Evaluation of the Rough Shoulder.
Last updated Thursday, February 10, 2005
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Figure 12 - Functional deficits of patients with degenerative joint disease
Figure 13 - Functional deficits of patients with rheumatoid arthritis
Figure 14 - Functional deficits of patients with capsulorraphy arthropathyapsulorraphy arthropathy
Figure 15 - Functional deficits of patients with avascular necrosis
Figure 16 - Functional deficits of patients with cuff tear arthropathy
The functional effects of loss of smoothness
Quality of life
Using the Simple Shoulder Test,
we collected data on the functional effects of some common causes of
shoulder roughness when patients presented for evaluation. We have data
for degenerative joint disease (figure 12), rheumatoid arthritis
(figure 13), capsulorraphy arthropathy (figure 14), avascular necrosis
(figure 15), and cuff tear arthropathy (figure 16).
We have also completed an extensive study of "Patient
Self-Assessment of Health Status and Function in Glenohumeral
Degenerative Joint Disease" which we present here.
Orthopedists are vitally concerned with optimizing the quality of
life for their patients. The quantification of health status and
function is central to understanding the impact of chronic
musculoskeletal conditions and to determining the effectiveness of
different management strategies. With the growing interest in managing
health and health care, such measurements may help determine which
conditions and which treatments merit the highest priority.
Recently, patient self-assessment questionnaires have been
established as meaningful and practical tools for evaluating health
status and function. The effects of musculoskeletal conditions are
often quite apparent to the patient; thus these effects are readily
detectable by patient self-assessment.
The purposes of this article are:
- to demonstrate the practicality of office-based patient
self-assessment in the documentation of health status and function in a
population of individuals with a well-defined musculoskeletal
condition: primary glenohumeral degenerative joint disease,
- to compare the health status results with those expected in a general population that is age matched, and
- to determine which general health status parameters were most closely associated with loss of shoulder function.
Methods: Patient population
This study concerns 103 consecutive patients presenting to the senior
author for evaluation and management of primary glenohumeral
degenerative joint disease. Each patient met established necessary and
sufficient conditions for this condition. Seventy-seven were male,
twenty-six female. The mean age was sixty-three years (± 13 SD, range
30-94). Sixty-three were right dominant, thirty-eight were left
non-dominant, seven were left dominant, and five were right
non-dominant.Self-assessment of health status
Each patient completed a questionnaire consisting of thirty-six
questions regarding their general health status, the Short Form-36 (SF
36). The health status questions were scored using an established
protocol and converted into eight health status parameter scores for
each of which "100" represented the most healthy and "0" the least
healthy score. The data from the 103 subjects with primary glenohumeral
degenerative joint disease were compared to the published results using
the same health status questionnaire for three separate
population-based health status surveys: the Geisinger Health Plan
Survey (1,760 subjects), the AT&T American Trans Tech "MASH" Trial
(702 subjects), and the Northwest Area Foundation Health Survey (1,814
subjects). Initially, the comparison was made for men and women
separately, but the sex-related differences were small and these have
been omitted from this presentation for reasons of brevity. The
reference data cohorts did not exclude patients with comorbidities. For
those subjects under sixty-five years of age, the most prevalent
chronic diseases included chronic low back pain (11.1%), arthritis
(9.6%), asthma, hypertension, and visual impairment. Among the subjects
over the age of sixty-five, the most prevalent conditions were
arthritis (56.3%), chronic low back pain (37.5%), hypertension, angina,
and gastrointestinal problems. Thus the referenced data represent a
cross-section of the populations studied and do not represent the
health status of disease-free individuals.
The health status scores of the SF 36 are age dependent; thus both
the data on our patients and the reference cohort data were graphed as
a function of patient age. For each health status parameter, the means,
means plus one standard deviation and the means minus one standard
deviation for the combined reference cohort were plotted. For each
health status parameter, the percent of patients more than one standard
deviation below the mean were determined from these graphs.
Self-assessment of shoulder function
Each patient completed twelve questions concerning the function of
their shoulder, the Simple Shoulder Test (SST ). Comparison shoulder
function data were not available on the same population used for the
health status reference. Instead, we compared the shoulder function of
our patients to that of 80 individuals aged 60-70 years who had no
evident shoulder disease on a standardized history, physical, and
ultrasonographic examination of the rotator cuff. Of these 80 patients,
all could perform all twelve of the simple shoulder test functions,
except for one patient who could not lift eight pounds to shoulder
level and three who could not throw overhand twenty yards.Results: Self-assessment of health status
We prepared plots of pain (see figure 17) and physical role function
(see figure 18) scores for each of the 103 subjects as a function of
the patient's age. (In these plots, the dots indicate subjects from
this study. Lines demonstrate mean ± standard deviation data from
population-based comparison cohort). Similar plots were carried out for
the six other health status parameters. On each of these graphs, the
number of subjects scoring more than one standard deviation below the
mean was counted and expressed as a percent of the total number of
patients. We determined the percent of patients who were more than one
standard deviation below the mean for each of the eight health status
parameters (see figure 19). (In this plot, if all distributions were
normal, seventeen percent of the subjects would have been expected to
lie more than one standard deviation below the population-based mean
(vertical line)). For example, over 50% of the patients' pain and
physical role functioning scores were more than one standard deviation
below the mean. If the distribution of the two populations had been
normal, only 17% of the subjects would score more than one standard
deviation below the mean.Shoulder function
A substantial number of subjects were unable to perform each of the
twelve shoulder functions (see figure 20). Over 50% of subjects were
unable to sleep on the affected side, wash the back of the opposite
shoulder, place their hand behind their head with the elbow out to the
side, reach their low back to tuck in a shirt, and toss twenty yards
overhand.Discussion
This study demonstrated that both the quality of life and the
shoulder function were compromised in this series of 103 patients with
primary glenohumeral degenerative joint disease. These patients are
obviously a subset of patients meeting the criteria for this diagnosis:
they were sufficiently impaired to present to our referral medical
center for evaluation and management of their disease. Thus, these
results may not be representative of the population of patients with
primary glenohumeral degenerative joint disease or those presenting in
other practice settings.
While this is one of the first studies to apply the method to
shoulder disease, the use of self-assessment tools to document the
impact of musculoskeletal conditions has been recently demonstrated by
others. These studies indicate that musculoskeletal conditions, when
compared to other medical disorders, have a great impact on health and
function. In this study, most of the health status parameters derived
from the SF 36 were lower in these patients with primary glenohumeral
degenerative joint disease than for general comparison populations.
This is of interest because none of the health status parameters of the
SF 36 directly assess upper extremity function.
While many orthopedic scoring systems have been developed to
document disease severity, many of these scoring systems focus on
"objective" parameters, such as range of motion, strength and
radiographic appearance. The SF 36 and other self-assessment
instruments have the advantage of emphasizing the patients'
perspective. Self-assessment forms are also more practical (less
patient time, less cost) to administer and offer the potential for
periodic followup assessments without the patient having to return to
the office.
Short form generic health surveys, such as the SF 36, have been
shown to be as effective and reliable as the longer surveys. The SF 36
has also been shown to be useful in documenting the outcome of
orthopedic surgery. The importance of the SF 36 to orthopedics is
that this instrument is used in other fields of medicine as well; thus
the impact of musculoskeletal problems on self-assessed health status
can be compared to the impact of other chronic conditions, such as
endometriosis, renal failure, angina, gastrointestinal disease and
hypertension. The generality of the SF 36 also means that conditions
other that the one under study (comorbidities) may affect the results.
The published reference health status parameter data indicate a trend
for diminished scores with increasing age, no doubt reflecting a
growing prevalence of comorbidities with age. In comparison to the
reference populations, the distribution of bodily pain and physical
role function scores for the subjects with primary glenohumeral
degenerative joint disease were skewed so that over 50% of the subjects
were more than one standard of deviation below the referenced mean.
For the study of shoulder disease, the Simple Shoulder Test provides
a needed compliment to the SF 36. In performing the twelve functions of
the SST, subjects have been shown to use the shoulder in a wide variety
of positions, ranging from sixty degrees of elevation in the minus
fifty degree thoracic plane (tucking in the shirt), to 120 degrees of
elevation near the coronal plane (placing the hand behind the head with
the elbow out to the side) to seventy degrees of elevation in the plus
130 degree thoracic plane (washing the back of the opposite shoulder).
As a group, the patients with primary glenohumeral degenerative joint
disease had much poorer shoulder function than the nearly perfect
function of apparently disease-free shoulders of similar age.
Some of the health status parameters correlated strongly with the
patients' ability to perform different shoulder functions. Overall
bodily pain and physical functioning were the most strongly affected.
In the future, study of the effectiveness of treatment of shoulder
disorders will indicate whether improvements in these health status
parameters parallel improvements in the shoulder functions.
The SF 36 and SST represent practical examples for generic and
condition-specific measurement of the health and functional status in
patients with primary glenohumeral degenerative joint disease. Our
subjects had no difficulty in completing these self-assessment
questionnaires. The collection of these data did not require physician
or staff time other than passing out and collecting the forms. The
Simple Shoulder Test requires no calculation. The standardized
algorithms for calculating the SF 36 health status parameters are
easily incorporated into a spreadsheet. No research person or
specialized equipment was required to collect or analyze these data.
The incorporation of these tools into the context of a busy office
practice provides a practical method for quantitating the impact of
shoulder conditions on health status and shoulder function.
Disclaimer
This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient. Additional information may be found at http://www.orthop.washington.edu or by contacting the UW Department of Orthopaedics and Sports Medicine.
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