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Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: The value of shoulder outcome scores

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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. 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:

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.

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.


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