(2)) and involved repeated measures of shoulder pain and function (Shoulder Pain And Disability Index (SPADI) questionnaire), painful arc of motion, peak torque and 3-dimensional scapular attitudes. During the intervention phase, each subject participated in 12 exercise sessions supervised by a physiotherapist. Measures taken during the intervention and post-intervention phases were compared to pre-intervention values. All subjects showed significant improvement in the SPADI at the end of the study. A disappearance of a painful arc of motion in flexion and abduction (n=6), an increase in isometric peak torque in lateral rotation (n=3) and abduction (n=2), and changes in the scapular kinematics, mainly in the sagittal plane, were also observed. The present results provide preliminary evidence to support the use of shoulder control exercises to reduce pain and improve function of persons with shoulder impingement.

Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis.

Background Different diagnostic imaging modalities, such as ultrasonography (US), MRI, MR arthrography (MRA) are commonly used for the characterisation of rotator cuff (RC) disorders. Since the most recent systematic reviews on medical imaging, multiple diagnostic studies have been published, most using more advanced technological characteristics. The first objective was to perform a meta-analysis on the diagnostic accuracy of medical imaging for characterisation of RC disorders. Since US is used at the point of care in environments such as sports medicine, a secondary analysis assessed accuracy by radiologists and non-radiologists. Methods A systematic search in three databases was conducted. Two raters performed data extraction and evaluation of risk of bias independently, and agreement was achieved by consensus. Hierarchical summary receiver-operating characteristic package was used to calculate pooled estimates of included diagnostic studies. Results Diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears was high with overall estimates of sensitivity and specificity over 0.90. As for partial RC tears and tendinopathy, overall estimates of specificity were also high (>0.90), while sensitivity was lower (0.67–0.83). Diagnostic accuracy of US was similar whether a trained radiologist, sonographer or orthopaedist performed it. Conclusions Our results show the diagnostic accuracy of US, MRI and MRA in the characterisation of full-thickness RC tears. Since full thickness tear constitutes a key consideration for surgical repair, this is an important characteristic when selecting an imaging modality for RC disorder. When considering accuracy, cost, and safety, US is the best option.

Upper limb motor strategies in persons with and without shoulder impingement syndrome across different speeds of movement

BACKGROUND Activities requiring repetitive arm movements, including high velocity actions, have been identified as a risk factor for shoulder impingement. However, the effect of speed on upper limb motor strategies has yet to be evaluated for individuals with shoulder impingement. The aims of this study were to characterize upper limb motor strategies in individuals with and without shoulder impingement during reaching at natural speed and to evaluate their adaptation to higher speeds of movement. METHODS Twenty healthy individuals and 33 individuals with shoulder impingement took part in one evaluation session. They performed reaching at natural and fast speeds, toward targets located at 90 degrees of arm elevation in two different planes. Reaching speed, upper limb kinematics and shoulder muscular activity were used to characterize motor strategies. FINDINGS Individuals with shoulder impingement present altered motor strategies during reaching tasks. However, changes with speed were comparable in both groups, showing similar adaptation to speed. Larger intergroup differences were found when individuals with shoulder impingement were separated into groups presenting higher or lower than normal clavicular elevation. In the frontal plane, increased clavicular elevation for individuals with impingement was associated with more trunk rotation, less elbow flexion and upper trapezius electromyographic activity during reaching, and a more anterior plane of shoulder elevation at the end of reaching as compared to the healthy individuals. INTERPRETATION The present results demonstrate that not all individuals with shoulder impingement present the same abnormal motor strategy. Therefore, characterizing motor strategies before implementing rehabilitation intervention is essential.

The Simple Shoulder Test Is Responsive in Assessing Change Following Shoulder Arthroplasty

STUDY DESIGN Prospective cohort study with repeated measures. OBJECTIVE To establish the responsiveness of the Simple Shoulder Test (SST) in comparison to other commonly used clinical outcomes in patients undergoing shoulder arthroplasty. BACKGROUND Responsiveness statistics are a useful means to compare different outcomes in terms of their ability to detect clinical change. While the responsiveness of the SST has been established for rotator cuff repair, it has not been determined for patients undergoing arthroplasty. METHODS Patients undergoing shoulder arthroplasty (n=120) were evaluated prior to surgery and 6 months after. The evaluation included the SST, Disabilities of the Arm, Shoulder and Hand questionnaire, range of motion, and isometric strength. Responsiveness to change was assessed using standardized response mean (SRM), while longitudinal construct validity was evaluated using Pearson correlation. Receiver operating characteristics curves were plotted to determine clinically important difference of SST. RESULTS The SST and Disabilities of the Arm, Shoulder and Hand questionnaire were highly responsive (SRM, >1.70) for this population. For the assessment of impairment, range of motion (SRM, 0.64-1.03) was moderately to highly responsive, while isometric strength was minimally to moderately responsive (SRM, 0.32-0.69). The clinically important difference of the SST was established at 3.0 SST points. Pearson correlations indicated moderate associations between the change scores of the SST and the Disabilities of the Arm, Shoulder and Hand questionnaire (r=0.49). CONCLUSIONS The SST has been previously shown to be valid and highly reliable. The present results show that the SST is also responsive following shoulder arthroplasty and that it has a clinically important difference of 3.0 SST points. This should provide confidence to clinicians who wish to use a brief shoulder-specific measure in their practice.

The concurrent validity of a hand-held versus a stationary dynamometer in testing isometric shoulder strength.

STUDY DESIGN Clinical Measurement-Validity. INTRODUCTION Validity of the JTech PowerTrack II hand-held dynamometer (JTech; JTech Medical, Salt Lake City, UT) for measuring shoulder strength has yet to be established. PURPOSE OF THE STUDY To examine the concurrent validity of isometric strength scores obtained with the JTech PowerTrack II, and on a stationary dynamometer, the LIDO WorkSET (LIDO; LoredanBiomedical, West Sacramento, CA). METHODS Thirty-eight subjects performed three maximal efforts of shoulder flexion, abduction, and external rotation on a single occasion on the two dynamometers. Two testers were randomly assigned to administer the tests. RESULTS Pearson correlations between the scores on the two dynamometers (r.0.81) indicated a good concurrent validity. Correlations were similar when the results were subdivided by tester or gender. CONCLUSIONS This study suggests that either the JTech PowerTrack II or LIDOWorkSET provide comparable scores for shoulder strength. Although not interchangeable because of the differences in units of measurement, the relative conclusions about strength should be similar, regardless of which instrument is used. LEVEL OF EVIDENCE Not applicable.

Psychometric properties of presenteeism scales for musculoskeletal disorders: a systematic review.

OBJECTIVE To conduct a systematic review of the psychometric evidence relating to presenteeism scales in workers with musculoskeletal disorders. METHODS A structured search was conducted in 3 databases (MEDLINE, CINAHL, Embase) for articles published between 1966 and 2010. Sixteen articles met eligibility criteria. Pairs of raters used structured tools to analyse these articles through critical appraisal and data extraction. Descriptive synthesis of the psychometric evidence was then performed. RESULTS Methodological quality ratings of 56% of the studies reviewed reached a level of 75% or higher. Seven presenteeism scales were evaluated. Overall, presenteeism scales demonstrated acceptable validity content, were moderately to highly correlated (r > 0.50) to each other and to work- and disease-oriented constructs, and were able to differentiate between different populations and disability levels (p < 0.05). Limited evidence exists on the reliability and responsiveness of presenteeism scales, as reliability had only been evaluated for two scales and responsiveness in two studies. CONCLUSION None of the identified scales demonstrated satisfactory results for all evaluated psychometric properties. For most scales, data regarding properties such as reliability and responsiveness were insufficient. Therefore, there is no substantial evidence to recommend one questionnaire over the others based solely on psychometric properties.

Rotational strength, range of motion, and function in people with unaffected shoulders from various stages of life

BackgroundDifferent measurements are used to assess shoulder function, including range of motion, strength, functional performance and self-report function. To understand disablement, it is necessary to understand the relationship between impairments and function in persons without shoulder problems. This study was conducted to enhance existing comparative data in subjects without upper extremity pathology, and to assess the relationships between impairments (range of motion, strength) and self-reported or measured function/disability. The impact of age, gender and dominance was determined.MethodsTwo-hundred ninety-four subjects with unaffected shoulders were recruited. The subjects (mean age: 37 years old) were divided into three subgroups, 18–39, 40–59, and over 60 years of age. During a single session, at least two of the following variables were measured: self-reported function (shoulder disability scales), range of motion, isometric rotational strength, or upper limb functional performance (FIT-HaNSA). Two-way analysis of variance was used to determine, for each variable, the effects of age and gender. The relationship between the outcomes was established using Pearson product correlations.ResultsMen were significantly stronger than women for all age categories. There was an age-related decline in strength in men in the over-60 age category. Significant negative correlations between strength and range of motion were demonstrated (-0.22 <r < -0.32). Women had a significantly higher range of motion than men for external rotation in the 40–59 age category. Furthermore, the subjects in the over-60 age category experienced a decrease of range of motion. There was minimal disability reported in all age groups on self-report scales. Only the Simple Shoulder Test demonstrated significant decreases in the over-60 age category and correlated with age (r = -0.202).ConclusionSelf-reported disability was low in individuals without upper extremity problems, although recruitment of such individuals was difficult in the older age groups due to the high prevalence of shoulder pathology. A low correlation between self-report disability and strength/range of motion in these unaffected subjects reflects the lack of disability reported by all subjects without pathology despite normal variations in strength and motion.